Skin-reducing mastectomy and one-stage implant reconstruction with a myodermal flap: a safe and effective technique in risk-reducing and therapeutic mastectomy.

INTRODUCTION: Immediate reconstruction following mastectomy for breast cancer has been shown to be oncologically safe and associated with improved psychosocial outcomes for patients. Bostwick described a technique for one-stage implant based reconstruction, combining skin-sparing mastectomy with concurrent reduction of the skin envelope. This report reviews the experience of a single centre using skin-reducing mastectomy and one-stage implant reconstruction in both early stage breast cancer and risk-reducing mastectomy, with specific reference to frequency of complications, implant loss and oncological outcomes. METHODS AND RESULTS: A retrospective review was undertaken to identify women who had undergone skin-reducing mastectomy and one-stage implant reconstruction using a de-epithelialised dermal flap, between October 2008 and October 2012. One hundred and four consecutive mastectomies, with reconstruction, were performed by two surgeons on 64 patients. No complications were seen in 43.8% of patients. At three months, four implants were lost (3.8% of breast reconstructions, 6.3% of patients), due to either peri-implant infection or mastectomy skin flap necrosis. One patient required unplanned return to theatre for evacuation of a haematoma. Minor mastectomy skin flap necrosis was seen in 10 breasts (9.6% of reconstructed breasts) and superficial wound infection in 8 breasts (7.7% of reconstructed breasts). All of these complications were managed conservatively and none required operative intervention. At a median follow up of 35 months (4-53 months) there had been one episode of ipsilateral axillary nodal recurrence. CONCLUSION: One-stage implant reconstruction using a myo-dermal flap technique following skin-reducing mastectomy is safe and should be considered in selected patients. Most complications are minor and will resolve with conservative management. Major complications such as implant failure or immediate reoperation, were relatively uncommon (6.3% patients, 3.8% of reconstructed breasts). Early follow-up suggests that oncological outcomes are satisfactory, but longer follow-up is required to substantiate this.

Expression of EZH2 and Ki-67 in colorectal cancer and associations with treatment response and prognosis.

BACKGROUND: Enhancer of zeste homologue 2 (EZH2) is a member of the Polycomb group of genes that is involved in epigenetic silencing and cell cycle regulation. METHODS: We studied EZH2 expression in 409 patients with colorectal cancer stages II and III. The patients were included in a randomised study, and treated with surgery alone or surgery followed by adjuvant chemotherapy. RESULTS: EZH2 expression was significantly related to increased tumour cell proliferation, as assessed by Ki-67 expression. In colon cancer, strong EZH2 expression (P=0.041) and high proliferation (>or=40%; P=0.001) were both associated with better relapse-free survival (RFS). In contrast, no such associations were found among rectal cancers. High Ki-67 staining was associated with improved RFS in colon cancer patients who received adjuvant chemotherapy (P=0.001), but not among those who were treated by surgery alone (P=0.087). In colon cancers stage III, a significant association between RFS and randomisation group was found in patients with high proliferation (P=0.046), but not in patients with low proliferation (P=0.26). Multivariate analyses of colon cancers showed that stage III (hazard ratio (HR) 4.00) and high histological grade (HR 1.80) were independent predictors of reduced RFS, whereas high proliferation indicated improved RFS (HR 0.55). CONCLUSION: Strong EZH2 expression and high proliferation are associated features and both indicate improved RFS in colon cancer, but not so in rectal cancer.

Satisfactory long-term results after Nissen fundoplication.

BACKGROUND: Complications and unsatisfactory long-term results after antireflux surgery in children have received increased attention. The aim of this study was to report parental assessment of outcome after Nissen fundoplication. METHODS: Ninety-three patients operated with primary Nissen fundoplication between 1990 and 2001 were included. Medical records were reviewed, and parents were interviewed for evaluation of postoperative results. RESULTS: Of the 93 children, 51 were neurologically impaired and 14 children had repaired esophageal atresia. Median follow-up time was 6.0 years. Total mortality for the patient population was 13%. Five children died as a complication of the surgery, whereas eight deaths were unrelated to the Nissen fundoplication. Ninety-two percent of the parents reported better well-being of the child after the Nissen fundoplication, and 83% were completely satisfied with the postoperative results. Pulmonary symptoms were reduced in 59%, and quality of sleep improved in 68% of the children. Nine children (10%) had been operated with a redo NF. CONCLUSION: The majority of parents were satisfied with the long term results of the Nissen fundoplication.

Monitoring urinary bladder volume and detecting post-operative urinary retention in children with an ultrasound scanner.

BACKGROUND: Post-operative urinary retention (PUR) is associated with a risk of over-distension and permanent detrusor damage. The prevention of PUR by routine catheterization may increase the risk of urinary tract infection. Post-operative monitoring of the bladder volume is a reliable method in adults, but has not been evaluated for reliability in children. METHODS: Forty-eight patients who, according to current clinical guidelines, required urinary bladder emptying were scanned before catheterization using the Bladderscan. Volumes estimated with ultrasound were compared with volumes measured after emptying the bladder with a catheter. Bladder emptying was controlled by concomitant fluoroscopy in 20 children. RESULTS: The mean difference between the ultrasound estimates and the catheter-emptied urine volumes was 4 ml [standard deviation (SD) = 25 ml] in 26 children above the age of 3 years and -18 ml (SD = 19 ml) in 22 younger children. In the subpopulation in whom complete bladder emptying could be confirmed by fluoroscopy (14 children; median age, 3 years; range, 1-11 years), the mean difference between the ultrasound estimates and the catheter-emptied volumes was -11 ml (SD = 24 ml). CONCLUSIONS: This study confirms agreement between the ultrasound scanner estimates of urinary bladder volume and the urine volume measured by emptying the bladder. Reliability was good in children above the age of 3 years. The volume was underestimated in younger children. Thus, routine monitoring of urinary bladder volume with an ultrasound scanner is a non-invasive, pain-free and reliable way of preventing over-distension of the urinary bladder in children after surgery and other procedures under general anaesthesia.

Accentuated oxidative stress following reperfusion injury in diabetic rats.

BACKGROUND: This study investigates whether diabetes mellitus accentuates hind limb ischemia-reperfusion injury. METHODS: Male Wistar rats rendered diabetic (n=40) following injection of streptozotocin were compared to non-diabetic control rats (n=30). Each group was divided into sham, 4 hrs of hind limb ischemia, 4 hrs of ischemia followed by 10, 30 or 60 min of reperfusion. Plasma concentrations of an end-product of lipid peroxidation [malondialdehyde (MDA)] and antioxidants (vitamins A and E) were measured together with the resting membrane potential (RMP) of the gastrocnemius muscle. RESULTS: Following reperfusion, the diabetic group showed greater and more persistent elevation of MDA and greater reduction of antioxidants. This was associated with reduction in the RMP only in the diabetic group. There was significant correlation between MDA level and the RMP in both groups of animals. CONCLUSIONS: These results indicate that oxidative stress following reperfusion injury is greater in the presence of diabetes mellitus. This may lead to a decrease in the RMP and increase in the vascular permeability, which may be associated with more complications.

A previous abrasion in the contralateral eye influences the cell kinetics during healing of a central corneal abrasion.

PURPOSE: To study the influence of a previous erosion in the fellow eye on the proliferative response during healing of a central corneal erosion. METHODS: A corneal abrasion was made on the right eye of 20 rats. After 1 week a corneal erosion was made in the left eye of the pre-treated animals and in 20 previously untreated animals. Cell kinetic methods were used to estimate the labelling index (LI) and the mitotic rate (MR) after 1, 2, 4, 6 and 12 days. RESULTS: After 24 hours the corneal erosions were covered by epithelial cells in 3 of 4 animals in both groups. The LI and the MR were significantly higher in the pre-treated group on the 2nd day after erosion. CONCLUSIONS: The proliferation measured by LI and MR was increased when an abrasion was made in the contralateral eye 1 week earlier. This might explain the faster healing rate of the second eye reported by other authors (Rask et al. 1996). The healing process in the cornea is modulated by systemic influence.

[Enuresis nocturna--practical advice for examination and treatment]. / Enuresis nocturna--praktiske råd for utredning og behandling.

Children suffering from nocturnal enuresis have better self-esteem when they stay dry. A medical examination is necessary in order to exclude specific causes. The choice of treatment should be based on: motivation and age of the child, nocturnal polyuria versus bladder capacity, possibilities to borrow an alarm device, and follow-up. Informed choice treatment should be offered. Treatment with an alarm device and minimum standards are discussed. Desmopressin for short-term treatment or for three month periods are recommended for patient who respond to desmopressin. If organic causes are suspected, the child has diurnal incontinence symptoms, or does not stay dry in spite of the recommended treatment, referral to a paediatrician or a paediatric department is recommended. A better program for managing these patients at paediatric departments should be developed in collaboration with other specialists.

[Crohn disease of the oral cavity, illustrated by some cases]. / Crohns sykdom i munnhulen, belyst med noen kasuistikker.

BACKGROUND: We have several times experienced that Crohn's disease has not been diagnosed until several years after the start of oral symptoms. This article presents some patients with oral manifestations of Crohn's disease, as a contribution to more awareness of this possibility. MATERIAL AND METHODS: Clinical and histological data from four patients are presented. RESULTS: All patients had granulomatous inflammation of the oral mucosa. In three patients, the disease started in the mouth. The diagnosis of intestinal Crohn's disease was made from some months up to seven years later. In one patient, no granuloma was found in the intestinal tract, but the patient had intestinal symptoms. Two patients experienced disappointments in their contacts with the local health care system, with considerable delay in diagnosis. INTERPRETATION: We interpret these cases as evidence that a greater awareness of the possibility of Crohn's disease in the oral cavity may lead to a quicker diagnosis, earlier correct treatment, and less patient worry caused by uncertainty.

Dynamic MR-imaging in the diagnosis of pigmented villonodular synovitis of the knee.

The aim of this report was to study the rate of contrast enhancement at MRI in pigmented villonodular synovitis (PVNS). Dynamic MRI was performed in a patient with PVNS just before and 1 week and 3 years following synovectomy of the knee. As opposed to patients with rheumatic disease the patient with PVNS showed a slower enhancement rate before synovectomy than 1 week after. At 3 years follow-up the patient with PVNS showed an enhancement rate just above that of the normal controls. The results indicate that PVNS has features more common to hyperplastic or neoplastic lesions than to inflammatory ones. The results at 3 years follow-up also suggest that dynamic MRI may indicate the efficacy of arthroscopic synovectomy.

Modulation of TNF alpha and IL-6 in a peritonitis model using pentoxifylline.

Sepsis leads to release of reactants that play an important role in the development of multiple organ failure. The kinetics of two early mediators of the response to sepsis, tumour necrosis factor (TNF alpha) and interleukin 6 (IL-6), and their modulation with pentoxifylline (PTF), were investigated. An established and clinically relevant animal model was employed, and sepsis was induced by cecal ligation and puncture (CLP) in Wistar rats. Six hours after the operation, there was an increase in IL-6 in all animals, which declined toward normal by 18 hours. This early phase of IL-6 production was not influenced by PTF. TNF alpha and IL-6 were significantly higher in the CLP group than in the animals treated with PTF at 24 hours. The blood pressure of the CLP group at 24 hours was significantly lower than that of the shams, and this decrease was not influenced by PTF. This decline in blood pressure may have been the stimulus to TNF production and the second phase of IL-6 production, which appeared to be inhibited by PTF. Pentoxifylline appears to attenuate systemic cytokine production in this model and may have a role in the management of clinical sepsis.

Early cell kinetic effects of some drugs on the rat corneal and conjunctival epithelia.

The early cell kinetic response in the rat corneal and conjunctival epithelia was studied after a single topical application of dipivefrine, adrenaline and timolol with and without benzalkonium chloride. Benzalkonium chloride alone in different concentrations, 0.004%, 0.01%, 0.02% and 0.04%, respectively, was also evaluated. The stathmokinetic method and the tritiated thymidine technique were used to estimate the mitotic rate and the labelling index. Dipivefrine (Propine) gave a significant depression of the mitotic rate almost to the same extent as adrenaline in the corneal epithelium, whereas no changes were found in the limbal area and in the conjunctiva. Timolol (Oftan) with or without benzalkonium chloride, and benzalkonium chloride in different concentrations gave no obvious changes of the mitotic rate. No distinct drug effects on the labelling index were observed.

Histopathologic changes of the temporomandibular joint disk in patients with chronic arthritic disease. A comparison with internal derangement.

Histopathologic examination was performed of the disk and the posterior attachment extirpated from 17 temporomandibular joints from 15 patients with chronic arthritic disease. Seven patients had rheumatoid arthritis (including two with juvenile type), five had ankylosing spondylitis, and three had psoriatic arthropathy, which affected more joints than the temporomandibular joint. Specimens removed from 16 temporomandibular joints from 15 patients with internal derangement were used for histopathologic comparison. In both groups of patients, inflammatory changes were observed, but no specific histopathologic signs could distinguish the groups. Patients with chronic arthritic disease seemed to have more pronounced changes of vascular proliferation, perivascular cellular infiltrate, inflammatory cells, and fibrosis throughout the soft tissues. Destruction of the disk was another finding evident in patients with chronic arthritic temporomandibular joint disease; there was no visible disk structure in 8 of these 17 joints, compared with 1 of the 16 joints in the internal derangement group.

Time dependency in the regenerative response to injury of the rat corneal epithelium.

In the present study a central corneal epithelial defect (diameter 3.5 mm) was made in both eyes at 12:00 h in one group of rats and at 24:00 h in another group to see if the regenerative proliferation is influenced by circadian rhythms. The labeling index and the mitotic rate were registered at 4-h intervals in the perilimbal conjunctiva, the limbal area, and different parts of the cornea from the following morning until noon the day after that. The most pronounced regenerative proliferation was seen in the midperipheral and peripheral cornea. The regenerative response occurred in both groups 24-28 h after the injury, but was highly influenced by the normal circadian rhythms, especially with regard to the mitotic rate. The results support the theory that even regeneration is influenced by a circadian proliferative factor.

Pentoxifylline improves intracellular electrolytes in sepsis.

Sepsis is associated with a generalised membrane dysfunction leading to an increase in intracellular sodium, chloride, and water. The decrease in extracellular water is thought to act as a nonosmotic stimulus to the secretion of antidiuretic hormone. The resultant hyponatraemia is associated with increased surgical morbidity and mortality. Treatment aimed at improving intracellular electrolytes may improve surgical morbidity and mortality. An animal model of peritonitis was used to evaluate the effect of pentoxifylline. Previously, this dimethyl xanthine derivative was shown to stabilise the cell membrane. Administration of pentoxifylline significantly lowered intracellular sodium and chloride, particularly when given after caecal ligation and puncture. This may have clinical implications in the treatment and prevention of hyponatraemia.

Prenatal diagnosis of urinary tract anomalies. The value of two ultrasound examinations.

OBJECTIVE: To determine when fetal urinary tract anomalies were detected by ultrasound screening during pregnancy and to discuss the possible consequences if only one early ultrasound examination is performed. DESIGN: A retrospective study of 47 cases where fetal urinary tract malformations were diagnosed in a two-stage screening program (17th and 32nd week of gestation) covering 22,310 women over ten years, 1982-91. SETTING: Ullevål University Hospital in Oslo which serves as a referral center for obstetric and neonatal diseases. RESULTS: Urinary tract anomalies were diagnosed in 0.18% of the pregnancies. Of these, 61.7% were found at the second routine ultrasound screening. The most difficult differential diagnoses were those of hydronephrosis without megaureter and a multicystic kidney. Hydronephrosis was found in 51% and a multicystic kidney in 21% of the cases. The tentative prenatal diagnoses were confirmed postnatally in 83% of the cases. Six of the fetuses had anomalies regarded as incompatible with postnatal life. These pregnancies were terminated, and the diagnoses verified by autopsy. Two other infants died perinatally, one of them as a result of the urinary tract anomalies. CONCLUSION: If only one ultrasound scanning had been performed in the 17th week, approximately two-thirds of the cases would not have been detected. Early intervention and follow-up after delivery would only have been performed if the infants had developed symptoms or complications related to the urinary tract anomalies.