The rise and potential fall of pancreas transplantation.

BACKGROUND: The aim of this review is to bring pancreatic transplantation out of the specialist realm, informing practitioners about this important procedure, so that they feel better equipped to refer suitable patients for transplantation and manage, counsel and support when encountering them within their own speciality. SOURCES OF DATA: Narrative review conducted in May 2017. OVID interface searching EMBASE and MEDLINE databases, using Timeframe: Inception to June 1, 2017. Articles were assessed for clinical relevance and most up to date content with articles written in english as the only inclusion criteria. Other sources, used included conference proceedings/presentations, unpublished data from our institution (Oxford Transplant Centre). AREAS OF AGREEMENT: Pancreas transplantation has evolved from an experimental procedure to the gold standard of care for patients with type 1 diabetes and uraemia. Currently, it remains the most effective method of establishing and maintaining euglycemia over the longer term, halting and potentially reversing many of the secondary complications associated with diabetes. Significant improvements to quality of life and better life expectancy make it in the longer term, a lifesaving procedure compared to waiting candidates. AREAS OF CONTROVERSY: The future of solid organ pancreas transplantation remains uncertain, with extensive comorbidity and advances in alternative therapies makes the long-term growth of the procedure questionable. GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH: Therapies to alleviate problems associated with ischaemia reperfusion injury, graft pancreatitis and more effective monitoring methods for detecting and treating organ rejection are the key areas of growth.

The value of ultrasonography in the diagnosis of appendicitis.

INTRODUCTION: Ultrasonography is a commonly used investigation in the UK for patients with right iliac fossa pain where the diagnosis of appendicitis is unclear. The published sensitivity and specificity of ultrasonography is higher than the results observed by clinicians in every day practice. The aim of this study was to elucidate the real-world value of ultrasonography in the diagnosis of appendicitis, and its impact on negative appendicectomy rates (NAR). METHODS: A retrospective multicentre audit was conducted at three UK hospitals over a twelve month period in 2012. RESULTS: 573 patients underwent ultrasonography prior to appendicectomy. The appendix was not visualised in 45% of scans. The sensitivity and specificity of ultrasonography for the diagnosis of appendicitis was 51.8% and 81.4%. The mean NAR was 26.7%, or 18.3% after a positive ultrasound scan. CONCLUSION: In clinical practice at UK centres, ultrasonography commonly does not visualise the appendix, and has a low sensitivity for appendicitis. To reduce the NAR, management options include a return to observation and serial examination, increased use of CT or a commitment to improving the performance of ultrasonography.

Melanoma in buckinghamshire: data from the inception of the skin cancer multidisciplinary team.

Background. Melanoma incidence is increasing faster than any other cancer in the UK. The introduction of specialist skin cancer multidisciplinary teams intends to improve the provision of care to patients suffering from melanoma. This study aims to investigate the management and survival of patients diagnosed with melanoma around the time of inception of the regional skin cancer multidisciplinary team both to benchmark the service against published data and to enable future analysis of the impact of the specialisation of skin cancer care. Methods. All patients diagnosed with primary cutaneous melanoma between January 1, 2003 and December 3, 2005 were identified. Data on clinical and histopathological features, surgical procedures, complications, disease recurrence and 5-year survival were collected and analysed. Results. Two hundred and fourteen patients were included, 134 female and 80 males. Median Breslow thickness was 0.74 mm (0.7 mm female and 0.8 mm male). Overall 5-year survival was 88% (90% female and 85% male). Discussion. Melanoma incidence in Buckinghamshire is in keeping with published data. Basic demographics details concur with classic melanoma distribution and more recent trends, with increased percentage of superficial spreading and thin melanomas, leading to improved survival are reflected.

Critical assessment of the anterolateral thigh flap donor site.

BACKGROUND: The free anterolateral thigh flap (ALT) is now used as a 'workhorse flap'. The donor site morbidity is thought to be minimal, although most evidence derives from questionnaire-based studies rather than rigorous objective clinical assessment. In particular, robust quantitative data on thigh sensibility and quadriceps function is lacking. The aim of this study was to provide a comprehensive clinical assessment of donor site morbidity. METHODS: We performed a prospective study of consecutive free ALT perforator flaps performed at Salisbury Foundation Trust between March 2008 and April 2010. The donor site was assessed at six months including a questionnaire (symptoms, function), scar analysis (Vancouver Scar Scale, VSS), and evaluation of quadriceps power and lateral thigh sensibility (compared with the contralateral unoperated thigh). RESULTS: One hundred ALT flaps were performed on 97 patients (mean age 46.8 years). The donor site was closed directly in 88 cases and using a split skin graft in 12 cases. At follow-up (n=68), tingling was the most common reported symptom (59%), whereas pain, itching and muscle herniation were reported infrequently. Donor site scars were mostly flat, pale and soft but widened. Pathological scarring was rare. Sensibility was reduced in donor thighs (p<0.001) and correlated with flap width but peak quadriceps contraction was similar between donor and unoperated thighs. CONCLUSIONS: There was a high throughput and diverse application of ALT flap reconstructions during the study period. Reduced sensibility was common around the scar but rarely troublesome. Quadriceps function was not affected even when dissection of intramuscular perforators was required. The ALT is a versatile flap that can deliver a large skin paddle with minimal impact on thigh function.

Excessive hazards of pregnancy and child birth in the third world.

PIP: The National Conference on Safe Motherhood in 1987 established the goal of reducing maternal mortality by 50% by the year 2000. At that time, there were 500,000 deaths from maternal causes, of which all but about 4000 occurred in developing countries. 87% of births globally occurred in developing countries. Maternal mortality was highest in Africa, particularly in Western, Central, and Eastern Africa. The average risk of dying from pregnancy related causes in Africa was over 1 in 20 compared to the 1 in 2000 risk in developed countries. In southern Asia there were 29% of the world's births, but about 50% of the world's maternal deaths. African maternal mortality could reach 1000/100,000 live births in rural areas and 500/100,000 in some cities, while in rural Bangladesh the figures were 600/100,000 and in rural Andhra Pradesh, India, 874/100,000 in 1984-85. The ratios in remote rural areas of China were 200/100,000; the ratios could be as high as 700/100,000 in some areas of Southeastern and Western Asia. In Latin America, the average was 200/100,000 without consideration of underreporting which was estimated at the highest at 60%. In the developed countries of Europe, maternal mortality averaged 10/100,000 or lower; a high value could be 30/100,000. Because fertility was low in developed countries, the actual numbers were 4000-5000 or 1% of the total. Global risks declined by about 5%, but births have increased by 7%. In developed countries, the maternal mortality ratio declined by 13%. Some evidence of decline was apparent in Asia, except for East Asia, and in Latin America. Little progress has been made in improving maternal mortality when the African lifetime risk of dying from pregnancy-related causes was 1 in 20 and a woman's risk in a developed country was 1 in 2000.^ieng

Measuring maternal mortality.

PIP: There are various methods of measuring maternal mortality each with its own advantages and disadvantages. Most official maternal mortality statistics underestimate true maternal mortality levels. Major reasons for underestimates depend on death certification practices and the advancement of the vital registration system. Only 35% of the world's population routinely record cause of death. Misclassification of the cause of death accounts for much of the bias in areas with good vital registration. In France, clerks miscode maternal-related causes of death as something else, e.g., they misclassified cerebral hemorrhages as diseases of the circulatory system and not complications of pregnancy, childbirth, and the puerperium. In countries with few maternal deaths, pregnant or puerperium women in life-threatening conditions are transferred from obstetric departments so cause of death on the certificate may not be the obstetric condition which precipitated the fatal series of events. Governments must determine the type of measurement method for maternal mortality by balancing precision against human and financial costs. Statisticians can measure the maternal mortality rate using several methods. They can include questions about maternal mortality such as maternal deaths of sisters of the adult women or of any women they know who had died from maternal causes in the last year in ongoing household surveys. These surveys tend to be expensive, however . A more cost-effective and successful method is reproductive age mortality surveys which consist of investigating the causes of all deaths of women of reproductive age. If civil registration or other population-based data do not exist, researchers can use hospital data despite their limitations. They can also use records at the primary care level. They can use incomplete data to estimate maternal mortality and to evaluate rates obtained from civil registers, studies, or other sources.^ieng

On the assessment of maternal mortality.

PIP: Well over 1/2 the maternal deaths in the world occur in 3 countries in southern Asia: India, Pakistan, and Bangladesh. In general, the incidence of maternal death correlates with 2 factors: a high risk of dying during or just after pregnancy due to sepsis, inadequate facilities for dealing with complicated births or other health problems such as exacerbation of existing disease, poor nutrition, overwork, and/or closely spaced pregnancies; and a high fertility rate. This report outlines methods for measuring maternal mortality and presents data for developing nations in each continent, comparing it to developed nations and determing its contribution to overall mortality. The risk of dying as a result of a given pregnancy in a developed nation is at least 100-fold smaller than that in the poorest countries in Africa and Asia. Estimated mortality due to pregnancy is 460,000 more women in the undeveloped nations compared to the developed nations.^ieng

Overview of the health of women and children

Better Health for Women and Children through Family Planning. Population Council; 5-9 Oct. 1987

. World Health Organization

. International Planed Parenthood Federation

. UNICEF

. UNDP

. PNUD

. World Bank

. Banco Mundial