[Sentinel node-positive melanoma].

Two recent randomised studies found no survival difference in patients, who had melanoma with metastasis to the sentinel node (SN) and underwent immediate complete lymph node dissection (CLND), compared with patients, who were followed closely with ultrasound scans and only underwent CLND if metastases developed. From 2018, the Danish guidelines concur: SN-positive patients will no longer undergo routine CLND, which has high morbidity, but will be followed with ultrasound scans of the SN-positive region(s) at their follow-up visits every third month for two years, then every six month for three years, except if PET-CT is performed.

Non-integrated acellular dermal matrix in breast reconstruction: a case report.

Acellular Dermal Matrices have become increasing popular in breast reconstruction especially in the last decade. There is a debate on whether Acellular Dermal Matrices increase the risk of complications or not. Common complications include infection, wound dehiscence, necrosis, seroma, haematoma, capsular contracture, extrusion, loss of implant and reconstruction failure. Non-integration is not listed as a typical complication to the use of Acellular Dermal Matrices. We report a case of a completely non-integrated Acellular Dermal Matrix following breast reconstruction in a patient without significant risk factors.

Mucosal Melanoma: a Literature Review.

PURPOSE OF REVIEW: Mucosal melanoma is of great interest due to its aggressive behavior and less favorable prognosis. The literature is mainly case reports and case series. Here, we will collect the knowledge on mucosal melanoma from the last decade and review the literature. The main focus is being site-specific clinical features, treatment, and prognosis. RECENT FINDINGS: The use of immunotherapy gain ground as for others subsets of melanoma. Anti-CTLA-4 and anti-PD-1/ PD-L1 blockade in mucosal melanoma have been evaluated in recent studies. Clinical trials are ongoing. The etiology of mucosal melanomas remains unknown. Head and neck mucosal melanomas are most common. Wide excision surgery is the treatment of choice. The effect of adjuvant therapy on survival remains questionable due to the limited knowledge. Radiotherapy seems to give better local control. The overall five-year survival rate for mucosal melanomas is 0-45%. Recent data indicates that this may be improved by the immunotherapy in the years to come.

Sentinel node biopsy (SNB) in malignant melanoma as same day procedure vs delayed procedure: clinical and economic outcome.

The aim of this study was to compare a delayed sentinel node biopsy (dSNB) procedure with a same-day procedure (sSNB) in malignant melanoma. In March 2012, Aarhus University Hospital went from the dSNB to the sSNB procedure defined by lymphoscintigraphy (LS) and sentinel node biopsy (SNB) performed on the same day. Before that time, LS was performed 24 hours prior to SNB. The aim was to investigate whether differences between the two procedures exist. Patients who underwent the SNB procedure between April and July 2011 and 2012, respectively, were included in the study. The criteria for SNB were malignant melanoma thickness >1 mm, Clark level IV/V, and ulcus or unknown thickness of the melanoma. All patients underwent re-excision and SNB at the same time. Pathological evaluation was not changed in the observation periods; however, the LS procedures varied. Only a minor turnover among the surgeons was observed. One hundred and eight patients were included in the study, 59 (dSNB) from 2011 and 49 (sSNB) from 2012, respectively. A median of 2.17 (dSNB) and 2.31 (sSNB) SLNs were removed, with no statistical differences. No difference in node positivity rates was observed. However, the number of hospitalisation days differed significantly, with 1.94 days in dSNB and 0.49 days in sSNB. Rates of complications at the site of the SNB procedure were similar. No differences in disease-free survival (DFS) or overall survival (OS) were recorded. SNB does not increase the overall survival. It is, therefore, essential to keep the morbidity and economic costs low, while keeping the quality of the procedure high.

Fast detection of renal ischemia in transplanted kidneys with delayed graft function-an experimental study.

BACKGROUND: The newly transplanted kidney is difficult to monitor with regard to postoperative vascular thrombosis, especially when there is delayed graft function. We evaluated microdialysis as a tool for early ischemia detection in porcine kidneys with delayed graft function early after transplantation. METHODS: Sixteen pigs were transplanted with 26-hr cold ischemia kidneys. A microdialysis catheter was placed in the lateral renal cortex. Five hours after graft reperfusion, the pigs were randomized to renal arterial clamping or open artery, n=8 in each group, and further observed for 2 hr. RESULTS: The diuresis and glomerular filtration rate were low and decreasing throughout the study, with no significant differences between groups. Until arterial clamping, there were no significant differences in the development of local renal metabolites between the two groups. Renal artery clamping immediately caused significantly different development of all metabolites (P<0.02 for all) compared to the open artery group. After clamping, levels of glutamate and glycerol were significantly increased within 30 min (P=0.0049 and P=0.0061, respectively). CONCLUSIONS: Microdialysis provided an early warning of arterial occlusion in transplanted grafts with delayed graft function. It may become a valuable tool for postoperative monitoring and detection of thrombosis after renal transplantation.

[Scurvy is not entirely a historical disease]. / Skørbug er ikke kun en historisk sygdom.

Scurvy, lack of vitamin C, is a rare disease and is often called seafarers' disease. This case story describes a 36 year-old female patient with scurvy after a gastric bypass operation. Scurvy led to severed bullae on the skin, haemorrhagia and loose skin. After intensive care treatment and a minor split skin graft the patient was discharged from the university hospital to a local hospital for further mobilization. Three months later the patient died due to sepsis.

Temporal differences in the development of organ dysfunction based on two different approaches to induce experimental intra-abdominal hypertension in swine.

BACKGROUND: Intra-abdominal hypertension [IAH] occurs frequently among critically ill patients and is associated with increased mortality and organ failure. Two porcine models of IAH that cause abdominal compartment syndrome [ACS] with organ dysfunction were created. We investigated whether the two methods used to create IAH - CO2 pneumoperitoneum or adding volume to the intra-abdominal space - exerted different impacts on the temporal development of organ dysfunction. METHODS: Twenty-four 40-kg female pigs were allocated to four groups: 25 mmHg IAH with CO2 pneumoperitoneum (n = 8), >20 mmHg IAH caused by addition of volume (n = 8), and two corresponding sham groups (each n = 4). The two sham groups were later pooled into one control group (n = 8). The animals were monitored for 12 h. Repeated serial measurements were taken of group differences over time and analyzed using analysis of variance. RESULTS: Thirty-eight percent of the animals (n = 3) in each intervention group died near the end of the 12-h experiment. Both intervention groups experienced kidney impairment: increased creatinine concentration (P <0.0001), anuria (P = 0.0005), hyperkalemia (P <0.0001), decreased abdominal perfusion pressure, and decreased dynamic lung compliance. CO2 pneumoperitoneum animals developed hypercapnia (P <0.0001) and acidosis (P <0.0001). CONCLUSIONS: Both methods caused ACS and organ dysfunction within 12 h. Hypercapnia and acidosis developed in the CO2 pneumoperitoneum group.

Microdialysis for detection of renal ischemia after experimental renal transplantation.

PURPOSE: We designed an experimental renal transplantation model and evaluated microdialysis as a detector of induced postoperative ischemia, a feared complication that when caused by vascular thrombosis most often causes renal graft loss. MATERIALS AND METHODS: Two microdialysis catheters were placed in the left kidney in 16 pigs, including 1 superficially in the renal cortex and 1 fixed on the renal capsule. Two-hour baseline measurements were made at steady state, after which the kidney was removed and subjected to warm and cold ischemia. It was subsequently re-anastomosed end to end in situ and reperfused for 5 hours. Pigs were then randomized into a total renal artery occlusion and a control group. RESULTS: At baseline there were no changes in local metabolites (glucose, glutamate, glycerol and lactate) and no significant difference between the groups. Glycerol increased 4-fold in each group during cold ischemia but there were no pivotal alterations in other metabolites. After kidney reperfusion glycerol decreased and all metabolites were in steady state after 1 hour. At 30 minutes after postoperative ischemia was introduced there were significant increases in all kidneys in ischemia vs steady state reperfusion levels of cortical lactate, glutamate, glycerol and the lactate-to-glucose ratio (each rank sum test p <0.001). No metabolic changes were seen in controls. CONCLUSIONS: Microdialysis detected significant metabolic changes after postoperative ischemia in pigs with experimental renal transplantation, while no metabolic changes were observed in controls. In the future microdialysis may become a valuable tool for postoperative observation of transplanted kidneys, most probably with major impact on early graft survival.

Pharmacokinetics of linezolid in bone tissue investigated by in vivo microdialysis.

Pharmacokinetics of unbound anti-infectives in bone is difficult to characterize. The aim of this study was to assess the feasibility of the microdialysis technique to cancellous bone for single dose pharmacokinetic investigations of the anti-infective linezolid. Serial bone biopsies (left tibia) and microdialysate samples (right tibia: 2 catheters) as well as plasma and bone marrow samples were obtained from 10 pigs. The concentrations of linezolid reached bacteriostatic levels in plasma, bone marrow, bone biopsies and microdialysates. With the use of microdialysis we here present the first results for unbound linezolid bone penetration. Unbound linezolid concentrations in bone obtained by microdialysis were lower than might have been expected from previous bone biopsy studies. To achieve effective concentrations (24 h) for susceptible organisms the chosen dose of linezolid might not be sufficient.

Early detection of renal ischemia by in situ microdialysis: an experimental study.

PURPOSE: Acute vascular thrombosis of the renal artery or vein is a feared and devastating complication after renal operations, especially transplantation. We evaluated microdialysis as a possible new tool for the rapid and reliable detection of renal ischemia in a porcine model. MATERIALS AND METHODS: A total of 20 healthy anesthetized pigs were randomized to experiments on the left or right kidney and into 3 groups, including arterial ischemia in 8, venous ischemia in 8 and 4 controls. One microdialysis catheter was inserted superficially in the renal cortex and 1 was placed outside on the renal capsule. The contralateral kidney was removed. After 2 hours of baseline measurements ischemia was introduced by clamping the renal artery or vein in the first 2 groups. Microdialysis samples were taken every 30 minutes during baseline and the following 5 hours. The samples were analyzed for glucose, lactate, glutamate and glycerol. The mean change from baseline was analyzed for each metabolite in all groups. RESULTS: At 30 minutes after the introduction of arterial or venous ischemia there was a significant increased mean change from baseline of glutamate, glycerol and lactate in the cortex and of glutamate extracapsularly. The mean change from baseline of glucose in the cortex decreased significantly 60 minutes after venous ischemia and 90 minutes after arterial ischemia. In controls these metabolites did not change significantly from baseline with time. CONCLUSIONS: Microdialysis from just outside the renal capsule is a reliable tool for the early detection of acute renal ischemia. It may be used to detect acute vascular complications in the first days after renal transplantation.

Regional changes in renal cortical glucose, lactate and urea during acute unilateral ureteral obstruction.

OBJECTIVE: Acute unilateral ureteral obstruction (UUO) leads to changes in kidney function and metabolism. Microdialysis offers the possibility of topical analysis of changes in kidney metabolism. We applied microdialysis to the porcine kidney and evaluated its impact on gross kidney function. Furthermore, we investigated regional variations in renal interstitial fluid (RIF) glucose, lactate and urea during acute UUO. MATERIAL AND METHODS: Eight anesthetized pigs were used. Microdialysis probes were inserted in the upper, middle and lower thirds of the left renal cortex and perfused with Ringer's chloride at a rate of 0.3 microl/min. Dialysates were fractionated for 30-min periods. Bilateral intrapelvic pressure, urinary output, urinary osmolality, the excretion fractions of sodium and potassium, renal blood flow and the glomerular filtration rate were measured. Subsequently, left-sided graded ureteral obstruction was initiated, using the kidney's own urine production as a counter-pressure. RESULTS: The application of three microdialysis probes did not have any impact on kidney function. Ureteral obstruction decreased RIF glucose in the upper and lower thirds of the kidney, but not in the middle third. RIF lactate did not change. Interstitial urea increased in all regions of the kidney, but most markedly in the upper and lower poles. CONCLUSIONS: Microdialysis is of potential value for assessing the renal interstitial milieu under different pathophysiological conditions. Ureteral obstruction resulted in regional differences in cortical metabolites, predominantly affecting the upper and lower poles.

Application of microdialysis to cancellous bone tissue for measurement of gentamicin levels.

OBJECTIVES: Knowledge concerning the distribution of antibiotics in bone tissue is valuable for pharmacokinetic and clinical use. Unfortunately, appropriate techniques are difficult to apply. We introduced microdialysis catheters to cancellous bone tissue for the investigation of gentamicin levels and compared the pharmacokinetics measured with values obtained from bone samples. METHODS: After two microdialysis catheters had been inserted into cancellous bone, eight pigs received an intravenous bolus of 240 mg of gentamicin. Microdialysates and bone samples were obtained over a period of 6 h and drug concentrations were measured. RESULTS: The area under the curves of the two microdialysates and bone samples were 1569, 1721 and 1533 mg.min/L (ANOVA, P=0.81). Reproducibility of the measurements from the microdialysates was defined as the mean ratio of AUC6/catheter no. 1/AUC6/catheter no. 2. This ratio was 1.02. CONCLUSIONS: Microdialysis is a suitable, relatively non-invasive and reproducible technique for dynamic and quantitative measurement of gentamicin levels in experimental research.

The metabolism of the diabetic foot: in vivo investigation with microdialysis.

BACKGROUND: Many amputations might be delayed or prevented by more effective clinical supervision of the diabetic foot ulcer. The aim of this study was to measure the local metabolism on the edge of a diabetic ulcer and compare it to healthy subcutaneous tissue. PATIENTS AND METHODS: In 5 non-fasting diabetic patients, we inserted a microdialysis catheter into the edge of a diabetic ulcer and a reference catheter into healthy abdominal subcutaneous tissue, and recorded the local concentrations of glucose, lactate and glycerol during rest. RESULTS: The concentrations of glucose in the ulcers were 7.8 mM (SEM 1.9) and in the reference tissue 10.6 mM (SEM 1.8) (p = 0.4). The concentrations of lactate were 2.9 mM (SEM 0.7) and 2.1 mM (SEM 0.7) (p = 0.2), while those of glycerol were 290 microM (SEM 84) vs 98 microM (SEM 7.2) (p = 0.002). INTERPRETATION: This study shows that microdialysis can detect differences in dialysate concentrations of metabolites in diabetic ulcers and a reference tissue, providing valuable information concerning metabolites in the diabetic foot ulcer. Future studies should combine the technique with measurements of local blood flow.

In situ gentamicin concentrations in cortical bone: an experimental study using microdialysis in bone.

We used microdialysis to study gentamicin in cortical bone and compared these results to values obtained in bone specimens. 10 healthy pigs were given an intravenous bolus of 160 mg of gentamicin. We measured reproducibility by inserting two microdialysis catheters into the cortex of tibial diaphyses and by taking samples of serum, dialysates and bone specimens during 6 hours and measuring the concentrations of this antibiotic. The peak concentrations in the two microdialysis probes and bone specimens were 3 mg/L, 2.9 mg/L and 2.6 mg/L (Anova, p = 0.3). Similarly, the areas under the curve from 0 to 6 hours (AUC6h) were 704 mg/min/L, 661 mg/min/L and 569 mg/min/L (Anova, p = 0.07). The reproducibility of the measurements of the microdialysates was evaluated with the mean AUC(6h/catheter no.1)/AUC(6h/catheter no. 2) ratio, which was 1.12. It seems that microdialysis is a suitable method for making dynamic and quantitative measurements of gentamicin in bone.