Significantly reducing implant loss rates in immediate implant-based breast reconstruction: A protocol and completed audit of quality assurance.

INTRODUCTION: Immediate implant-based breast reconstruction (IBR) rates have increased considerably with the advent of acellular dermal matrices. Implant loss is a significant complication and is costly to patients and the NHS. National Mastectomy and Breast Reconstruction Audit and Implant-Based Breast Reconstruction Audit data have demonstrated national implant loss rate of 9% at 3 months. National Oncoplastic Guidelines for Best Practice cite a < 5% target. We aimed to reduce implant loss by introducing a protocol with pre-, intra- and post-operative interventions. METHODS: Audit of IBR at a single oncoplastic breast unit was commenced and implant loss at 3 months was recorded (May 2012-July 2014). Patients were identified from a prospectively maintained database, and case notes were examined by identifying factors associated with implant loss. A team involving microbiology, theatre staff, infection control and surgeons was established. A novel, evidence-based intervention bundle, including more than 25 protocol changes, was introduced. Prospective re-audit of IBR (April 2015-December 2017) was completed following introduction of the new protocol and implant loss was recorded at 3 months. RESULTS: The first retrospective audit of 77 reconstructions (54 patients) demonstrated 11 implant losses at 3 months (14%). Re-audit, post-intervention, comprised 129 reconstructions (106 patients) with no implant loss at 3 months. Fisher's exact analysis revealed statistically significant reduction in implant loss rate (P < 0.00001) following protocol introduction. CONCLUSIONS: Implant loss rate following IBR can be reduced to an exceptionally low level, well below national targets, by adhering to this evidence-based intervention bundle. Our protocol could improve outcomes nationally.

Comparative transcriptomics of mountain pine beetle pheromone-biosynthetic tissues and functional analysis of CYP6DE3.

BACKGROUND: The mountain pine beetle (MPB, Dendroctonus ponderosae Hopkins) is a highly destructive pest of pine forests in western North America. During flight to a new host tree and initiation of feeding, mountain pine beetles release aggregation pheromones. The biosynthetic pathways of these pheromones are sex-specific and localized in the midgut and fat body, but the enzymes involved have not all been identified or characterized. RESULTS: We used a comparative RNA-Seq analysis between fed and unfed male and female MPB midguts and fat bodies to identify candidate genes involved in pheromone biosynthesis. The 13,407 potentially unique transcripts showed clear separation based on feeding state and gender. Gene co-expression network construction and examination using petal identified gene groups that were tightly connected. This, as well as other co-expression and gene ontology analyses, identified all four known pheromone biosynthetic genes, confirmed the tentative identification of four others from a previous study, and suggested nine novel candidates. One cytochrome P450 monooxygenase, CYP6DE3, identified as a possible exo-brevicomin-biosynthetic enzyme in this study, was functionally characterized and likely is involved in resin detoxification rather than pheromone biosynthesis. CONCLUSIONS: Our analysis supported previously characterized pheromone-biosynthetic genes involved in exo-brevicomin and frontalin biosynthesis and identified a number of candidate cytochrome P450 monooxygenases and a putative cyclase for further studies. Functional analyses of CYP6DE3 suggest its role in resin detoxification and underscore the limitation of using high-throughput data to tentatively identify candidate genes. Further functional analyses of candidate genes found in this study should lead to the full characterization of MPB pheromone biosynthetic pathways and the identification of molecular targets for possible pest management strategies.

Case report: cardiac hemangioma.

A report of an asymptomatic cardiac hemangioma in a middle-aged man is presented. This is followed by a literature review of mediastinal hemangiomas.

Clinical outcome of congenital talipes equinovarus diagnosed antenatally by ultrasound.

Congenital talipes equinovarus is a common anomaly which can now be diagnosed prenatally on a routine ultrasound scan at 20 weeks of gestation. Prenatal counselling is increasingly offered to parents with affected fetuses, but it is difficult to counsel parents if there is a chance that the fetus may not have talipes. Our study correlates the prenatal ultrasound findings of 14 infants diagnosed as having unilateral or bilateral talipes during their routine 20-week ultrasound scan with their clinical findings at birth and the treatment received. No feet diagnosed as talipes on the ultrasound scan were completely normal at birth and therefore there were no true false-positive results. One foot graded as normal at 20 weeks was found to have a mild grade-1 talipes at birth, but did not require treatment other than simple stretches. A total of 32% of feet required no treatment and so could be considered functional false-positive results on the scan. Serial casting was required by 13% of feet and surgical treatment by 55%. The severity of the talipes is difficult to establish before birth. A number of patients are likely to need surgical treatment, but a proportion will have talipes so mildly that no treatment will be required. In counselling parents at 20 weeks, orthopaedic surgeons need to know whether or not there is a small chance that the ultrasound diagnosis could be wrong and also that the talipes may be so mild that the foot will not require treatment.