Computer-aided surgical planning in the treatment of soft-tissue sarcoma.

INTRODUCTION: Soft-tissue sarcoma resections are often highly complex procedures that demand meticulous pre-operative planning in order to maximise the potential for complete excision with clear margins, while preserving vital neurovascular structures and muscle groups. SUBJECTS AND METHODS: We present a computer-aided model for surgical planning using Microsoft Powerpoint as a tool for cross referencing magnetic resonance images and normal anatomical diagrams. RESULTS: Using this system the operator follows a sequence of pre-planned steps, minimising intra-operative decision making and unexpected adverse events. Four case studies are discussed. CONCLUSIONS: The visual plan optimises the potential to meet surgical and oncological goals, and serves as an excellent adjunct to the operation note for documentation of the procedure.

Extranodal lymphomas presenting as soft tissue sarcomas to a sarcoma service over a two-year period.

Non-Hodgkin's lymphoma usually presents with lymphadenopathy at multiple sites but can also involve any part of the musculoskeletal system. Occasionally the presentation is with a soft tissue mass. The presentation of large, superficial lymphomatous masses is similar both clinically and radiologically to that of soft tissue sarcomas. The six cases of lymphoma presenting to the Exeter Sarcoma Service as suspected soft tissue sarcomas, over a two-year period (2002-2004), are presented. We describe the clinical and imaging characteristics of these tumours and their subsequent management. Our cases showed variability in presentation. Only one of the six cases presented with pain and one with tenderness. Four of the cases had no lymphadenopathy and the other two had lymphadenopathy restricted to one nodal basin. Overlying soft tissue swelling occurred in four cases and in distal limb swelling beyond the mass in one case. Radiologically, lymphomas are known to be likely to exhibit confluent lymphadenopathy that is rare in patients with soft tissue sarcoma. Confluent lymphadenopathy was demonstrated in only one case of this series of patients. It is thought that lymphomas infiltrate across anatomical fascial planes more readily than sarcomas and in four of our six cases this feature was present. Clinical history, examination and MRI are insufficient to differentiate between soft tissue sarcoma and lymphoma and the importance of obtaining a pathological diagnosis prior to surgery is clear. It is crucial to differentiate lymphoma from sarcoma in order to avoid unnecessary excisional procedures in lymphoma patients.

Biphasic solitary fibrous tumour: a report of two cases with epithelioid features.

We present two cases of solitary fibrous tumour (SFT) showing biphasic morphology with a spectrum of malignant epithelioid components. Slides prepared from formalin-fixed and paraffin-embedded tissue from both cases were stained with haematoxylin and eosin and by immunohistochemistry. Interphase fluorescent in situ hybridisation studies were performed in both cases using paraffin-embedded tissue to look for the t(X;18) translocation, thereby to exclude synovial sarcoma. Both cases showed biphasic morphology with some areas having typical benign spindled SFT morphology (including CD34 expression) and other areas having a malignant epithelioid appearance. In one of the cases, the epithelioid area, which was well circumscribed and showed packeting of cell groups, demonstrated expression of cytokeratin and epithelial cadherin but not of CD34. In the second case, the immunophenotype of the epithelioid component was similar to that of the benign SFT component. These findings suggest that epithelioid change in SFT shows a range of differentiation at one end, similar to that of a standard SFT, and at the other end, possibly acquiring epithelial characteristics.

An association of multiple well differentiated liposarcomas, lipomatous tissue and hereditary retinoblastoma.

Well differentiated liposarcoma (atypical lipomatous tumour) is a low grade tumour, with no metastatic potential unless dedifferentiation supervenes. When superficial, it recurs locally only occasionally after marginal excision. We present a patient in whom bilateral childhood retinoblastoma was followed by later development of massive confluent areas of low grade liposarcoma and lipomatous tissue affecting the upper extremities and trunk. We discuss the role of mutations in the retinoblastoma gene (RB1) in linking these conditions and demonstrate the surgical management of an extremely unusual and challenging case.

Screening for lung cancer: a systematic review and meta-analysis of controlled trials.

BACKGROUND: Lung cancer is a substantial public health problem in western countries. Previous studies have examined different screening strategies for lung cancer but there have been no published systematic reviews. METHODS: A systematic review of controlled trials was conducted to determine whether screening for lung cancer using regular sputum examinations or chest radiography or computed tomography (CT) reduces lung cancer mortality. The primary outcome was lung cancer mortality; secondary outcomes were lung cancer survival and all cause mortality. RESULTS: One non-randomised controlled trial and six randomised controlled trials with a total of 245 610 subjects were included in the review. In all studies the control group received some type of screening. More frequent screening with chest radiography was associated with an 11% relative increase in mortality from lung cancer compared with less frequent screening (RR 1.11, 95% CI 1.00 to 1.23). A non-statistically significant trend to reduced mortality from lung cancer was observed when screening with chest radiography and sputum cytological examination was compared with chest radiography alone (RR 0.88, 95% CI 0.74 to 1.03). Several of the included studies had potential methodological weaknesses. Controlled studies of spiral CT scanning have not been reported. CONCLUSIONS: The current evidence does not support screening for lung cancer with chest radiography or sputum cytological examination. Frequent chest radiography might be harmful. Further methodologically rigorous trials are required before any new screening methods are introduced into clinical practice.

Use of colour duplex Doppler imaging in the postoperative assessment of buried free flaps.

The postoperative assessment of free flaps is essential to identify and act on signs of incipient flap failure. Where the flap is completely buried, this becomes almost impossible unless part of the flap is exteriorised or an overlying skin window is used. Alternatively, complicated and often impractical monitoring devices have been advocated, but these have failed to gain widespread acceptance. A simpler solution to this problem has been evaluated in a series of patients using colour duplex Doppler imaging. This re-appraisal of a previously reported technique has been facilitated by updated technology in diagnostic radiology. Duplex Doppler imaging was confirmed as an accurate, non-invasive, and inexpensive tool for the postoperative measurement of blood flow within the pedicles of five buried free flaps in four patients undergoing surgery in our unit.

Validity evidence for using a general critical thinking test to measure nursing students' critical thinking.

This study examined validity evidence for using a general test of critical-thinking skills and dispositions to measure nursing students' critical-thinking abilities. Content evidence indicated strong support for the theoretical framework underlying the test but less support for the way in which the critical-thinking constructs were specifically measured. Scores related to critical-thinking skills demonstrated significant but low correlations with grade point averages, were moderately correlated with SAT scores, and were uncorrelated with scores related to critical-thinking dispositions. The evidence suggests that nursing programs may need to reconsider how critical thinking should be measured and evaluated.

Healing at skin graft donor sites dressed with chitosan.

Chitosan is a derivative of chitin, extracted from the exoskeleton of lobsters, crabs and shrimps. As a semi-permeable biological dressing, it maintains a sterile wound exudate beneath a dry scab, preventing dehydration and contamination of the wound to optimise conditions for healing. In this study, evaluation of healing at split skin graft donor sites, dressed half with chitosan and half with a conventional dressing, showed that chitosan facilitated rapid wound re-epithelialisation and the regeneration of nerves within a vascular dermis. In addition, digital colour separation analysis of donor site scars demonstrated an earlier return to normal skin colour at chitosan-treated areas.

Can a picture really paint a thousand words?

Plastic surgeons require a three-dimensional appreciation of form and function in order to meet reconstructive challenges. The popular perception that plastic surgeons must be artistic was tested in an observational study of sketch illustrations in plastic surgery case notes. Only in the trunk and breast category of illustrations could career plastic surgeons demonstrate superior artistic skill to non-career plastic surgeons and there was little correlation between the artistic merit of a diagram and the likelihood of its meaning being understood by an independent observer. Simple but accurate outline sketches are as capable of leading an observer to the correct diagnosis as complex works of art, while illustrations with low diagnostic scores are not only misleading but may also have medico-legal implications.

Unravelling the secrets of foetal wound healing: an insight into fracture repair in the mouse foetus and perspectives for clinical application.

This study was designed to investigate the nature of mammalian foetal fracture healing in utero. A compound 'pinch' fracture was created in the foetal mouse ulna at the end of the second trimester, prior to mineralisation, and healing observed in whole mount limbs and in histological section. Cartilaginous ends gained initial contact within a perichondrial sleeve by 24 h. Bony union was achieved within 48 h by cartilage remodelling during the phase of primary endochondral ossification in the limb, a process to which adult fracture healing aspires. The molecular response to wounding was investigated using a whole mount in situ hybridisation technique and antisense mRNA probes to three target genes (BMP-2, BMP-4 and GDF-5). These experiments failed to identify altered expression in wounded limbs compared with controls.

Neural tube defects in Victoria, Australia: potential contributing factors and public health implications.

OBJECTIVES: To measure population prevalence and determine potential predictors of neural tube defects. METHOD: Analysis of all births reported to a mandated collection of perinatal data, and terminations prior to 20 weeks' gestation that have been reported to a data collection of birth defects in Victoria from 1983 to 1997. Prevalence at birth and risk ratios of infant and maternal characteristics associated with neural tube defects were calculated. RESULTS: Prevalence of spina bifida has remained steady for 15 years and was 8.8/10,000 in 1997. Anencephaly increased to 7.9/10,000 in 1997. After exclusion of pregnancy terminations, the 1997 birth prevalence was 4.5/10,000 for spina bifida and 2.4/10,000 for anencephaly. Neural tube defects are identified in 1 in 1600 fetuses, the risk being significantly higher for epileptic women (Adjusted Odds Ratio (AOR) = 3.70, 95% CI 2.25-6.07), multiple births (AOR = 4.56, 95% CI 3.46-6.02), teenage mothers (AOR = 1.47, 95% CI 1.09-2.00) compared with those aged 25-29, and women with three or more previous pregnancies (AOR = 1.40, 95% CI 1.10-1.78). The risk was lower for women of East Asian (AOR = 0.70, 95% CI 0.49-1.00) and Middle Eastern origin (AOR = 0.60, 95% CI 0.35-1.02) and these differences were approaching statistical significance. CONCLUSION: Total prevalence of neural tube defects did not decline up to 1997. IMPLICATIONS: It is unlikely that targeting 'at risk' groups identified in this study would make a difference to neural tube defect incidence. However, consideration could be given to identifying larger 'at risk' groups such as those with homocysteine metabolism defects.

Reducing non-attendance at outpatient clinics.

Outpatient non-attendance is a common source of inefficiency in a health service, wasting time and resources and potentially lengthening waiting lists. A prospective audit of plastic surgery outpatient clinics was conducted during the six months from January to June 1997, to determine the clinical and demographic profile of non-attenders. Of 6095 appointments 16% were not kept. Using the demographic information, we changed our follow-up guidelines to reflect risk factors for multiple non-attendances, and a self-referral clinic was introduced to replace routine follow-up for high risk non-attenders. After these changes, a second audit in the same six months of 1998 revealed a non-attendance rate of 11%--i.e. 30% lower than before. Many follow-up appointments are sent inappropriately to patients who do not want further attention. This study, indicating how risk factor analysis can identify a group of patients who are unlikely to attend again after one missed appointment, may be a useful model for the reduction of outpatient non-attendance in other specialties.

Evolution of the Emergency Management of Severe Burns (EMSB) course in the UK.

The principle of the 'golden hour' is now well established and forms the basis of a growing number of instructional courses teaching a systematic approach to the management of major trauma. In April 1997, the EMSB course, developed by the Australian and New Zealand Burn Association, was adopted by the British Burn Association to meet the needs of health professionals dealing with major burn injuries in this country. The experience of the first 13 courses following the introduction of EMSB is discussed and the course is recommended as a requirement for the training of UK plastic surgeons and plastic surgery nurses.

The Hyphecan cap: a biological fingertip dressing.

An occlusive biological dressing, the Hyphecan cap, was evaluated in the management of full-thickness pulp defects of fingers and thumb in 20 consecutive patients. The cap was applied directly to the tip of the injured finger and allowed to separate gradually over the course of several weeks as new skin regenerated. This approach proved simple and effective in achieving a good functional and cosmetic result within a relatively short time, and eliminated the pain and discomfort associated with conventional dressing changes. We recommend the use of this dressing material in the Accident and Emergency department for the out-patient management of de-epithelializing fingertip injuries in both children and adults.