The use of genomic assays reduces rates of chemotherapy: a single-institution experience.

INTRODUCTION: The National Institute for Clinical Excellence recommends the use of tumour profiling tests to guide adjuvant chemotherapy in breast cancer. The Oncotype DX™ score (Genomic Health) has superseded more traditional tools such as PREDICT in appropriate patients (ER + ve, HER2-ve, lymph node negative and with a Nottingham Prognostic Index [NPI] ≥ 3.4). The aim of this study was to see whether the introduction of Oncotype DX within our institution resulted in an overall reduction in rates of chemotherapy. METHOD: Data was collected retrospectively using the Somerset Cancer Register, Pathology department databases and the institution's own online medical records system. Two groups were compared: (1) pre-oncotype (Jan 2012-Dec 2014) and (2) post-oncotype (Jan 2016-July 2018). RESULTS: During the pre-oncotype period, 28/82 (34%) patients who would have been eligible for testing (patients who were ER + ve, HER2-ve, and a NPI ≥ 3.4) received chemotherapy compared to 34/135 (25%) who were sent for oncotype during the second study period (p = 0.157). For grade 3 cancers, and those aged under 50, the results were more marked: grade 3 pre-oncotype 23/43 (53%), post-oncotype 29/76 (38%) (p = 0.101), aged under 50 pre-oncotype 8/15 (53%), post-oncotype 10/31 (32%) (p = 0.197). CONCLUSION: Within our institution, overall rates of chemotherapy have reduced since the introduction of Oncotype DX with the results more marked in subgroups of traditional indicators of tumour aggression. As genomic assays provide a more accurate prediction of the benefit of chemotherapy, its overall reduction has potential cost saving implications as well as reducing risk in patients who will derive little benefit.

Does 'Prison Napalm' work? Measuring the cooling temperature of sugar solution burns in a porcine model.

Non-accidental scalds sustained with sugar solution are potentially devastating and often associated with assaults within prisons where they are commonly known as 'Napalm' attacks. However, little is known about the mechanism behind such injuries. Proposed explanations have included a higher initial temperature, increased viscosity compared to water and lower emissivity, although these have yet to be demonstrated in any experimental model. We therefore set out to measure the post-exposure cooling temperature of the dermis after exposure to different concentrations of boiled sugar solution in a dead porcine model. Dead pork belly tissue was pre-heated to human body temperature (36.3-38.4 °C). Five solutions with different concentrations of sugar (0, 250, 500, 1000 and 2000 g/L) were heated to boiling point using standard commercially available kettles and then poured directly onto the tissue. Intradermal temperatures of the dermis were measured at one-minute intervals for a duration of 10 min. At one-minute after exposure, average intradermal porcine temperatures were 46.7 °C, 47.9 °C, 48.9 °C, 50.8 °C and 51.7 °C respectively for increasing concentrations of sugar solution. The rate of cooling was similar in all solutions with an average loss of 1.5 °C per minute. Using a generalised mixed model accounting for concentration and time period, it was identified that increasing sugar concentration resulted in statistically higher temperatures of burn (p = 0.006). Our report finds that higher concentrations of boiled sugar solution caused a higher initial temperature of burn but did not influence cooling rates. This suggests that 'Prison Napalm' attacks will indeed cause more severe burns than those utilising plain water, but not for all the widely believed reasons. We therefore recommend that access to kettles in prison cells should be limited, but where such access is deemed a right, consideration should be given to temperature restricted devices, as is the case in other countries.

Wound healing: what is the NICE guidance from the UK?

Alteration of wound healing increases the risk of a patient's morbidity and mortality. This can lead to scarring, infection, malignant transformation and a reduction in quality of life. Management of wounds costs the UK an estimated £5.3 billion annually which is paid for by the state, with further financial burden due to health related productivity loss. Wound care is managed by a broad spectrum of different health professionals leading to different standards of care. For example, only 16% of lower leg wounds have either an ankle-brachial pressure index measurement or Doppler scan. Due to this variation in wound care, we have summarised all available NICE guidelines and guidance up to February 2021 on the topic of wound healing listed in the National Institute for Health and Care Excellence (NICE) archives. The goal is to provide an easy to access summary of wound care interventions. Our search provided us with 18 technology appraisals related to wound healing which have been summarised.

Operative management of cholecystogastric fistula: case report and literature review.

We present a patient who was managed surgically for cholecystogastric fistula. The patient was presented with nonspecific symptoms (upper abdominal pain, belching) and, after being investigated, was proceeded for laparoscopic cholecystectomy for gallbladder stones. Unexpectedly, intraoperative, she was found to have cholecystogastric fistula, which was operated with open single-stage approach. We highlight the incidence of these cases, the difficult preoperative clinical presentation and possible diagnostic imaging; explain further about the different surgical approaches to manage these cases and finally review the literature regarding the presentation and the management of bilioenteric fistulas.

The value of a bariatric specific chart to initiate resuscitation of adult bariatric burns.

INTRODUCTION: The prevalence of obese adults is rising across the world with a tripling of rates since 1975. The resuscitation of large burns in obese patients brings unique challenges leading some to advocate the use of a bariatric specific burn chart. AIMS: We sought to determine whether bariatric burn specific charts can better estimate burn percentage to prevent under resuscitation. We also reviewed the impact of obesity upon the length of hospital stay, morbidity and mortality at our institution. METHODS: A retrospective case note review, of patients identified from the prospective International Burns Injury Database (iBID), was undertaken of patients' ≥18 years of age with burns ≥15% of their total body surface area. RESULTS: There were 79 overweight and 53 bariatric patients from a total of 232 patients identified. There was no statistical difference in burn percentage or fluid input estimation between the Lund & Browder and Neaman charts. Complications were seen in 51% of the normal weight patients. Obese patients had a similar incidence of death (24%) compared to the normal weight group (26%). The class I obese had the lowest complication rate at 28% and lowest mortality rate at 11%. CONCLUSIONS: Bariatric specific charts did not demonstrate any benefits in optimising bariatric resuscitation. There appears to be a 'physiological benefit' in the class I obese who sustained burns undergoing resuscitation.

The Bacteriological Profile of Burn Wound Infections at a Tertiary Burns Center in Nepal.

In Nepal, burn is the third most common injury after falls and road traffic accidents. Infection is the leading cause of mortality in burn injury. A profile exploring predominant flora and antimicrobial sensitivity is important to facilitate treatment ahead of microbiology results and to aid prevention of multidrug-resistant organisms. The aim of this study was to document epidemiological and bacteriological data of burn wound infections at a tertiary level burns center in Nepal. Samples were collected from January 2017 to May 2017, over a period of 5 months. Patient notes were referred to and information regarding baseline characteristics and burn wound infection data was collected. A total of 76 patients were included in the study during the 5-month period, which resulted in 113 samples being included for review. Females were injured most with burns 70% (n = 53) compared with males 30% (n = 23). Only 6 (8%) of 77 patients lived locally in Kathmandu. The average distance traveled by patients was 233 km (median 208, range 0-765, SD 181). Average TBSA% of burn was 22% (median 20, range 3-50, SD 12). Gram-negative organisms predominated, with Acinetobacter spp. in 42 cases (55%), Pseudomonas aeruginosa in 26 cases (34%), and Enterobacter spp. in 16 cases (21%). Colistin, polymyxin B, and tigecycline were found to be most sensitive covering 108, 98, and 94 organisms. Gram-negative bacteria colonized the majority of burn wounds. Colistin, polymyxin B, and tigecycline were the most sensitive to gram-negative bacteria. Gram-positive Staphylococcus aureus was sensitive most to vancomycin and tigecycline.

Validated Outcomes in the Grafting of Autologous Fat to the Breast: The VOGUE Study. Development of a Core Outcome Set for Research and Audit.

BACKGROUND: Autologous fat grafting is an important part of the reconstructive surgeon's toolbox when treating women affected by breast cancer and subsequent tumor extirpation. The debate over safety and efficacy of autologous fat grafting continues within the literature. However, work performed by the authors' group has shown significant heterogeneity in outcome reporting. Core outcome sets have been shown to reduce heterogeneity in outcome reporting. The authors' goal was to develop a core outcome set for autologous fat grafting in breast reconstruction. METHODS: The authors published their protocol a priori. A Delphi consensus exercise among key stakeholders was conducted using a list of outcomes generated from their previous work. These outcomes were divided into six domains: oncologic, clinical, aesthetic and functional, patient-reported, process, and radiologic. RESULTS: In the first round, 55 of 78 participants (71 percent) completed the Delphi consensus exercise. Consensus was reached on nine of the 13 outcomes. The clarity of the results and lack of additional suggested outcomes deemed further rounds to be unnecessary. CONCLUSIONS: The VOGUE Study has led to the development of a much-needed core outcome set in the active research front and clinical area of autologous fat grafting. The authors hope that clinicians will use this core outcome set to audit their practice, and that researchers will implement these outcomes in their study design and reporting of autologous fat grafting outcomes. The authors encourage journals and surgical societies to endorse and encourage use of this core outcome set to help refine the scientific quality of the debate, the discourse, and the literature. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Safe burn excision prior to military repatriation: an achievable goal?

Burn excision is the gold standard treatment for full thickness and some deep partial thickness burns. Early burn excision (24-96 hours) has been shown to improve patient outcomes. However, in the military setting, transporting the patient to a centre which can provide this procedure can be delayed. Especially as control of airspace in the future may be hampered due to the political landscape. For this reason, focus on how to achieve safer burn excision prior to repatriation should be addressed. This paper considers the barriers to early burn excision in the military setting and offers potential solutions for the future.

Negative Pressure Wound Therapy to the Dura.

Negative-pressure wound therapy is historically contraindicated in patients with osteomyelitis or exposed dura. The authors present a case of a complex reconstruction of an infected full thickness scalp burn, where negative-pressure wound therapy was successfully used over the dura.

Evaluating the Functional Results and Complications of Autograft vs Allograft Use for Reconstruction of the Anterior Cruciate Ligament: A Systematic Review.

The aim of our review is to identify the reconstruction technique that has a superior functional outcome and decreased number of complications for the anterior cruciate ligament (ACL). We have divided our review into 2 sections. Our primary question evaluates the functional results and complications of autografts compared to allografts for ACL reconstruction. Our subsidiary question evaluates the functional results and complications of bone-patellar tendon-bone (BPTB) autografts compared to hamstring tendon autografts. We conducted a systematic review (SR) based on high quality evidence provided by Cochrane, PubMed and National Health Service evidence searches for papers comparing different ACL reconstruction techniques. Results from 2 primary studies, 1 SR and 1 meta-analysis showed no significant statistical difference when comparing clinical outcomes such as pain, range of motion, laxity, International Knee Documentation Committee score, single assessment numerical evaluation score, Tegner activity score and patient reported satisfaction with regards to autografts vs allografts. Allografts had worse outcomes for postoperative tibial tunnelling and graft failure. Results of 3 SRs showed statistically significant differences in incidence of anterior knee pain, kneeling pain and knee stability, which were all found to be greater amongst those who had received a BPTB autograft. Knee extension was significantly reduced in patients with BPTB grafts when compared to patients with Hamstring tendon autografts. However, with regards to return to prior levels of activity, there was no statistically significant difference between those that received BPTB autografts and those that received Hamstring tendon autografts. Autograft reconstruction of the ACL was shown to provide better postoperative outcomes when compared to allograft reconstruction, although the difference was not statistically significant. When researching different autograft options BPTB autografts were associated with greater pain but also greater stability of the knee joint postoperatively when compared to hamstring tendon autografts.