Comparison of incidence of medial meniscal injury in small dogs (≤15 kg) and medium-to-large dogs (>15 kg) with naturally occurring cranial cruciate ligament disease undergoing tibial plateau levelling osteotomy: 580 stifles (2015 - 2019).

OBJECTIVES: To investigate whether a difference exists in incidence of medial meniscal tears between small (≤15 kg) and medium-to-large (>15 kg) dogs with naturally occurring cranial cruciate ligament disease. MATERIALS AND METHODS: Records were retrospectively reviewed to identify the incidence of medial meniscal tears in dogs undergoing tibial plateau levelling osteotomy. Degree of cruciate insufficiency, method of identification (arthroscopy or arthrotomy), tibial plateau angle, weight and signalment were recorded. A two-proportion z-test with clustering adjustment was used to compare the meniscal tear rate between the two groups. Logistic regression analysis was used to investigate the effects of variables on medial meniscal tears. RESULTS: Seventy-six stifles in 67 small dogs and 504 stifles in 384 medium-to-large dogs were included. The rate of meniscal injury at index surgery was 38.2% in small dogs and 36.7% in medium-to-large dogs. The subsequent meniscal tear rate was 1.3% in small dogs and 8% in medium-to-large dogs. The difference in meniscal tear rate was not statistically significant at either index surgery or subsequently. Degree of cruciate ligament insufficiency and use of arthroscopy were significantly associated with medial meniscal tears at index surgery. No variables were significantly associated with subsequent medial meniscal tears. CLINICAL SIGNIFICANCE: No significant difference exists in medial meniscal tear rate between small and medium-to-large dogs either at index surgery or subsequently. The index of suspicion of concurrent medial meniscal tears should be higher in dogs with complete tear of the cranial cruciate ligament but a partial tear does not preclude meniscal pathology.

Fibroblastic Subtype has a Favourable Prognosis in Appendicular Osteosarcoma of Dogs.

Osteosarcoma (OS) is an aggressive malignant bone neoplasm that occurs mostly in the appendicular skeleton of dogs and people. OS is classified based on the presence of malignant stroma and the formation of extracellular matrix into osteoblastic, chondroblastic and fibroblastic forms. This study investigated the correlation between the three histological subtypes of canine OS and clinical outcome. Additionally, we examined whether there was any difference in the immunolabelling of desmin, S100 and neuron-specific enolase (NSE) between the three histological subtypes. Formalin-fixed and paraffin wax-embedded tissues from 87 dogs with primary OS were available for this study. The survival times were correlated with appendicular OS subtypes in dogs that were treated surgically, received adjuvant chemotherapy and had no pulmonary metastasis at the time of diagnosis. Dogs with an appendicular fibroblastic OS had significantly prolonged mean average survival times (546 ± 105 days) in comparison with dogs having appendicular osteoblastic (257 ± 48 days) or appendicular chondroblastic (170 ± 28 days) OS (P = 0.003, Log Rank). The results also revealed that the appendicular chondroblastic subtype is a significant indicator for poor prognosis in dogs compared with the fibroblastic or osteoblastic subtypes (P = 0.006, Cox regression). Moreover, the findings indicated that there was no significant correlation between the localization of desmin, NSE or S100 and histological subtypes. Importantly, dogs with appendicular fibroblastic OS were found to have a better prognosis when compared with dogs with other subtypes. This may suggest that histological subtypes of appendicular OS have diverse behaviour and could be used to categorize patients for risk-based assessment.

Identification of patients with cervical SCI suitable for early nerve transfer to achieve hand opening.

STUDY DESIGN: Retrospective audit. OBJECTIVES: The objective of this study was to identify the proportion of patients with cervical spinal cord injury who would potentially benefit from nerve transfer surgery to gain active hand opening, and to determine when a safe nerve transfer decision can be made. SETTING: Christchurch, New Zealand. METHODS: Case note review of the first 12 months following acute cervical spinal cord injury (2007-2012). Neurological assessment at 6 weeks, 12 weeks and 1 year following injury. RESULTS: Fifty-three patients had complete assessments and showed changes in the level of injury and severity of neurological injury between assessments. Forty-two percent of patients had motor complete C5-7 level injuries 12 weeks following injury and would benefit from consideration for nerve transfer to improve hand opening. Fewer (26%) would benefit 1 year following injury owing to a change in the neurological level of injury. CONCLUSIONS: Twelve-week neurological assessment identifies patients who may benefit from nerve transfer surgery. This enables referral for comprehensive upper limb assessment and reassessment of motor function to determine suitability for surgical intervention. Nerve transfer within the window of opportunity provides active hand opening for patients following cervical spinal cord injury.

Incidence of cutaneous squamous cell carcinoma in a New Zealand population of chronic lymphocytic leukaemia patients.

BACKGROUND: Chronic lymphocytic leukaemia (CLL) is associated with an increased incidence and aggressiveness of skin cancers, particularly cutaneous squamous cell carcinoma (cSCC), but little is known about cSCC incidence in Australasian CLL patients. AIM: In this retrospective study, we analysed the incidence of cSCC in patients seen at a tertiary hospital in New Zealand (NZ). METHODS: We retrospectively assessed the clinical history and histology data of CLL patients (n = 371) who presented to the Haematology Department, Christchurch Hospital, NZ during the period 1996-2015. Baseline characteristics, incidence of second cancers, treatment details and overall survival were analysed. RESULTS: During follow-up (median = 11.8 years), 221 second cancers were recorded in 88 patients. Of these cancers, 185 were cSCC, removed from 61 patients. In 56% of these patients, >1 cSCC was removed, and the majority of cSCC occurred following the treatment for CLL. The cumulative incidence of a first cSCC was 11% at 5 years, whereas the cumulative incidence of a subsequent cSCC was 88% at 5 years. The incidence of cSCC in male patients was threefold higher than that reported for the general NZ population. CONCLUSION: NZ CLL patients have a high incidence of cSCC relative to the levels observed in the general population, which are themselves among the highest in the world. The careful monitoring of CLL patients is warranted, particularly those who have a progressive disease or have had a first cSCC removed.

Treatment of ulcerated necrobiosis lipoidica with ovine forestomach matrix.

Necrobiosis lipoidica (NL) results from degradation of the collagen extracellular matrix; these recurring ulcerated lesions are an especially challenging condition to treat. Ovine forestomach matrix (OFM) is a decellularised extracellular matrix and was used to successfully close a pretibial ulcer resulting from NL. Complete closure of the wound was achieved in 22 weeks, after four applications of OFM. This suggests OFM may be considered for the treatment of these challenging wounds.

Salvage of failed prosthetic breast reconstructions by autologous conversion with free tissue transfers.

OBJECTIVE: Implant-based breast reconstructions are conceptually simple but prone to surgical revisions. Additional procedures often fail to address the problems associated with the reconstructive outcome, especially in patients who have received radiotherapy. However, conversion to free flaps may improve symptoms and aesthetic results. We reviewed our experience in the United Kingdom with autologous replacement of failed prosthetic reconstructions with the aims of documenting the indications for "tertiary" reconstructions and comparing our outcomes with those of other centers. METHODS: Patients undergoing salvage surgery for suboptimal prosthetic breast reconstructions between 2000 and 2012 were retrospectively reviewed for their original reconstructive operation, previous radiotherapy, indications for revision, corrective procedures undertaken, and final outcomes. RESULTS: Of 14 patients identified, 7 had delayed and 7 had immediate reconstructions. Twelve had received radiotherapy; 6 before the initial delayed prosthetic reconstructions and 6 after immediate reconstructions. Ten patients presented after undergoing previous revisions of their original reconstructions (average 1.6). Indications for autologous conversion were capsular contracture, persistent pain, and poor cosmetic outcomes (often in combination). Salvage comprised explantation, total capsulectomy, and abdominal free flap reconstruction using deep inferior epigastric artery flaps (9) and transverse rectus abdominis myocutaneous flaps (5). The average interval between initial reconstruction and salvage was 8 years (r = 1-14). All flap transfers were successful with satisfactory aesthetic outcomes (average 21 months follow-up). CONCLUSIONS: We recommend early salvage autologous conversion of implant-based reconstructions once initial prosthetic reconstructions become unsatisfactory, particularly in recipients of radiotherapy. Many of these patients may have been better served by initial autologous reconstruction; the challenge is to identify them prospectively.

Resource implications of bilateral autologous breast reconstruction--a single centre's seven year experience.

INTRODUCTION AND AIMS: Since the recent introduction of ''Payment by Results'' as part of NHS financial reforms, it has been noted that there is an imbalance between allocated Healthcare Resource Group tariffs and actual resource use for certain procedures. This study was undertaken to assess the impression that bilateral breast reconstruction using autologous flaps is under-funded. MATERIAL AND METHODS: Patients who underwent bilateral flap breast reconstruction following mastectomy between 2000 and 2006 at Addenbrooke's University Hospital were identified. Resource cost analysis for each patient was based on the following parameters: number of operating consultants, theatre running costs, and length of hospital stay. The estimated hospital costs were then compared to the national tariff for the Healthcare Resource Group ''Complex Breast Reconstruction using Flaps''. KEY RESULTS: Over the 7-year period 24 patients underwent bilateral flap breast reconstruction (7 paired latissimus dorsi and 17 paired abdominal flaps). The mean operative time was 9.4h (£4.5/min), the mean hospital stay was 10 days (£150/day) and ten patients required 2 consultants (£34/h) operating. The average total cost equated to £5 492. CONCLUSION: The allocated tariff of £4 053 is insufficient, even before the inclusion of hidden costs. Bilateral free flap breast reconstructions are grossly under-funded at present. With increasing financial pressures on NHS Trusts there may be a drive towards simpler operations, which receive proportionally greater remuneration.

Myocardial metastasis of cutaneous squamous cell carcinoma in a renal transplant recipient.

Myocardial metastasis from a cutaneous squamous cell carcinoma (SCC) is rare. Herein we have presented a case of metastasis from cutaneous SCC to the myocardium in a renal transplant recipient, which was confirmed by a cardiac fine-needle biopsy. Postmortem examination revealed disseminated metastatic disease involving myocardium, lungs, thyroid, skin, and peritoneum secondary to cutaneous SCC likely related to immunosuppression. At 46 years of age, he received a renal transplant for chronic renal failure caused by chronic glomerulonephritis. He started to develop multiple nonmelanoma skin cancers 4 years later. At least 23 invasive SCCs and 14 basal cell carcinomas were excised. His immunosuppressive regimen consisted of cyclosporine (150 mg), azathioprine (75 mg), and prednisone (10 mg daily), which was not modified despite multiple nonmelanoma skin cancers. Our case report further illustrates the potentially aggressive and fatal nature of cutaneous SCCs that can develop in organ transplant recipients. It argues for modification of the immunosuppressive regimen in such patients. The management of renal transplant patients with nonmelanoma skin cancers remains difficult and complex.

Peripheral neuropathy in Tangier disease.

Peripheral nerve morphometry was assessed in four patients with Tangier disease. Three patients with a relapsing and remitting multiple mononeuropathy had prominent peripheral nerve demyelination and remyelination with affected internodes clustered along particular nerve fibres. Putative lipid vacuoles were almost exclusively confined in this multifocal neuropathy syndrome to Remak cells. By contrast a fourth patient with a slowly progressive syringomyelia-like neuropathy had advanced peripheral nerve degeneration and a more global distribution of lipid vacuoles within peripheral nerve. A review of Tangier disease in the literature indicated the possibility of additional peripheral nerve syndromes. The clinical heterogeneity raises the possibility of different metabolic errors in Tangier disease or a common metabolic error subject to genetic influences. The results of this study indicate that normal serum cholesterol levels do not exclude a diagnosis of Tangier disease. It is therefore advisable to determine both high density lipoproteins and serum cholesterol levels in patients with undiagnosed multifocal neuropathy or syringomyelia-like syndromes.

Tangier disease with normal serum cholesterol.

Three patients with Tangier Disease (hypoalphalipoproteinaemia) from the same family are described. One shows the classically described lipid abnormalities of the disease, with a low serum cholesterol level, and almost absent high density lipoprotein (HDL). However, two of his siblings, although demonstrable as Tangier homozygotes, have serum cholesterol levels within the normal range. This anomaly has arisen because they are also heterozygous for familial combined hyperlipidaemia. The pattern of inheritance of the two disorders, Tangier Disease and combined hyperlipidaemia, appears to be unrelated.