Improved Survival in Male Melanoma Patients in the Era of Sentinel Node Biopsy.

BACKGROUND AND AIMS: Sentinel node biopsy is a standard method for nodal staging in patients with clinically localized cutaneous melanoma, but the survival advantage of sentinel node biopsy remains unsolved. The aim of this case-control study was to investigate the survival benefit of sentinel node biopsy. MATERIALS AND METHODS: A total of 305 prospective melanoma patients undergoing sentinel node biopsy were compared with 616 retrospective control patients with clinically localized melanoma whom have not undergone sentinel node biopsy. Survival differences were calculated with the median follow-up time of 71 months in sentinel node biopsy patients and 74 months in control patients. Analyses were calculated overall and separately in males and females. RESULTS: Overall, there were no differences in relapse-free survival or cancer-specific survival between sentinel node biopsy patients and control patients. Male sentinel node biopsy patients had significantly higher relapse-free survival ( P = 0.021) and cancer-specific survival ( P = 0.024) than control patients. In females, no differences were found. Cancer-specific survival rates at 5 years were 87.8% in sentinel node biopsy patients and 85.2% in controls overall with 88.3% in male sentinel node biopsy patients and 80.6% in male controls and 87.3% in female sentinel node biopsy patients and 89.8% in female controls. CONCLUSION: Sentinel node biopsy did not improve survival in melanoma patients overall. While females had no differences in survival, males had significantly improved relapse-free survival and cancer-specific survival following sentinel node biopsy.

Mental health nursing students' experiences of stress during training: a thematic analysis of qualitative interviews.

ACCESSIBLE SUMMARY: What is known on the subject? Stress can impact students on mental health nurse training. This can have implications at the individual level (e.g. their own mental health) and at the level of the organization (e.g. sickness absence and attrition). What this paper adds to existing knowledge? We interviewed 12 mental health nursing students regarding the stress they experienced during training. Participants described how the academic demands can at times be unbearable during clinical placements. There were also issues with 'being a student' on some placements, with participants describing negative attitudes towards them from staff. The younger participants reported feeling overwhelmed on their initial placements and described some of the main challenges of mental health work for them. Raising concerns about the quality of care on wards was also described as particularly challenging for the students. What are the implications for practice? This paper can be useful to help training providers support mental health nursing students. Recommendations include reducing academic demands during clinical placements and extending and promoting existing support services beyond normal 9 am-5 pm working hours, even if these services are limited. Younger students could be better supported by being allocated to the more well-resourced placements in the early stages of their training. Raising awareness among staff of the tasks students can and cannot perform can help improve staff/student relations. Finally, students should be educated about the issues around raising concerns on placements to help the government's drive for a more open and transparent National Health Service (NHS). INTRODUCTION: Previous studies investigating stress in nursing students focus on general nursing students or adopt quantitative measures. PURPOSE OF STUDY: A qualitative study focusing specifically on mental health nursing students is required. METHOD: One-to-one interviews were carried out with mental health nursing students (n = 12). Data were thematically analysed. RESULTS: Participants reported unreasonable demands during clinical blocks, and described how control/support is lowest on placements with staff shortages. Negative attitudes towards students from staff and related issues were also discussed. Younger participants described struggling with mental health work during the early stages of training. DISCUSSION: Training providers should strive to provide adequate support to students to help them manage stress during training. Implications for practice Academic demands should be reasonable during clinical blocks and support services outside normal working hours should be available for students, even if these are limited in scope. Greater consideration to the allocation of placements for younger students in the mental health branch could be helpful. Furthermore, staff on placements should be aware of the tasks students can and cannot perform, to help improve staff/student relations. Educating students on the issues of raising concerns can help the government's drive for a more open and transparent National Health Service (NHS).

Efficient infection of tumor endothelial cells by a capsid-modified adenovirus.

Targeted antiangiogenic gene therapy is an attractive approach to treat metastatic cancer. However, the relative paucity of the receptors of the commonly used adenovirus serotype 5 in endothelial cells as compared with liver cells undermines the use of this vector for targeting the endothelial cells in tumors. To overcome this problem, we analyzed the ability of a hybrid Ad5/35 virus, where the serotype 5 fiber has been replaced with the fiber from serotype 35, to target tumor vasculature. Infection of human umbilical vein endothelial cells (HUVECs) with Ad5/35 at MOI 120 infected 100% of cells. In contrast, infection with Ad5 at the same MOI infected only 10% HUVECs. Ad5/35 was even more effective in transducing human aortic endothelial cells (HAECs), as infection with Ad5/35 at MOI 3.6 was sufficient to transduce 95% of cells. Gene expression analyses demonstrated that infection of HUVECs and HAECs with Ad5/35 resulted in between 1 and 3 orders of magnitude higher gene expression than infection with Ad5. Furthermore, various liver-derived cells were less infectable with Ad5/35 than Ad5, indicating a favorable toxicity profile for this virus. In a rat colon carcinoma tumor model, Ad5 was located mainly in the liver parenchyma after hepatic artery administration. In contrast, Ad5/35 was found only in the angiogenesis-rich border region of the tumor. Double immunostaining revealed that Ad5/35 colocalized with CD31 and Flk-1 positive endothelial cells. These results indicate that Ad5/35 may be useful in anticancer strategies targeting tumor endothelial cells.

Demand for plastic surgical operations after primary breast cancer surgery.

BACKGROUND AND AIMS: The aim of this study is to evaluate the demand for plastic operations after primary breast cancer surgery. In addition, this study aims to increase knowledge on factors affecting the wish of women for breast reconstruction. MATERIAL AND METHODS: A questionnaire was sent to some 111 patients who had undergone either mastectomy or breast conserving surgery. The response rate was 76%. The questionnaire consisted of 20 structured questions. The data was analysed statistically using the t test and the chi-square test. RESULTS: 28% of the mastectomized patients wanted a breast reconstruction. Factors found to affect the patient's wish for reconstruction were age (p < 0.001) and whether the patient had received radio- (p < 0.05) or chemotherapy (p < 0.05). A difference was found between the mastectomy group and the breast conserving surgery group as to satisfaction in the general (p < 0.05) and the cosmetic (p < 0.05) outcome of the surgery, as well as patient's expectations regarding the outcome (p < 0.01). CONCLUSIONS: Rather fewer mastectomized patients wanted a reconstruction. The proportion, however, grew significantly larger in the younger age groups. This study also shows that receiving radio- or chemotherapy seems to predict a woman's choice against a reconstruction. Patients who receive radio- or chemotherapy may consider their illness more severe and life-threatening than those not receiving such treatments.

Gene transfer as a tool to induce therapeutic vascular growth in plastic surgery.

Sufficient tissue blood perfusion is critical for wound healing and for reconstructions in plastic surgery. There is considerable interest in the use of therapeutic angiogenesis to improve survival of ischemic flaps and to improve wound healing. Several growth factors have been tested in experimental flap models. Clinically, angiogenic therapy has been extensively studied in cardiovascular ischemic diseases and several clinical studies are ongoing in human patients. Results from these cardiovascular trials will benefit the planning of clinical trials in the field of plastic surgery. Furthermore, the development of strategies for local and controlled induction of lymphangiogenesis will hopefully improve the treatment of edema.

Microvascular temporomandibular joint and mandibular ramus reconstruction in hemifacial microsomia.

Microvascular temporomandibular joint (TMJ) and mandibular ramus reconstruction was performed in a 4-year-old hemifacial microsomia patient with multiple craniofacial and extracranial anomalies (Goldenhar syndrome). Her major craniofacial anomalies included bilateral cleft lip and palate, left macrostomia, left microtia, and complete absence of the left vertical mandibular ramus and TMJ. Most of her other anomalies had been corrected surgically before TMJ and vertical mandibular ramus reconstruction, which was accomplished with a metatarsophalangeal (MTP) joint transplantation. The MTP joint was placed in hyperextended position in the skull base inserting the proximal phalanx under the remnants of the zygomatic arch and replacing the vertical mandibular ramus with the metatarsal bone. Straight mouth opening, correction of the midline, and normalized lateral movements of the mandible were accomplished. The graft includes two epiphyseal plates, which should maintain growth of the transplant. During the follow-up period (16 months) the achieved results have been maintained without adverse effects. The present technique appears to be a promising alternative in the treatment of children with Pruzansky type 3 hemifacial microsomia.

Free flap reconstructions in the management of oral and pharyngeal cancer.

Fifty patients who had undergone microvascular free flap reconstruction of the oral cavity or pharynx for malignancy between 1989 and 1995 were retrospectively analysed to find factors predicting postoperative complications and outcomes. The mean follow-up time was 2.6 years. More than half (26/50) of the patients had a stage IV malignancy and 10 patients had a recurrent tumour. The overall flap success rate, with 2 flap losses, was 96%. Postoperative medical complications occurred in 29/50 (58%) cases. The recipient site of 10/50 (20%) flaps required re-exploration. Mortality was 2%, with 1 death occurring within 30 days. The mean survival rate after the microvascular operation was 1.6 years, and the 3- and 5-year survival rates were 42% and 23%, respectively. Patients with an oropharyngeal tumour seemed to have the best prognosis and those with a hypopharyngeal tumour the poorest. Men had a threefold greater risk of dying within < 1 year postoperatively compared with women. Tumour stage was the strongest attribute influencing survival. The risk of death after the microvascular procedure increased 2.8-fold when the stage advanced from II to III or from II to IV. None of the tested variables alone could predict complications.

Close-range shotgun and rifle injuries to the face.

The treatment of extensive shotgun and rifle injuries to the face is extremely difficult and demands experience in microsurgery and craniofacial surgery. Early aggressive surgery with immediate bone and soft tissue reconstruction is recommended for the management of extensive facial gunshot wounds. Experience has shown that early three-dimensional bone replacement can be achieved with bone grafts in the midfacial area if the bone grafts are covered with well-vascularized tissues. Large midfacial defects can be reconstructed safely and effectively with free-tissue transfers, including bone. In the acute stage, microvascular muscle flaps are preferred because of their good vascularity and good filling capacity. These flaps are able to cover the anterior cranial fossa. When vascularized bone is needed, the authors' first choice is a latissimus dorsi flap with scapular bone. Patients treated with an early and aggressive surgical strategy develop fewer problems in form of infection, contraction, scarring, and require fewer secondary corrections. Successful primary treatment allows the surgeon to use multiple modalities, including tissue expansion, free-tissue transfers, and local flaps in a noninfected environment. The treatment is rewarding, and the results are surprisingly good. It is extremely unusual for patients with self-inflicted gunshot injuries to reattempt suicide.

Evaluation of blood flow in free microvascular flaps.

Free flap surgery is routine today, yet little is known of its pathophysiology. In this study, the authors evaluated the hemodynamics in different types of free microvascular flaps, by measuring intraoperative transit-time flow. Eighty-six free transplants--21 free TRAM flaps for breast reconstruction, 18 radial forearm flaps for head and neck reconstructions, and 47 muscle flaps for head and neck, trunk and lower extremity reconstructions--were studied. Donor artery flow was highest in the radial artery (mean: 57.5 +/- 50 (SD) ml/min) but dropped (p < 0.001) to one tenth (6.1 +/- 2 ml/min) after anastomosis. The flow was lowest (4.9 +/- 3 ml/min) in the recipient artery of the TRAM flap but, after anastomosis, increased significantly (13.7 +/- 5 ml/min) to the level of the flow in the donor artery. The donor-artery flow in muscle flaps had a mean of 15.9 +/- 11 ml/min, and it significantly increased after anastomosing (23.9 +/- 12 ml/min). Weight-related intake of blood was highest in the radial forearm flap (18.5 +/- 6 ml/ min/100g) and lowest in the TRAM flap (2.5 +/- 1 ml/min/100g). The study showed that blood flow through a free microvascular flap does not depend on recipient artery flow. Even low-flow arteries can be used as recipients, because the flow increases according to free-flap requirements. The blood flow through a free microvascular flap depends on the specific tissue components of the flap.

Free microvascular tram flaps: report of 185 breast reconstructions.

The free TRAM flap is the most elegant technique currently available for breast reconstruction. We describe here the surgical technique, the complications, the possible effects of the prognosis of the breast cancer, and the learning curve of the surgical team. From December 1990 to the end of 1995 we reconstructed 185 breasts (10 bilateral) in 175 patients with free TRAM flaps; 27 were immediate reconstructions. We harvested the flap based on the inferior epigastric pedicle on the opposite side to the affected breast. To dissect the rectus muscle we used a muscle-sparing technique. The flap was designed and de-epithelialised while still on the abdomen, and was anastomosed to the thoracodorsal or circumflex scapular vessels with loupes only. In the immediate reconstructions we removed the breast tissue through a periareolar incision; we dissected the group I axillary lymph nodes and exposed the recipient vessels through a separate incision. The areolar complex was autotransplanted as a free skin graft. Only two flaps were lost. Eight patients were reoperated on for thrombosis of the vessels. The complication rate was nearly 50% among the first 50 patients. However, as surgical experience grew, the figure was reduced, eventually being down to 20%-25%. Of the patients who had delayed reconstructions only two died during the follow-up period of 48 months. One patient had a local recurrence above the TRAM skin. During the last eight years the free TRAM flap has been our main method of breast reconstruction. Free flaps today are reliable and the reconstruction does not seem to worsen the prognosis of breast cancer.

Microvascular free flaps in head and neck cancer surgery in Finland 1986-1995.

Microvascular free tissue transfer has in many cases replaced classic flap techniques and is now an established workhorse for head and neck reconstructions. In this retrospective study the over 300 patients, who had microvascular free flap reconstructions in head and neck cancer surgery in Finland during a 10-year period (1986-1995) were reviewed. The operations were performed in the University Hospitals by plastic surgeons, ENT specialists or maxillofacial surgeons. The cases consisted of defects resulting from resection of oral cavity tumors (63%), mid- or upper-face and skullbase tumors (20%) and hypopharyngo-esophageal tumors (17%). The series includes a wide range of flap types and analyses flap outcome and complications. A total of 313 cases was reconstructed by 317 flaps (forearm flaps 47%, latissimus dorsi flaps 19%, free jejunum or colon transfers 15%, free iliaca crest flaps 8% and other flaps 11%). Thrombosis of one of the vessels and haematoma were the most frequent causes of failure in microvascular free tissue transfer. A total flap necrosis occurred in 27 (8.5%) and a partial necrosis in 12 (4%) patients. The most reliable flap in terms of survival was the radial forearm flap. The ever-improving success of microvascular free tissue transfer has made it a useful procedure for head and neck reconstructions. There is also a growing need for microvascular team surgery in the field of head and neck cancer therapy.

Subchondral bone and cartilage repair with bioactive glasses, hydroxyapatite, and hydroxyapatite-glass composite.

The repair of an osteochondral defect in rabbit femur was studied with three kinds of bioactive glasses (BG), hydroxyapatite (HA), and hydroxyapatite-glass (HAG) composite. Seventy-two osteochondral defects were created in 18 rabbits. Sixty-four cylinders were implanted and eight defects were left empty as controls. Histomorphometry, scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDXA) were used for evaluation. Small osteochondral defects in rabbit femur found to heal themselves by regeneration. The three BGs, HA, and HAG led to direct lamellar bone repair of subchondral bone and restoration of articular surfaces mostly with hyalinelike cartilage in 12 weeks. However, the composition of the materials affects their behavior. Chondrogenesis took place earlier with the BGs than with HA. HAG degraded too much, glass 14 was too reactive and brittle, and the high alumina content in glass 11 disturbed its bone-bonding ability. Glass 7 and HA were the most balanced in the repair process. A special preparation method was used to retain soft tissues fairly unchanged and enable them to the observed together with hard tissues in SEM analysis.

Bioactive glass granules and plates in the reconstruction of defects of the facial bones.

Non-vascularised bone grafts that are used for reconstruction of skeletal deformities of the face after trauma or tumour surgery are prone to resorption. The outcome may, therefore, not be what was expected. Bone was reconstructed with bioactive glass S53P4 granules and plates at 36 sites in 13 patients. The behaviour of the material was compared with that of bone grafts at 16 sites in the same patients. Bioactive glass granules were used in facial bone defects in subperiosteal pockets and to obliterate frontal sinuses, whereas bioactive glass plates were used mostly in orbital wall reconstruction. Clinical examination, middle face radiographs, and computed tomograms (CT) showed that the material was well tolerated. A third of the glass granules and a quarter of the membranous bone grafts that were fixed with miniplates retained their original size. The glass plates did not change in size. Bone contact to the host bone was found more often with the bioactive glass plates than with the bioactive glass granules or the bone grafts. Both the glass plates and the bone grafts retained their density, but there was a reduction in density of the glass granules. The clinical outcome showed no relapses after one year's follow up. No further operations were needed because of the material used.

Return of sensibility and final outcome of breast reconstructions using free transverse rectus abdominis musculocutaneous flaps.

Thirty-nine patients who had had free transverse rectus abdominis musculocutaneous (TRAM) flaps were studied and interviewed 5 months to 2.3 years after the procedure. The main reason why the patients had wanted the reconstruction in the first place was difficulty with the external prosthesis. Thirty three of 39 would have had the operation again; three were hesitant, and three had regrets for reasons other than that the breast was not satisfactory. All patients considered that the symmetry of the breasts was good or satisfactory with bras; without bras, one patient thought that the symmetry was poor, and the physician thought that the symmetry was poor in nine patients. Two-point discrimination turned out to be too delicate for studying the sensitivity of the breast. When pressure sensitivity was studied with von Frey monofilaments, the threshold values were significantly lower on the lateral and medial side and under the reconstructed breast than on the opposite side. In 22 patients the lateral part, and in 23 the medial part, of the reconstructed breast was insensate. There was good or satisfactory pressure sensitivity on the lateral side in nine patients and on the medial side in eight. The return of sensitivity to the autogenous breast reconstruction was variable among the patients studied, but it did not affect their satisfaction with the reconstruction.

Hydroxyapatite-glass composite as a bone substitute in large metaphyseal cavities in rabbits.

This study evaluated hydroxyapatite-glass (HA-G) composite as a filler material when implanted into a proximal metaphyseal tibial cavity consisting of medullary tissue and cancellous bone in rabbits. The repair process was compared with that of autogenous bone grafts and untreated controls. Scanning electron microscopy, energy dispersive x-ray studies, radiography, histology with tetracycline fluorescence and morphometric bone measurements were used for evaluation. Equal amounts of mineralised bone were produced in both HA-G granule and autograft groups at 3 weeks; thereafter, autografts mostly resorbed, whereas there was appositional lamellar bone formation on the early woven bone in the HA-group. A relatively small proportion of the cavities was repaired by new bone. The HA-G granules were biocompatible without foreign body reaction and showed good osteoconductive potential. Mesenchymal cells were able to differentiate into osteoblasts on bioactive surfaces of the composite. Although HA-G was able to form Ca-P-rich and Si-rich layers, most of the granules underwent degradation through its glass matrix, resulting in fewer bony contacts than granules with no surface degradation.

Reconstruction of the Achilles tendon region by free microvascular flaps. 9 cases followed for 1-9 years.

In 1981-89, 9 patients underwent reconstruction for complex injuries in the Achilles tendon region. 10 free microvascular flaps were used: 5 fasciocutaneous and 5 muscle or musculocutaneous flaps. In addition, 4 Achilles tendons and 1 tibial posterior nerve were reconstructed, 1 femoropopliteal bypass was performed, and 6 tibial fractures were treated. The patients were re-examined on an average 3.5 years after the reconstruction. The stability of soft tissues was good in all patients. Good contour was achieved in superficial defects with fasciocutaneous and in deep injuries with latissimus dorsi free flaps. The calcaneal tendon function was good in 5, fair in 2 and poor in 2 patients, depending on the severity of the underlying skeletal injury. We conclude that free microvascular transfer offers one-stage reconstruction of complex, infected wounds in the Achilles tendon region, promotes fracture healing, and allows simultaneous tendon or nerve repair.