Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees?

BACKGROUND: It is essential that surgical trainees obtain adequate operative experience without compromising patient outcome. The aim of this study was to compare the reexcision and local recurrence rates between consultants (attending surgeons) and surgical trainees (residents) after breast conservation surgery. METHODS: Prospective data were obtained from the local breast cancer registry for all patients who had breast-conservation surgery between 1994 and 2000. Reexcision was carried out if the margins were deemed inadequate after taking the clinical and pathologic features into consideration. RESULTS: The primary operation (n = 505) was wide local excision = 377; wire-guided excisions = 107; and quadrantectomy = 21 patients. Sixty-five percent (n = 330) were operated on by consultants and 35% (n = 175) by residents. Second procedures (n = 137) were performed for involved margins in 95 and close margins in 31 patients. The patients in both groups were equally matched. The reexcision rate was similar for both groups of surgeons (P = 0.58). On multivariate analysis, the factors determining reexcision were nodal status, type of first procedure, and tumor type. The local recurrence rate was comparable in both groups (P = 0.33). CONCLUSIONS: In patients with breast cancer treated by conservation surgery during a 7-year period, the reexcision and local recurrence rates were similar for both groups of surgeons.     

Effect of immunosuppressive drugs on the release of metalloproteinases from human polymorphonuclear leukocytes

The concentration of the metalloproteinases type I collagenase and gelatinase was measured in isolated polymorphonuclear leukocytes (PMNLs) of renal transplant recipients treated either with cyclosporin A (CyA) and prednisolone (Pr) (n=8) or azathioprine (Aza) and Pr (n=8), and of healthy subjects (n=12). PMNLs of CyA- and Aza-treated transplant patients displayed markedly higher gelatinase content (2427±489 and 3284±357 ng/10⁷ cells) than PMNLs of controls (528±83 ng/10⁷ cells). There was also a higher content of type I collagenase in PMNLs (3374±292 ng/10⁷ cells) of Aza-treated patients and significantly elevated levels in PMNLs of patients receiving CyA (3625±229 ng/10⁷ cells) compared with healthy subjects (2878±151 ng/10⁷ cells). In contrast, neutrophil lactoferrin content was lower in transplant patients. Thus, immunosuppressive drugs may reduce the release of leukocyte proteinases, which are known for their deleterious role in proteolytic tissue and matrix breakdown. In vitro, the effects of different immunosuppressive drugs on the release of lactoferrin, collagenase and gelatinase were investigated on FMLPNTL-stimulated PMNLs isolated from healthy subjects. CyA but not Aza or Pr caused inhibition of gelatinase, collagenase and lactoferrin release.     

Clinicopathologic Impact of Early Medullary Ray Injury in Patients Following Kidney Transplantation

Background

Previously, we explored the histopathologic characteristics of medullary ray injury (MRI) inducing interstitial fibrosis and tubular atrophy (IF/TA) to determine its etiologies, which include calcineurin inhibitor (CNI) toxicity and urologic complications. However, we did not examine the effects of these etiologies on long-term kidney allograft prognosis, because biopsy timing differed among cases.

Electroencephalographic investigations in sellar tumours,with special regard to different methods of operative treatment

Summary Sixty-six patients with tumours in the sellar region were examined. All were operated on either by the transfrontal or the transsphenoidal route. Pre- and postoperative longitudinal electroencephalographic investigations were performed.Preoperative electroencephalograms showed a normal frequency content in cases of intrasellar tumours or those reaching the chiasma. Nearly all cases had irregularities in the temporal regions. Tumours compressing the third ventricle had slower average frequencies and a general slowing in all cases. Besides these alterations unilateral delta waves or bitemporal dysrhythmic groups were sometimes found.A connection between extension of the tumour and its histological nature could not be found, but the operative approach influenced the electroencephalographic disturbances enormously. After a transfrontal approach and removal of the tumour the electroencephalogram was unchanged. Sometimes a mild transient bitemporal slowing was present. But after a transfrontal operative approach a general slowing was common, usually with focal marked slow activity in the right fronto-temporal area.     

Aspects of personality in patients with pituitary adenomas

Summary In 24 patients suffering from pituitary tumours, aspects of personality as covered by the FPI (Freiburger Personality Inventory), the Gie\en test and the STAI (State-Trait-Anxiety Inventory) were investigated in order to find out changes or problems which demand special treatment.The most interesting result concerns state and trait-anxiety scores being increased pre-surgically and normalizing to some extent after treatment. Most of the other explored aspects did not show but tendencies which demand further investigation.Relationships between hormone levels and tumour size could not be shown. As a result of this investigation, special psychological treatment should be considered in acromegaly and Cushing's disease.Dedicated to Prof. Dr. Friedrich Loew on the occasion of his 65th birthday and the 25th anniversary of the Homburg Neurosurgical University Clinic, which has been founded and built up by him.     

Functional, life-threatening disorders and splenectomy following liver transplantation

Splenectomy (SPL) in cirrhotic patients undergoing liver transplantation (LTx) may resolve specific problems related to the procedure itself, in case of functional and life-threatening clinical situations often occurring as a result of liver cirrhosis and portal hypertension. METHOD: A single-center experience of ten splenectomies in a series of 180 consecutive adult liver transplant patients over a period of 6 yr is reported. The mean patient age was 46.8 +/- 9.5 yr (range 25 57 yr). Indications for SPL were post-operative massive ascitic fluid loss (n = 3), severe thrombocytopenia (n = 3), acute intra-abdominal hemorrhage (n = 2), infarction of the spleen (n = 1), and multiple splenic artery aneurysms (n = 1). RESULTS: Extreme ascites production due to functional graft congestion disappeared post-SPL, with an improvement of the hepatic and renal functions. SPL was also effective in cases of thrombocytopenia persistence post-LTx, leading to an increase in the platelet count after about 1 wk. Bleeding episodes related to left-sided portal hypertension or trauma were also resolved. The rejection rate during hospitalization was 0%, and no other episodes were recorded in the course of the long-term follow-up. However, sepsis with a fatal outcome occurred in 4 patients, i.e. between 2 and 3 wk post-SPL in three cases and 1 yr after the procedure as a result of pneumococcal infection in the last case. Fatal traumatic cranial injury occurred 3 yr post-LTx in another case. Five patients (50%) are still alive and asymptomatic after a median follow-up period of 36 months. CONCLUSION: The lowering of the portal flow appears to resolve unexplained post-operative ascitic fluid loss as a result of functional graft congestion following LTx. However, because of the enhanced risk of SPL-related sepsis, a partial splenic embolization (PSE) or a spleno-renal shunt could be used as an alternative procedure because it allows us to preserve the immunological function of the spleen. SPL is indicated in case of post-transplant bleeding due to left-sided portal hypertension and trauma, spleen infarction, and to enable prevention of hemorrhage in liver transplant patients with multiple splenic artery aneurysms. Severe and persistent thrombocytopenia could be treated with PSE. Because the occurrence of fatal sepsis post-SPL is a major complication in LTx, functional disorders, such as ascites and thrombocytopenia, should be treated with a more conservative approach.     

Macronutrients,minerals, vitamins and energy

Carbohydrates have the general formula C_n(H₂O)_n. Monosaccharides have between three and six carbon atoms and exist as chains or ring structures. As rings, they link with other monosaccharide rings. The major carbohydrate in humans is glucose, which is stored as glycogen: branching chains of glucose molecules. Fat (triglyceride), which makes up adipose tissue, consists of three fatty acids bonded to glycerol, but other lipids include phospholipids and steroids. Proteins are composed of chains of amino acids linked by amide bonds folded on each other to form protein structures. Vitamins and minerals are obtained from the diet and are required in varying quantities for a variety of metabolic processes. Energy is derived from the oxidation of carbohydrate, fat and protein. Energy expenditure and substrate oxidation can be calculated from oxygen consumption, carbon dioxide production and urinary nitrogen excretion.     

Cash transfers for HIV prevention: considering their potential

Introduction

Cash payments to vulnerable households and/or individuals have increasingly garnered attention as a means to reduce poverty, improve health and achieve other development-related outcomes. Recent evidence from Malawi and Tanzania suggests that cash transfers can impact HIV-related behaviours and outcomes and, therefore, could serve as an important addition to HIV prevention efforts.

Discussion

This article reviews the current evidence on cash transfers for HIV prevention and suggests unresolved questions for further research. Gaps include (1) understanding more about the mechanisms and pathways through which cash transfers affect HIV-related outcomes; (2) addressing key operational questions, including the potential feasibility and the costs and benefits of different models of transfers and conditionality; and (3) evaluating and enhancing the wider impacts of cash transfers on health and development.

Conclusions

Ongoing and future studies should build on current findings to unpack unresolved questions and to collect additional evidence on the multiple impacts of transfers in different settings. Furthermore, in order to address questions on sustainability, cash transfer programmes need to be integrated with other sectors and programmes that address structural factors such as education and programming to promote gender equality and address HIV.     

Macronutrients,minerals, vitamins and energy

Macronutrients comprise carbohydrates, fats and proteins and make up most of the body's soft tissue structure. Carbohydrates are organic molecules made of carbon, hydrogen and oxygen atoms. Fats are composed of carbon, hydrogen and oxygen, but the proportion of oxygen atoms to carbon and hydrogen is lower than in carbohydrates. Proteins are usually made up of more than 100 amino acids linked into chains by peptide bonds. Amino acids consist of an asymmetrical carbon atom with both an amino group (NH₂) and a carboxyl group (COOH) attached. Energy used for metabolic homeostasis, thermoregulation, physical activity and normal organ function is obtained from the oxidation of these macronutrients. Micronutrients (trace minerals and vitamins) are dietary components necessary to sustain health. Most trace minerals appear to function as cofactors for a number of enzymes. Vitamins have many roles in intermediary metabolism and in the specialized metabolism of specifc organs.     

Serologic follow-up of solid organ transplant recipients who received organs from donors with reactive syphilis tests: A retrospective cohort study

The increased procurement of organs from donors with risk factors for blood-borne diseases and the expanding syphilis epidemic have resulted in a growing number of organs transplanted from donors with reactive syphilis serology in our center. Based on guidelines, recipients typically receive therapy shortly after the transplant, but data on outcomes are limited. The primary objective of this study was to determine syphilis seroconversion rates at three months post-transplant in recipients of solid organs procured from donors with reactive syphilis serology. Organ donors and recipients were tested for syphilis antibody; positive results were confirmed with Treponema pallidum Particle Agglutination (TPPA). Eleven donors with reactive syphilis antibody donated organs to 25 syphilis negative recipients. Three recipients seroconverted at post-transplant month 3. All of them had received therapy shortly after transplant. TPPA was negative in all 3. Despite post-transplant treatment, 3 of 25 (12%) syphilis negative recipients of organs from syphilis positive donors seroconverted at 3 months. All remained TPPA negative possibly reflecting passive antibody transfer or differing test sensitivity to low level treponemal antibodies. Further studies are needed to assess optimal syphilis transmission prevention strategies and follow up recipient testing in organ transplantation.     

Macronutrients,minerals, vitamins and energy

Carbohydrates have the general formula C_n(H₂O)_n. Monosaccharides have between three and six carbon atoms and exist as chains or ring structures. As rings, they link with other monosaccharide rings. The major carbohydrate in humans is glucose, which is stored as glycogen: branching chains of glucose molecules. Fat (triglyceride), which makes up adipose tissue, consists of three fatty acids bonded to glycerol, but other lipids include phospholipids and steroids. Proteins are composed of chains of amino acids linked by amide bonds folded on each other to form protein structures. Vitamins and minerals are obtained from the diet and are required in varying quantities for a variety of metabolic processes. Energy is derived from the oxidation of carbohydrate, fat and protein. Energy expenditure and substrate oxidation can be calculated from oxygen consumption, carbon dioxide production and urinary nitrogen excretion.     

Dream anxiety in renal transplant recipients

Abstract

Objective: Although low quality of sleep has been reported in kidney transplant patients with functioning allografts, there are no previous studies investigating the dreams of these patients. We aimed to investigate the differences in dream anxiety level between renal transplant patients and healthy control subjects. We also planned to compare depression and anxiety symptoms, sleep quality and sleepiness level between these two groups. Methods: Twenty-two living-donor renal transplant recipients followed at an outpatient nephrology clinic and 22 healthy controls were enrolled in this observational cross-sectional study. Sociodemographic Data Collection Form, and the Van Dream Anxiety Scale (VDAS), the Pittsburg Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), Beck Depression and Anxiety Inventories were used for the assessment of the necessary features. Hemoglobin (Hb), blood urea nitrogen (BUN), creatinine (Cr) and glucose levels were measured. Results: There were no significant differences between the groups in terms of dream anxiety (p?=?0.45), depression (p?=?0.76), sleep quality (p?=?0.8), insomnia severity (p?=?0.08) and Hb (p?=?0.11) and glucose levels (p?=?0.14). Although, BUN (p?=?0.00) and creatinine (p?=?0.00) levels differed significantly between the two groups, both parameters were found to be within their normal range. Conclusions: In our study, chronic renal failure patients with a successful kidney transplant were found to be able to completely return to normal in terms of metabolic parameters, sleep quality and mood. Similar levels of dream anxiety are also consistent with these findings.     

UK registry analysis of donor substance misuse and outcomes following pancreas transplantation

Substance abuse is unfortunately common in organ donors. Often, these organs are declined for transplant, not only because of concerns around blood‐borne virus transmission but also because of perceived poor outcomes. In kidney transplantation, previous studies have demonstrated donor smoking status significantly impacts transplant outcome, but intravenous drug use or alcohol dependence does not. This study aims to clarify these issues in pancreas transplantation. Retrospective data on all UK solid organ pancreas transplants from 1994 to 2015 were obtained from the NHSBT UK Transplant Registry. The impact of illicit drug misuse, alcohol abuse, and smoking on graft and patient survival were analyzed using Kaplan‐Meier plots and a Cox regression model. A total of 1175 of the 2317 (49.5%) donors were categorized as substance misusers. Univariate survival analysis revealed no significant impact of substance misuse on 10‐year graft or patient survival. Multivariate analysis confirmed substance misuse was not associated with impaired graft or patient survival. A history of donor substance misuse does not negatively impact 10‐year graft or patient survival following pancreas transplantation. This is a large national registry analysis with long‐term follow‐up data and should therefore provide clinicians with reassurance when considering pancreas grafts from substance misuse donors.     

局灶节段透明变性及硬化在判断IgA肾病预后中的意义

目的　探讨IgA肾病 (IgAN)进展为慢性肾功能不全 (CRI)的病理学危险因素。方法　对 6 40例经肾活检确诊的IgAN病人进行平均 5 3个月的追踪观察。用病例对照法研究所有病人的病理学资料 ,同时还对其中 2 0 4例活检当时肾功能正常 ,5年后发展为CRI或终末期肾功能衰竭(ESRF) (n =18)以及 5年后肾功能仍保持正常 (n =186 )的病例进行了比较。结果　弥漫性系膜增生型 (DMP)为最常见的病理型 ,占 5 0 %。 / 间质纤维化 ,>40 %硬化肾小球 , / 血管病变 ,局灶节段透明变性及硬化 (FSHS)的均为预测肾功能恶化的危险因素 ,其中FSHS的意义更大 (P <0 0 0 0 1)。结论　FSHS的存在是IgAN病人正常肾功能进展恶化的显著指标。     

Solid organ donation after death in the United States: Data‐driven messaging to encourage potential donors

US deceased donor solid organ transplantation (dd‐SOT) depends upon an individual's/family's altruistic willingness to donate organs after death; however, there is a shortage of deceased organ donors in the United States. Informing individuals of their own lifetime risk of needing dd‐SOT could reframe the decision‐making around organ donation after death. Using United Network for Organ Sharing (UNOS) data (2007‐2016), this cross‐sectional study identified (1) deceased organ donors, (2) individuals waitlisted for dd‐SOT (liver, kidney, pancreas, heart, lung, intestine), and (3) dd‐SOT recipients. Using US population projections, life tables, and mortality estimates, we quantified probabilities (Pr) of (1) becoming deceased organ donors, (2) needing dd‐SOT, and (3) receiving dd‐SOT. Lifetime Pr (per 100 000 US population) for males and females of becoming deceased organ donors were 212 and 146, respectively, and of needing dd‐SOT were 1323 and 803, respectively. Lifetime Pr of receiving dd‐SOT was 50% for males, 48% for females. Over a lifetime, males were 6.2 and females 5.5 times more likely to need dd‐SOT than to become deceased organ donors. Organ donation is traditionally contextualized in terms of charity toward others. Our analyses yield a new tool, in the form of quantifying an individual's own likelihood of needing dd‐SOT, which may assist with reframing motivations toward deceased donor organ donation.     

The effect of stress-inducing conditions on the performance of a laparoscopic task

Background: The availability of objective means for assessment of surgical skills has made it possible to evaluate the effect of adverse environmental conditions on surgical performance. Methods: Participants performed a laparoscopic transfer task under five conditions: a simple verbal mathematical task (M), operating theatre background noise at 80 to 85 dB (N), performance as quickly as possible (T), all three stressors combined (A), and quiet conditions (Q). The effect of these conditions on performance was evaluated by using a motion analysis system and an error score. Results: The study included 13 right-handed surgeons with varying levels of laparoscopic experience. There was a significant increase in the path length per movement of the right hand (p = 0.001) under T and a significant increase in the path length per movement of the left hand under M (p = 0.002), T (p = 0.0l), and A (p = 0.02). A significantly higher number of errors occurred under all four stress-inducing conditions. The effect was more pronounced when all the stressors were applied in combination (p = 0.001) followed by performance under M (p = 0.005), then T (p = 0.01) and N (p = 0.03). Conclusions: All three stressors led to impaired dexterity and an increase in the incidence of errors.     

The roles of human lateral temporal cortical neuronal activity in recent verbal memory encoding

Activity of 98 single neurons in human lateral temporal cortexwas measured during memory encoding for auditory words, text,or pictures and compared with identification of material ofthe same modality in extracellular recordings during awake neurosurgeryfor epilepsy. Frequency of activity was divided into early orlate epochs or activity sustained throughout both; 44 neuronshad significant changes in one or more categories. Polymodaland sustained changes lateralized to dominant hemisphere andlate changes to nondominant. The majority of polymodal neuronsshifted categories for different modalities. In dominant hemisphere,the timing and nature of changes in activity provide the basisfor a model of the roles of temporal cortex in encoding. Superiortemporal gyrus excitatory activity was related to the earlyepoch, when perception and processing occur, and middle gyrusto the late epoch, when semantic labeling occurs. The superiortwo-thirds of middle gyrus also demonstrated sustained inhibition.In a subset of lateral temporal neurons, memory-encoding activityreflected simultaneous convergence of sustained attentionaland early perceptual inputs.