Exploring breast surgeons’ reasons for women not undergoing immediate breast reconstruction

IntroductionFactors influencing breast reconstruction rates in Canada are complex and multi-factorial, ranging from patient-related to systemic considerations. For plastic surgeons, rates of immediate breast reconstruction (IBR) hinge on referral patterns from general surgeons performing breast cancer surgery and informed discussions with patients about their goals and risk tolerance. We seek to understand the reasons Alberta patients are not receiving IBR as reported by general surgeons.MethodsThe Synoptec™ database is a synoptic operative report designed by Cancer Surgery Alberta™ and utilized by 95% of Alberta breast cancer surgeons. Within this report are mandatory questions regarding if a patient is receiving IBR and, if not, why. A retrospective review of this database was performed for all patients undergoing surgical treatment of breast cancer over two years. All statistical comparisons were made using chi-squared test for categorical variables with a p-value of 0.05 considered significant.ResultsOf 6253 patients undergoing breast cancer surgery, 2649 underwent mastectomy and 615 mastectomy patients received IBR. The most commonly reported reasons patients did not undergo IBR were patient preference (55%), high likelihood of postoperative radiation therapy (20%), and high risk due to patient co-morbidities (12%). Resource limitations (2%) and a lack of an IBR discussion (3%) was rarely cited as reasons for no IBR.ConclusionsThere are many reconstructive options following mastectomy in breast cancer survivors. This study provides a unique look into general surgeon reported reasons patients are not receiving IBR and demonstrates the need for further probing into the thought-process behind these reported reasons from both a surgeon and patient perspective.     

SUNAMO atrial retractor—a custom-made retractor for small left atrium

Many types of atrial retractors are available in practice. Though they have been used routinely for all types of procedures requiring exposure of mitral valve, we felt that these being rigid and having a fixed design and size, not suitable in certain conditions of redo mitral valve procedures where the left atrium is too small to accommodate the retractor. Moreover atrial wall in such situation is more fragile that little more pull on the retractor would cause tear in the wall of the atrial tissue. We have made a novel flexible type of retractor which can be assembled on the table with materials that are readily available in a cardiothoracic operating room.     

Placebo effect in osteoarthritis: Why not use it to our advantage?

Osteoarthritis is a major cause of pain and reduced quality of life in the elderly, as well as a major economic burden. Unfortunately, there is no currently effective therapeutic strategy to prevent the progression of Osteoarthritis, and its treatment poses a great challenge to the medical community. Most of the treatment modalities currently available for osteoarthritis have small to moderate effect sizes, according to main meta-analyses and treatment guidelines. On the other hand, literature has demonstrated that placebo is considerably effective. The present article discusses the history of placebo effect and its scientific evidence, comments on ethical issues and provides insights about how it may be used to our advantage when treating osteoarthritic patients.     

Pressure for beds--does it put our orthopaedic patients at risk?

INTRODUCTION: High occupancy rates of NHS beds has meant that increasing numbers of trauma patients find themselves on non-orthopaedic wards. Nursing staff on these wards may not have the specialist training to nurse such patients and may not recognise complications should they arise. The failure to recognise compartment syndrome was highlighted in a Clinical Governance meeting, leading to an assessment of nursing awareness of this condition. METHODS: Fifty orthopaedic trained nurses and a matched cohort of 50 non-orthopaedic trained nurses were asked a series of questions relating to compartment syndrome. RESULTS: The majority of non-orthopaedic nurses failed to recognise the signs of early compartment syndrome. CONCLUSION: Compartment syndrome is a limb-threatening condition which requires prompt recognition. Patients at risk should be nursed in an appropriate environment.     

The discovery of nephrouroameba: was it real or not?

In 1938 Procaccini showed scientific interest in a new kind of ameba, and called it "nephrouroameba" from which the disease "nephrouroamebiasis" is derived. He wrote a paper titled "La Nefrouroamoebiasi" thus describing its history, the biopathogenetic evolutionary cycle of the protozoon, its therapeutic, epidemiological, anatomo-biological, diagnostic, cultural, biological and morphological features. Between 1934 and 1939, Procaccini had the opportunity to follow many patients belonging to a group of Italian soldiers serving in the Eastern Italian Army in Ethiopia. At that time he was responsible for the biopathological laboratory. After a short preclinical stage of fatigue, patients suffering from nephrouroamebiasis showed a nephrotic syndrome with gross hematuria. The symptoms ceased within a few days but residual microhematuria, albuminuria and urine casts persisted for many months. After microscopic observation, he reproduced some protozoons and classified them as a kind of ameba. Critical analysis of his report leads to the morphological identification of Trichomonas, thus excluding his classification as nephrouroamebas.     

Traumatic extradural hematoma — role of non-surgical management and reasons for conversion

Background  

To study the role of conservative management and various reasons for conversion to surgical intervention in traumatic extradural hematoma (EDH).     

The utility of adipose-derived stem cells and stromal vascular fraction for oncologic soft tissue reconstruction: Is it safe? A matter for debate

Autologous free-fat grafting (AFG) has emerged as an attractive proposition for soft-tissue reconstruction of various contour defects because it obviates more complex reconstructive options and reduces operative times and donor-site morbidity. Nonetheless, a common complication of this procedure is the resorption of the engrafted fat. Cell-assisted lipotransfer (CAL) is now a well-regarded technique where adipose-derived stem cell (ASC)-rich stromal vascular fraction is admixed with lipoaspirate, increasing the volumetric outcome of fat grafts in light of its potent angiogenic and adipogenic properties. Criticisms, however, remain regarding this modality especially for the treatment of post-oncologic defects. Laboratory data has attested to its propensity to perpetuate tumor cells as a result of its paracrine effects on the host microenvironment. This review article aims to present the underlying facts behind ASC therapy and provide meaningful discourse as to its utility in post-oncologic soft tissue reconstruction.     

Missed blunt cerebrovascular injuries using current screening criteria — The time for liberalized screening is now

Diagnostic Criteria StudyBackgroundThe morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI).MethodsThis was a multi-institutional retrospective cohort study of trauma patients who presented between 2015-2020 with radiographically confirmed BCVI diagnosed using each institutions’ liberalized screening protocol, defined as automatic CTA of the head and neck for all patients undergoing head and neck CT. Outcomes of interest included AKI, stroke, and death due to BCVI. Outcomes were reported as frequency, percent, and 95% confidence interval as calculated by the Clopper-Pearson method. Incidence of medical follow-up within 1 year of first medical visit was quantified as the median and inter-quartile range of days to follow-up visit.ResultsWe identified 433 BCVI patients with a mean age of 45.2 (standard deviation 18.9) years, 256 men and 177 women, 1.73 m (0.10) tall, and weighed 80.3 kg (20.3). Forty-one patients had strokes (9.5% [95% confidence interval 6.9, 12.6] and 12 patients (2.8% [1.4, 4.5]) had mortality attributable to BCVI. Of 433 total cases, 132 (30.5% [26.2, 35.1]) would have been missed by DC and 150 (34.6% [30.2, 39.3]) by eDC. Incidence of AKI in our BCVI population was 6 (1.4% [0.01, 3.0]).ConclusionsBCVI would be missed over 30% of the time using the DC and eDC compared to liberalized use of screening CTA. Risk of AKI due to CTA did not occur at a clinically meaningful level, supporting liberal CTA screening.     

Sources of human hematopoietic stem cells for transplantation—a review

Transplantation of hematopoietic stem cells provides a means of replacing a defective hematopoietic system in patients with a wide range of malignant and nonmalignant disorders that affect the blood forming tissue. The same procedure has also allowed dose-escalation of standard chemotherapy and radiotherapy in the treatment of malignant disease of nonhematological origin. Until recently, bone marrow has been the sole source of hematopoietic stem cells, but limitations of conventional bone marrow transplantation have stimulated a search for alternative sources and uses of stem cells. Fetal tissues (especially liver) are a recognized source of transplantable stem cells and offer the great advantage of reduced immunogenicity, potentially removing the problems of tissue type matching. Umbilical cord blood is also a rich source of stem cells and, although it contains alloreactive cells, it is readily available without special ethical constraints. Both fetal tissue and cord blood suffer the disadvantages of limited numbers of stem cells per donation, and there is much interest in the development of technologies for the safe and reliable expansion and/or pooling of stem and progenitor cells. The observation that small numbers of stem cells are found in the peripheral blood of adults has led to the exploitation of the blood as a further source of stem cells. The ability to mobilize these cells from the medullary compartment into the periphery by the use of chemotherapy and/or recombinant hematopoietic growth factors has enabled the collection of sufficient numbers of cells for transplantation purposes. All of these advances are increasing the options and the range of choices available to clinicians and patients in the arena of hematopoietic stem cell transplantation.     

Single stage versus two stage repair for univentricular heart—our experience

Background  

Definitive palliation for complex cardiac anomalies with a functional single ventricle usually involves different modifications of Fontan operation/ Total Cavopulmonary Connection (TCPC). However, whether it should be done as one-stage procedure or two-stage procedure with initial bidirectional Glenn shunt remains an area of debate though many recent studies have shown benefit of two stage procedure particularly in high risk cases.