Dissections of regional lymph nodes for treatment of skin cancer: predicting annual caseloads that will optimise outcomes

IntroductionDissection of regional lymph nodes (RLNs) can lead to significant morbidity and a high prevalence of complications. Published guidance states that these procedures should be carried out by surgeons who are members of a specialist skin multidisciplinary team who carry out a combined minimum of 15 axillary/groin dissections per year. However, there is little evidence to guide this minimum figure of procedures. We report on the burden of service provision and prevalence of complications across the South West of England and Wales.MethodsA 12-month review of dissections of RLNs for skin cancer was undertaken covering five Plastic Surgery Units with a collective catchment of 8.4 million people. Detailed data were collected on patient demographics, pathology, timing of surgery, and prevalence of complications.ResultsA total of 163 dissections were carried out. Forty-three per cent of patients experienced one or more complication. In that 12-month period, an average of 8 axillary/groin dissections was carried out per surgeon. A funnel plot demonstrated that the prevalence of complications for individual surgeons was within the limit of the plot but, in many cases, this was based only on a relatively small number of procedures per consultant. If surgeons carried out 10 procedures per year, the upper and lower limits on the plot were 73% and 11%, respectively.ConclusionsFunnel plots can provide a useful guide as to whether the prevalence of complications for procedures for individual surgeons lies within acceptable limits. Based on these results, 10 procedures per consultant per year should be sufficient to enable meaningful assessment of the prevalence of complications.     

Two-dimensional echocardiography and Doppler color flow mapping in the diagnosis and prognosis of ventricular septal rupture

Doppler color flow mapping in conjunction with two-dimensional echocardiography was used to evaluate ventricular septal rupture after myocardial infarction (seven anterior and eight inferior) in 15 patients and to correlate these findings with cardiac catheterization and surgical or autopsy data. Ventricular septal rupture was diagnosed by turbulent flow traversing the ventricular septum. The direction and velocity of shunt flow was determined by color M-mode and conventional Doppler methods. In all patients, Doppler color flow mapping correctly defined the site of septal rupture, which occurred at areas of discordant septal wall motion or "hinge points" (six posterior inlet, three anterior inlet, and six apical trabecular septum). Each of three patients with moderate tricuspid regurgitation and three of four patients with right-to-left shunting during diastole died, and all had an elevated right ventricular end-diastolic pressure. Right ventricular wall motion index was significantly higher in the patients who died compared with those who survived (mean +/- SEM; 2.8 +/- 0.2 vs. 2.0 +/- 0.2, p = 0.012), but there was no difference in left ventricular wall motion index. The rupture size measured by Doppler color flow imaging (1.7 +/- 0.1 cm) correlated with the size determined during surgery or autopsy (1.8 +/- 0.2 cm, r = 0.68, p = 0.022) and the pulmonic-to-systemic shunt flow ratio by cardiac catheterization (2.4:1 +/- 0.3, r = 0.74, p = 0.004). Color-guided continuous-wave Doppler estimates of right ventricular systolic pressure (47 +/- 2 mm Hg) correlated with cardiac catheterization measurements (48 +/- 3 mm Hg, r = 0.90, p = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)     

Nodding syndrome in Mundri county,South Sudan: environmental,nutritional and infectious factors

Background

Nodding Syndrome is a seizure disorder of children in Mundri County, Western Equatoria, South Sudan. The disorder is reported to be spreading in South Sudan and northern Uganda.

Objective

To describe environmental, nutritional, infectious, and other factors that existed before and during the de novo 1991 appearance and subsequent increase in cases through 2001.

Methods

Household surveys, informant interviews, and case-control studies conducted in Lui town and Amadi village in 2001–2002 were supplemented in 2012 by informant interviews in Lui and Juba, South Sudan.

Results

Nodding Syndrome was associated with Onchocerca volvulus and Mansonella perstans infections, with food use of a variety of sorghum (serena) introduced as part of an emergency relief program, and was inversely associated with a history of measles infection. There was no evidence to suggest exposure to a manmade neurotoxic pollutant or chemical agent, other than chemically dressed seed intended for planting but used for food. Food use of cyanogenic plants was documented, and exposure to fungal contaminants could not be excluded.

Conclusion

Nodding Syndrome in South Sudan has an unknown etiology. Further research is recommended on the association of Nodding Syndrome with onchocerciasis/mansonelliasis and neurotoxins in plant materials used for food.     

Hepatitis C and blood transfusion among children attending the Sickle Cell Clinic at Mulago Hospital,Uganda

Background

Hepatitis C virus (HCV) accounts for 90% of post-transfusion hepatitis. In Uganda, there has been limited research of prevalence of HCV among sickle cell anaemia (SS) patients, a group at risk for multiple transfusions.

Objectives

To establish prevalence of HCV infection and determine whether blood transfusion increases risk among SS patients.

Methods

244 SS patients aged 1–18 years were recruited by consecutive sampling. Socio-demographic, clinical and transfusion history was collected. Clinical examination done and blood tested for HCV by MEIA.

Results

244 children were recruited. Of these, 159 (65%) had a history of blood transfusion. Among the transfused, five patients were HCV positive. Four of these were over 12 years of age. Among patients with no history of transfusion, one patient aged 14 years was HCV positive. Risk of HCV was higher among the transfused OR 2.7(CI 0.31–24). Patients who received more than two units were more likely to be HCV positive (p=0.03).

Conclusions

HCV prevalence of 2.5% was low but higher than that reported by other investigators in Uganda. Blood transfusion was a major contributing factor in occurrence of HCV. Children who get repeated transfusions should be screened for Hepatitis C and screening of blood for HCV prior to transfusion would help reduce occurrence of the disease.     

Intracardiac surgery in infants under age 3 months: Incremental risk factors for hospital mortality

During the 13 year period from January 1967 to July 1980, the hospital mortality rate for open intracardiac operations in infants in the first 3 months of life was 43 percent (75 deaths among 194 patients), higher than the 22 percent mortality rate (35 deaths in 161 patients) for closed operations in the same age group. The mortality rate was lower late in the experience (p = 0.0001). Poor preoperative condition of the patient increased the mortality rate 87 percent in patients preoperatively acidotic or in shock [preoperative class V]and 22 percent in patients with moderate or severe symptoms but without recent hemodynamic deterioration (preoperative class II or III). The presence of major associated cardiac lesions increased hospital mortality (p < 0.0001). The hospital mortality rate was highest (59 per cent) in infants less than age 1 month, possibly in part because of their sensitivity to the damaging effects of cardiopulmonary bypass. This hypothesis is supported by the association of a long period of cardiopulmonary bypass with increased hospital mortality (p = 0.05) and of total circulatory arrest during profound hypothermia with decreased mortality (p = 0.05). Most deaths (72 percent) occurred in association with acute postoperative cardiac failure. The length of cardiac ischemia (aortic cross-clamping time) was directly related to the probability of cardiac death, unless cold cardioplegia was used. Thirteen percent of the hospital deaths were associated with acute postoperative respiratory failure. Current mortality rates in typical cases without acute hemodynamic deterioration is estimated from these data to be 7 percent (70 percent confidence limits 4 to 12 percent), as a result of the scientific advances made over this period of time. Research into mechanisms of the damaging effects of cardiopulmonary bypass should further improve results in these very young patients.