Short-term outcome after gluteus maximus myocutaneous flap reconstruction of the pelvic floor following extra-levator abdominoperineal excision of the rectum

Aim Extra‐levator abdominoperineal excision (APE) of the rectum has been introduced with the aim of improving the oncological outcome of low rectal cancer. The procedure includes resection of the levator muscles en bloc with the mesorectum, leaving a larger perineal defect than after conventional APE. This study reports short‐term outcome of gluteus maximus myocutaneous flap reconstruction on perineal wound healing. Method Sixty‐five patients were studied after extra‐levator APE and a one‐sided myocutaneous flap for a low or locally recurrent rectal cancer at the Karolinska University Hospital from January 2002 to December 2008. Fifty‐nine had received neoadjuvant radio‐ or radiochemotherapy. All perineal complications occurring within 30 days after surgery were registered. In addition, the status of the perineal reconstruction at 6 months and 1 year after surgery was assessed based on medical records from outpatient visits. Results Twenty‐seven (41.5%) patients had one or more perineal wound complications. A minor wound infection occurred in 15, while 12 had either a more severe infection with dehiscence or a pelvic abscess. The reconstruction was completely healed in 91% of the patients at 1 year. Conclusion Although the vast majority of the perineal reconstructions were healed at 1 year, the short‐term perineal wound complication rate of gluteus maximus flap reconstruction was high.     

Echocardiographic and clinical findings in patients with Fabry disease during long-term enzyme replacement therapy: a nationwide Danish cohort study

Objectives: In patients with Fabry disease (FD), left ventricular hypertrophy and arrhythmias are frequently observed and cardiac involvement is the leading cause of death. Long-term efficacy of enzyme replacement therapy (ERT) on cardiac involvement is unclear. We assessed and compared long-term progression of cardiac involvement according to ERT and non-ERT. Methods: We retrospectively assessed and compared long-term progression of cardiac involvement in adult patients with FD in the nationwide Danish cohort. We followed clinical signs, symptoms and findings by echocardiography, electrocardiography and Holter-monitoring. Results: We included 66 patients; 47 patients (27 women) received ERT (ERT group) and 19 patients (15 women) did not (non-ERT group). The groups were followed for a median of 8 [0–12] years and 6 [0–13] years, respectively. Comparison between ERT and non-ERT receiving patients by left ventricular mass (echocardiographic assessment) and Sokolow-Lyon voltage- and Cornell product criteria (electrocardiographic assessment) revealed no significant differences. In the ERT group, we observed no change in left ventricular mass but a decrease in Sokolow-Lyon voltage- and Cornell product criteria from baseline to follow-up; 30?mm [15–53] vs. 25?mm [3–44], p?p?Discussion: We raise concerns regarding the efficacy and benefit of ERT on cardiac involvement in Fabry disease and stress the need for further research.     

Glutamate infusion associated with reduced rises of p-Copeptin after coronary surgery: Substudy of GLUTAMICS II

Background

Glutamate plays a key role for post-ischaemic recovery of myocardial metabolism. According to post hoc analyses of the two GLUTAMICS trials, patients without diabetes benefit from glutamate with less myocardial dysfunction after coronary artery bypass surgery (CABG). Copeptin reflects activation of the Arginine Vasopressin system and is a reliable marker of heart failure but available studies in cardiac surgery are limited. We investigated whether glutamate infusion is associated with reduced postoperative rises of plasma Copeptin (p-Copeptin) after CABG.

Methods

A prespecified randomised double-blind substudy of GLUTAMICS II. Patients had left ventricular ejection fraction ≤0.30 or EuroSCORE II ≥3.0 and underwent CABG ± valve procedure. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h was commenced 10–20 min before the release of the aortic cross-clamp and then continued for another 150 min P-Copeptin was measured preoperatively and postoperatively on day one (POD1) and day three. The primary endpoint was an increase in p-Copeptin from the preoperative level to POD1. Postoperative stroke ≤24 h and mortality ≤30 days were safety outcomes.

Results

We included 181 patients of whom 48% had diabetes. The incidence of postoperative mortality ≤30 days (0% vs. 2.1%; p = .50) and stroke ≤24 h (0% vs. 3.2%; p = .25) did not differ between the glutamate group and controls. P-Copeptin increased postoperatively with the highest values recorded on POD1 without significant inter-group differences. Among patients without diabetes, p-Copeptin did not differ preoperatively but postoperative rise from preoperative level to POD1 was significantly reduced in the glutamate group (73 ± 66 vs. 115 ± 102 pmol/L; p = .02). P-Copeptin was significantly lower in the Glutamate group on POD1 (p = .02) and POD 3 (p = .02).

Conclusions

Glutamate did not reduce rises of p-Copeptin significantly after moderate to high-risk CABG. However, glutamate was associated with reduced rises of p-Copeptin among patients without diabetes. These results agree with previous observations suggesting that glutamate mitigates myocardial dysfunction after CABG in patients without diabetes. Given the exploratory nature of these findings, they need to be confirmed in future studies.     

Intravesical bacillus Calmette-Guèrin therapy: experience with a reduced dwell-time in patients with pronounced side-effects

OBJECTIVE: To report the side-effects after a reduction in the dwell-time in patients who had pronounced symptoms after intravesical bacillus Calmette-Guèrin (BCG) treatment, as side-effects such as fever, haematuria, and frequency are common and sometimes severe after BCG treatment in patients with bladder cancer. PATIENTS AND METHODS: The dwell-time was reduced to < or = 30 min in 51 patients who had pronounced side-effects after the preceding BCG instillation. All patients self-reported side-effects after each instillation in a questionnaire. RESULTS: After reducing the BCG dwell-time, fever, chills, dysuria and the overall time-to-recovery were significantly reduced but frequency and haematuria were not influenced. Patients with carcinoma in situ had significantly less dysuria than patients with papillary tumours. There was no difference in the treatment results between patients who had a normal dwell-time and a reduced dwell-time, determined at the first and second follow-up cystoscopy. CONCLUSION: Reducing the BCG dwell-time to < or = 30 min could be an alternative to a dose reduction in patients who experience pronounced side-effects after BCG instillations. The long-term outcome after reducing dwell-time and after dose reduction has not been studied and warrants further investigation.     

Breast Units in Europe – Certification in 9 European Countries 9 Years after the European Society of Mastology Position Paper

Summary

Introduction

We aimed to take a snapshot of breast units in the European Union 9 years after the publication of the European Society of Mastology (EUSOMA) position paper.

Methods

In order to obtain information on breast units throughout the European Union, we designed a questionnaire comprising 5 questions on certification, audit frequency and number of breast units in each country. Our primary contacts were national cancer societies, breast cancer study groups, breast cancer organizations, national associations and societies of breast treatment, as well as experts in the field of breast cancer.

Results

Information on characteristics of the certification process and number of breast units was obtained for 9 countries of the European Union. 7 of the 9 countries (78%) have a certification process of the breast units. Certification is carried out by public authorities in 4 (57%) countries and by private companies in 3 (43%) countries. Information on frequency of auditing was reported in 4 countries and varied between annual audits (Austria, Ireland and Germany) and audits once every 3 years (United Kingdom).

Conclusions

The current study suggests that the European breast unit landscape is a heterogeneous field. 9 years after the EUSOMA position paper, we do not have any standard European guidelines, neither for the development nor for the mandatory prerequisites of a breast unit. The development and operation of breast units are still country specific.Key Words: Breast units, Breast cancer, Certification criteria     

Bone Disease in Thalassemia: A Frequent and Still Unresolved Problem

Adults with β thalassemia major frequently have low BMD, fractures, and bone pain. The purpose of this study was to determine the prevalence of low BMD, fractures, and bone pain in all thalassemia syndromes in childhood, adolescence, and adulthood, associations of BMD with fractures and bone pain, and etiology of bone disease in thalassemia. Patients of all thalassemia syndromes in the Thalassemia Clinical Research Network, ≥6 yr of age, with no preexisting medical condition affecting bone mass or requiring steroids, participated. We measured spine and femur BMD and whole body BMC by DXA and assessed vertebral abnormalities by morphometric X‐ray absorptiometry (MXA). Medical history by interview and review of medical records, physical examinations, and blood and urine collections were performed. Three hundred sixty‐one subjects, 49% male, with a mean age of 23.2 yr (range, 6.1–75 yr), were studied. Spine and femur BMD Z‐scores < ?2 occurred in 46% and 25% of participants, respectively. Greater age, lower weight, hypogonadism, and increased bone turnover were strong independent predictors of low bone mass regardless of thalassemia syndrome. Peak bone mass was suboptimal. Thirty‐six percent of patients had a history of fractures, and 34% reported bone pain. BMD was negatively associated with fractures but not with bone pain. Nine percent of participants had uniformly decreased height of several vertebrae by MXA, which was associated with the use of iron chelator deferoxamine before 6 yr of age. In patients with thalassemia, low BMD and fractures occur frequently and independently of the particular syndrome. Peak bone mass is suboptimal. Low BMD is associated with hypogonadism, increased bone turnover, and an increased risk for fractures.     

Der freie und gestielte Muskeltransfer als Therapieoption in der urologischen Chirurgie

Zusammenfassung Verschiedene Anforderungen der Rekonstruktion definieren die Technik zur Wiederherstellung. Das Grundprinzip besteht in einer optimalen anatomischen und funktionellen Rekonstruktion bei gleichzeitiger minimaler Hebedefekt-Morbidität. In Abhängigkeit von der Ätiologie des Defekts stehen unterschiedliche Möglichkeiten der Rekonstruktion zur Verfügung, um ein optimales Ergebnis zu erreichen. Eine sofortige einzeitige Rekonstruktion kann gerade unter Einbeziehung eines interdisziplinären Teams erreicht werden, wobei das bestmögliche Ergebnis individuell für jeden Patienten im Vordergrund steht. In dieser Übersicht werden die häufigsten Indikationen und Prinzipien zur Lappenauswahl entsprechend den rekonstruktiven Erfordernissen vorgestellt, um die Patienten früher zu rehabilitieren oder aber eine weitere notwendige adjuvante Therapie früher einleiten zu können.     

What do patients,their relatives and medical staff know about genetic therapy?

Objectives: To investigate the knowledge of, and attitudes towards gene therapy of cancer patients, their relatives, and the staff treating the patients. Design: Cross sectional questionnaire study. Subjects: a) One hundred patients with ovarian cancer either 1) in current treatment with chemotherapy, or 2) in follow up after chemotherapy. b) The relatives accompanying these patients to clinic. c) Fifty doctors and fifty nurses at the hospital in question. Main outcome measures: Knowledge about genes and gene therapy, attitudes toward gene therapy and its introduction in the NHS, willingness to accept additional side-effects for a given-therapeutic gain. Results: Patients and relatives have only limited knowledge about genes and gene therapy, but knowledge is also limited about how chemotherapy works. The attitude towards gene therapy is positive, and the worry about gene therapy being like 'playing God' is accepted by less than 10%. There is a strong belief that if gene therapy is effective it should be paid by the NHS (over 85% agree with this).