Is outcome worse in a small volume Canadian trauma centre?

The minimum number of seriously injured patients required to maintain clinical competence and achieve acceptable clinical competence in a single trauma centre is unknown. It has been suggested that the probability of survival is improved in hospitals treating greater than 200 trauma patients annually. We sought to determine if probability of survival was lower in our small volume centre. Between 1986 and 1989, 752 (522 male, 230 female; average age, 36 years) trauma patients were admitted to our institution. The major mechanism of injury was blunt (89%). All patients underwent trauma severity scoring. Trauma Score, Injury Severity Score, and a Revised Trauma Score were used to derived the probability of survival by the TRISS method. The mean Injury Severity Score was 23.3 and the mean Trauma Score was 13.2. The overall mortality rate was 15.8%. The Z statistic demonstrated no significant difference between actual and predicted deaths for the 4-year period or for any individual year (range, -1.05 to 1.26, p greater than 0.05). The M statistic was 0.753. We conclude that, despite fewer trauma patient admissions (less than 200 per year), comparable clinical results can be achieved by surgeons dedicated to trauma management.     

1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma (MelMarT): A Feasibility Study

Background

There is a lack of consensus regarding optimal surgical excision margins for primary cutaneous melanoma?>?1 mm in Breslow thickness (BT). A narrower surgical margin is expected to be associated with lower morbidity, improved quality of life (QoL), and reduced cost. We report the results of a pilot international study (MelMarT) comparing a 1 versus 2-cm surgical margin for patients with primary melanoma?>?1 mm in BT.

Methods

This phase III, multicentre trial [NCT02385214] administered by the Australia & New Zealand Medical Trials Group (ANZMTG 03.12) randomised patients with a primary cutaneous melanoma?>?1 mm in BT to a 1 versus 2-cm wide excision margin to be performed with sentinel lymph node biopsy. Surgical closure technique was at the discretion of the treating surgeon. Patients’ QoL was measured (FACT-M questionnaire) at baseline, 3, 6, and 12 months after randomisation.

Results

Between January 2015 and June 2016, 400 patients were randomised from 17 centres in 5 countries. A total of 377 patients were available for analysis. Primary melanomas were located on the trunk (56.9%), extremities (35.6%), and head and neck (7.4%). More patients in the 2-cm margin group required reconstruction (34.9 vs. 13.6%; p?<?0.0001). There was an increased wound necrosis rate in the 2-cm arm (0.5 vs. 3.6%; p?=?0.036). After 12 months’ follow-up, no differences were noted in QoL between groups.

Discussion

This pilot study demonstrates the feasibility of a large international RCT to provide a definitive answer to the optimal excision margin for patients with intermediate- to high-risk primary cutaneous melanoma.

     

Chronic mucocutaneous candidiasis with macrophage dysfunction, a plasma inhibitor, and co-existent aplastic anemia.

A 56-year-old man developed chronic mucocutaneous candidiasis (MCC) and pernicious anemia. Nine years later he developed aplastic anemia which ultimately was fatal. A small thymoma was found at autopsy. He was anergic and his mononuclear leukocytes (MNL) failed to undergo a proliferative response in culture to soluble antigens. His monocytes did not mediate a proliferative response by lymphocytes from sensitized control donors when stimulated with Monilia albicans antigen but did mediate a mixed leukocyte reaction normally. His plasma contained a poten inhibitor of -3H-thymidine incorporation by sensitized control MNL when stimulated with soluble antigens but was not inhibitory of the mixed leukocyte reaction, lymphoproliferative responses to plant mitogens, and was not shown either in vivo or in vitro to depress hematopoiesis. Patient lymphocytes were responsive to plant mitogens, Monilia antigen, in the mixed leukocyte reaction, and produced macrophage migration inhibitory factor in response to Monilia antigen. After plasmapheresis, delayed hypersensitivity and lymphoproliferative responses to soluble antigens were temporarily restored. This case implicates the macrophage in the pathogenesis of MCC and demonstrates some consequences of chronic monocyte dysfunction. The inhibitor of some expressions of cell-mediated immunity was removed by plasmapheresis.     

A direct method for the diagnosis of human hepatic type 1b and type 1c glycogen-storage disease

1. Type 1b and type 1c glycogen-storage disease are caused respectively by deficiencies of the glucose-6-phosphate translocase and the phosphate/pyrophosphate translocase of the human hepatic microsomal glucose-6-phosphatase system. 2. Current methods of unequivocally diagnosing type 1b and type 1c glycogen storage disease are indirect and complex. 3. We have therefore developed a simple, rapid and direct microfiltration assay for the glucose-6-phosphate translocase and the phosphate/pyrophosphate translocase. 4. We have demonstrated that the microfiltration assay can be used to directly diagnose type 1b and 1c glycogen-storage disease in microsomes isolated from hepatic needle-biopsy samples.