Breast cancer surgery without suction drainage and impact of mastectomy flap fixation in reducing seroma formation (2017)

Type of publication:
Conference abstract

Author(s):
*Zaidi S.; *Hinton C.

Citation:
European Journal of Surgical Oncology; May 2017; vol. 43 (no. 5)

Abstract:
Background: One of the most invalidating complications after breast cancer surgery is seroma formation. The incidence of seroma formation after breast surgery varies from 3% to 85%. Seroma formation and inadequate drainage of seroma may lead to infections, pain, hospitalization and delay in treatment. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants. Aim: To determine the effect of a ‘no drains’ policy on seroma formation and other complications in women undergoing breast cancer surgery and to evaluate the effect of obliteration of dead space by suture fixation of the mastectomy flaps to the underlying chest wall, on the amount and duration of postoperative fluid drainage and incidence of seroma formation after breast surgery. Materials and methods: A retrospective analysis was performed on a consecutive series of patients that had been treated with mastectomy with or without axillary surgery for breast cancer for the last 1 year. Patients divided into Group 1 the wound was closed in the conventional method at the edges and closed suction drains are used. Group 2; after completing the mastectomy procedure, using absorbable sutures (vicryl), continuous stitches 3 cm apart were taken, in rows, between the subcutaneous tissues of the skin flaps and the underlying muscles. Special attention is taken to the obliteration of the largest potential dead space, the empty axillary apex. Closed suction drains are used. Group 3 similar procedure but no drain used. The patient characteristics collected were: age, type of surgery, side of the affected breast, neoadjuvant chemotherapy, diabetes, body mass index (BMI), smoking, anticoagulants usage and length of hospital stay. Definitions: Postoperative haematoma: clear postoperative haematoma formation in the area of the operation, for which intervention is necessary. Wound infection: clinical signs of infection (pain, swelling, erythema, fever, exudate, delayed wound healing or breakdown), purulent discharge or a positive microbiological culture. Seroma production: palpable fluid collection, with serous consistency, produced subcutaneous in the area of operation or axilla Results: 113 women were included in the study. Women underwent modified radical mastectomy (MRM) and ALND , MRM +/- sentinel lymph node biopsy (SLNB) /axillary node sampling (ANS) and simple Mx. There was no significant difference between the studied groups concerning the age, type of surgery, side of the affected breast, neoadjuvant chemotherapy, diabetes, body mass index (BMI), smoking, anticoagulants usage. There were six patients with evacuation of haematoma postoperatively and belong to group 1 and 2 with drains. The number (and percentage) of women with wound infection was none in the group 1, 8 in gp 2 and 2 among gp 3 patients. Seroma formation was 10 in gp 1, 9 in gp 2 and 4 in gp 3. The length of hospital stays (days) was 2.7 in gp 1, 2.6 in gp 2 and 1.3 days in gp 3 patients with no drains (ND). Conclusion: This study investigated that wound drainage following mastectomy could be avoided by suturing flaps to the underlying chest wall, thereby facilitating early discharge with no associated increase in surgical morbidity. This study suggests that MRM +/- ALND/SLNB/ANS can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a ‘nodrains’ policy may also contribute to earlier hospital discharge.

Link to full-text: http://www.ejso.com/article/S0748-7983(17)30225-1/abstract

Term admissions to neonatal units in England: A role for transitional care? A retrospective cohort study (2017)

Type of publication:
Journal article

Author(s):
Battersby C.; Michaelides S.; Upton M.; Rennie J.M.; Babirecki M.; Harry L.; Rackham O.; Wickham T.; Hamdan S.; Gupta A.; Wigfield R.; Wong L.; Mittal A.; Nycyk J.; Simmons P.; Singh A.; Seal S.; Hassan A.; Schwarz K.; Thomas M.; Foo A.; Shastri A.; Whincup G.; Brearey S.; Chang J.; Gad K.; Hasib A.; Garbash M.; Allwood A.; Adiotomre P.; Ahmed J.S.; Deketelaere A.; Khader K.A.; Shephard R.; Mallik A.; Abuzgia B.; Jain M.; Pirie S.; Zengeya S.; Watts T.; Jampala C.; Seagrave C.; Cruwys M.; Dixon H.; Aladangady N.; Gaili H.; James M.; Lal M.; Ambadkar; Rao P.; Hickey A.; Dave D.; Pai V.; Lama M.; Miall L.; Cusack J.; Kairamkonda V.; Jayachandran; Kollipara; Kefas J.; Yoxall B.; Whitehead G.; Krishnamurthy; Soe A.; Misra I.; Pillay T.; Ali I.; Dyke M.; Selter M.; Panasa N.; Alsford L.; Spencer V.; Gupta S.; Nicholl R.; Wardle S.; McBride T.; Shettihalli N.; Adams E.; Babiker S.; Crawford M.; Gibson D.; Khashu M.; Toh C.; Hall M.; Sleight E.; Groves C.; Godambe S.; Bosman D.; Rewitzky G.; Banjoko O.; Kumar N.; Manzoor A.; Lopez W.; D’Amore A.; Mattara S.; Zipitis C.; De Halpert P.; Settle P.; Munyard P.; McIntyre J.; Bartle D.; Yallop K.; Fedee J.; Maddock N.; Gupta R.; *Deshpande S.; Moore A.; Godden C.; Amess P.; Jones S.; Fenton A.; Mahadevan; Brown N.; Mack K.; Bolton R.; Khan A.; Mannix P.; Huddy C.; Yasin S.; Butterworth S.; Edi-Osagie N.; Cairns P.; Reynolds P.; Brennan N.; Heal C.; Salgia S.; Abu-Harb M.; Birch J.; Knight C.; Clark S.; Van Sommen V.; Murthy V.; Paul S.; Kisat H.; Kendall G.; Blake K.; Kuna J.; Kumar H.; Vemuri G.; Rawlingson C.; Webb D.; Bird; Narayanan S.; Gane J.; Eyre E.; Evans I.; Sanghavi R.; Sullivan C.; Amegavie L.; Leith W.; Vasu V.; Gallagher A.; Vamvakiti K.; Eaton M.; Millman G.

Citation:
BMJ Open; May 2017; vol. 7 (no. 5)

Abstract:
Objective: To identify the primary reasons for term admissions to neonatal units in England, to determine risk factors for admissions for jaundice and to estimate the proportion who can be cared for in a transitional setting without separation of mother and baby. Design: Retrospective observational study using neonatal unit admission data from the National Neonatal Research Database and data of live births in England from the Office for National Statistics. Setting: All 163 neonatal units in England 2011-2013. Participants: 133 691 term babies born >=37 weeks gestational age and admitted to neonatal units in England. Primary and secondary outcomes: Primary reasons for admission, term babies admitted for the primary reason of jaundice, patient characteristics, postnatal age at admission, total length of stay, phototherapy, intravenous fluids, exchange transfusion and kernicterus. Results: Respiratory disease was the most common reason for admission overall, although jaundice was the most common reason for admission from home (22% home vs 5% hospital). Risk factors for admission for jaundice include male, born at 37 weeks gestation, Asian ethnicity and multiple birth. The majority of babies received only a brief period of phototherapy, and only a third received intravenous fluids, suggesting that some may be appropriately managed without separation of mother and baby. Admission from home was significantly later (3.9 days) compared with those admitted from elsewhere in the hospital (1.7 days) (p<0.001). Conclusion: Around two-thirds of term admissions for jaundice may be appropriately managed in a transitional care setting, avoiding separation of mother and baby. Babies with risk factors may benefit from a community midwife postnatal visit around the third day of life to enable early referral if necessary. We recommend further work at the national level to examine provision and barriers to transitional care, referral pathways between primary and secondary care, and community postnatal care

Link to full-text: http://bmjopen.bmj.com/content/7/5/e016050

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Gefitinib and EGFR Gene Copy Number Aberrations in Esophageal Cancer (2017)

Type of publication:
Journal article

Author(s):
Petty, Russell D; Dahle-Smith, Asa; Stevenson, David A J; Osborne, Aileen; Massie, Doreen; Clark, Caroline; Murray, Graeme I; Dutton, Susan J; Roberts, Corran; Chong, Irene Y; Mansoor, Wasat; Thompson, Joyce; Harrison, Mark; *Chatterjee, Anirban; Falk, Stephen J; Elyan, Sean; Garcia-Alonso, Angel; Fyfe, David Walter; Wadsley, Jonathan; Chau, Ian; Ferry, David R; Miedzybrodzka, Zosia

Citation:
Journal of Clinical Oncology : official journal of the American Society of Clinical Oncology; July 10;35(20):2279-2287

Abstract:
Purpose The Cancer Esophagus Gefitinib trial demonstrated improved progression-free survival with the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor gefitinib relative to placebo in patients with advanced esophageal cancer who had disease progression after chemotherapy. Rapid and durable responses were observed in a minority of patients. We hypothesized that genetic aberration of the EGFR pathway would identify patients benefitting from gefitinib. Methods A prespecified, blinded molecular analysis of Cancer Esophagus Gefitinib trial tumors was conducted to compare efficacy of gefitinib with that of placebo according to EGFR copy number gain (CNG) and EGFR, KRAS, BRAF, and PIK3CA mutation status. EGFR CNG was determined by fluorescent in situ hybridization (FISH) using prespecified criteria and EGFR FISH-positive status was defined as high polysomy or amplification. Results Biomarker data were available for 340 patients. In EGFR FISH-positive tumors (20.2%), overall survival was improved with gefitinib compared with placebo (hazard ratio [HR] for death, 0.59; 95% CI, 0.35 to 1.00; P = .05). In EGFR FISH-negative tumors, there was no difference in overall survival with gefitinib compared with placebo (HR for death, 0.90; 95% CI, 0.69 to 1.18; P = .46). Patients with EGFR amplification (7.2%) gained greatest benefit from gefitinib (HR for death, 0.21; 95% CI, 0.07 to 0.64; P = .006). There was no difference in overall survival for gefitinib versus placebo for patients with EGFR, KRAS, BRAF, and PIK3CA mutations, or for any mutation versus none. Conclusion EGFR CNG assessed by FISH appears to identify a subgroup of patients with esophageal cancer who may benefit from gefitinib as a secondline treatment. Results of this study suggest that anti-EGFR therapies should be investigated in prospective clinical trials in different settings in EGFR FISH-positive and, in particular, EGFR-amplified esophageal cancer.

Does CIN2 Have the Same Aggressive Potential As CIN3? A Secondary Analysis of High-Grade Cytology Recurrence in Women Treated with Cold-Coagulation Cervical Treatment (2017)

Type of publication:
Journal article

Author(s):
*Papoutsis D.; *Underwood M .; *Parry-Smith W.; *Panikkar J.

Citation:
Geburtshilfe und Frauenheilkunde; Mar 2017; vol. 77 (no. 3); p. 284-289

Abstract:
Introduction To determine whether women with CIN2 versus CIN3 on pretreatment cervical punch biopsy have less high-grade cytology recurrence following cold-coagulation cervical treatment. Materials and Methods This was a retrospective study of women having had cold coagulation between 2001-2011 in our colposcopy unit. Women with previous cervical treatment were excluded. Results We identified 402 women with 260 (64.7?%) cases of CIN2 and 142 (35.3?%) cases of CIN3 on pretreatment cervical punch biopsy. In the total sample, the mean age of women was 27.5 years (SD = 4.9), 75.1?% were nulliparous and 36.6?% were smokers. Referral cytology and pretreatment colposcopic appearance were high-grade in 62.7?% and 57.1?%. The mean follow-up period was 2.8 years (SD = 2.1). Women with CIN2 on pretreatment cervical biopsy when compared to those with CIN3 had less frequently high-grade referral cytology and high-grade pretreatment colposcopic appearances, and had less pretreatment cervical biopsies taken. During the follow-up period, women with CIN2 on pretreatment cervical biopsy had less high-grade cytology recurrence when compared to those women with CIN3 (1.9 vs. 5.6?%, p = 0.046). Multiple stepwise Cox regression analysis showed that women with CIN3 on pretreatment cervical biopsy had 3.21 times greater hazard for high-grade cytology recurrence (HR = 3.21, 95?% CI: 1.05-9.89; p = 0.041) in comparison with CIN2 cases. Conclusion We found that women with CIN2 on pretreatment cervical punch biopsy had less high-grade cytology recurrence following cold-coagulation treatment in comparison to those with CIN3. This finding lends support to the theory that CIN2 even though a high-grade abnormality might not have the same aggressive potential as CIN3.

Anatomical siting of the splenic flexure using computed tomography (2017)

Type of publication:
Journal article

Author(s):
*Meecham, L; *Brookes, A; *Macano, Caw; *Stone, T; *Cheetham, M

Citation:
Annals of the Royal College of Surgeons of England; Mar 2017; vol. 99 (no. 3); p. 207-209

Abstract:
INTRODUCTION Often, left-sided colorectal surgery requires splenic flexure mobilisation (SFM) to allow a tension-free anastomosis to be carried out. This step is difficult and not without risk. We investigated a system of anatomical siting of the splenic flexure using computed tomography (CT). METHODS The Shrewsbury Splenic Flexure Siting (SSFS) system involves siting of the splenic flexure using the vertebral level (VL) as a reference point. We asked three surgical registrars (SRs) to analyse 20 CT scans of patients undergoing colonic resection to ascertain the anatomical site of the splenic flexure using the SSFS system. The distance from the centre of the vertebral body to the lateral edge (CVBL) of the splenic flexure was measured, as was the distance from the centre of the vertebral body to the inner abdominal wall (CVBI) along the same line, on axial images. RESULTS VL assessment demonstrated substantial inter-observer agreement with a kappa (κ) value of 0.742 (95% confidence interval (CI), 0.463-0.890). CVBL and CVBI demonstrated very strong inter-observer agreement (CVBL: κ = 0.905 (95% CI, 0.785-0.961); CVBI: 0.951 (0.890-0.979) (p<0.001). Overall, there was strong correlation between assessments by all three SRs across the three variables measured. CONCLUSIONS The SSFS system is an accurate method to site the splenic flexure anatomically using CT. We can use the SSFS system to develop a validated scoring system to help colorectal surgeons assess the difficulty of SFM.

Etest versus broth microdilution for ceftaroline MIC determination with Staphylococcus aureus: Results from PREMIUM, a European multicentre study (2017)

Type of publication:
Journal article

Author(s):
Canton R.; Morosini M.I.; Livermore D.M.; Diaz-Reganon J.; Rossolini G.M.; Verhaegen J.; Cartuyvels R.; Claeys G.; De Beenhouwer H.; Delmee M.; Denis O.; Glupczynski Y.; Leven G.; Melin P.; Pierard D.; Pagani L.; Arena F.; Luzzaro F.; Gesu G.P.; Serra R.; D’Argenio A.; Sarti M.; Pecile P.; Mazzariol A.; Biscaro V.; Manso E.; Catania M.R.; Giraldi C.; Stefani S.; Labonia M.; Aschbacher R.; Giammanco A.; Cristino M.; Sancho L.; Diogo J.M.; Ramalheira E.; Ramos H.; Pinheiro D.; Garcia-Castillo M.; Calvo J.; Oliver A.; Gimeno C.; Pascual A.; Quintano F.T.; Bartolome R.; Cisterna R.; Cercenado E.; Merino P.; Marco F.; Bou G.; Sanchez J.E.G.; Cilla G.; Iglesias M.R.; Droz S.; Frei R.; James D.; Mushtaq S.; Howe R.; Paton R.; Gould K.; Eyre A.; Jepson A.; Swann A.; Weston D.; *Harvey G.; Humphrey H.

Citation:
Journal of Antimicrobial Chemotherapy; 2017; vol. 72 (no. 2); p. 431-436

Abstract:
Objectives: To compare the concordance of ceftaroline MIC values by reference broth microdilution (BMD) and Etest (bioMerieux, France) for MSSA and MRSA isolates obtained from PREMIUM (D372SL00001), a European multicentre study. Methods: Ceftaroline MICs were determined by reference BMD and by Etest for 1242 MSSA and MRSA isolates collected between February and May 2012 from adult patients with community-acquired pneumonia or complicated skin and soft tissue infections; tests were performed across six European laboratories. Selected isolates with ceftaroline resistance in broth (MIC >1 mg/L) were retested in three central laboratories to confirm their behaviour. Results: Overall concordance between BMD and Etest was good, with >97% essential agreement and >95% categorical agreement. Nevertheless, 12 of the 26 MRSA isolates found resistant by BMD scored as susceptible by Etest, with MICs <1 mg/L, thus counting as very major errors, whereas only 5 of 380 MRSA isolates found ceftaroline susceptible in BMD were miscategorized as resistant by Etest. Twenty-one of the 26 isolates with MICs of 2 mg/L by BMD were then retested twice by each of three central laboratories: BMD MICs of 2 mg/L were consistently found for 19 of the 21 isolates. Among 147 Etest results for these 21 isolates (original plus six repeats per isolate) 112 were >1 mg/L. Conclusions: BMD and Etest have good overall agreement for ceftaroline against Staphylococcus aureus; nevertheless, reliable Etest based discrimination of the minority of ceftaroline-resistant (MIC 2 mg/L) MRSA is extremely challenging, requiring careful reading of strips, ideally with duplicate testing.

Link to full-text: jac.oxfordjournals.org/content/early/2016/10/19/jac.dkw442.full.pdf

End of Life Care Marriages in a Hospital setting (2017)

Type of publication:
Post on the Academy of Fab NHS Stuff website

Author(s):
Jules Lewis

Abstract:
Shrewsbury and Telford Hospital NHS Trust Staff have been working hard to have a clear process for when an End of Life Care Patient wishes to get married in Hospital.

Flowcharts have been designed for both Ward Staff and the Chaplaincy service to follow to ensure the process is done without confusion and nothing is forgotten at this special and emotional time, this includes required documentation for special licence and contact details of people who will be able to assist in and out of hours.

Both religious and civil services can be offered depending on the couples preference.

The end of life care team have created a wedding bag to assist the ward staff in making this day as special as possible, this includes bunting, a ring box, a wedding card, champagne glasses and fizz, confetti, pen, paper, a keepsake gift and the flow charts on the process.

The Ward staff together with the End of Life Care Team get flowers and cake on the big day.

Ward Staff even managed to get a photographer to capture the special day for the wedding earlier this year with our hospital photographer printing the photos for the couple next working day, the wedding even took place in our swan room which made it extra special.

Thank you to everyone involved in making this happen from the Registrar services, Hospital Chaplaincy Team, End of Life Care Team, Communications Team, Photographer, Ward Staff and to the Director of Corporate Governance.

Together we made it happen because it’s the right thing to do as we have one chance to get it right.

Link to more details

Comparison of cure rates in women treated with cold-coagulation versus LLETZ cervical treatment for CIN2-3 on pretreatment cervical punch biopsies: a retrospective cohort study (2017)

Type of publication:
Journal article

Author(s):
*Papoutsis D, *Underwood M , *Parry-Smith W, *Panikkar J.

Citation:
Archives of Gynecology and Obstetrics. 2017 Apr;295(4):979-986

Abstract:
PURPOSE:
To compare the cure rates between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 (CIN2) or 3 (CIN3) on pretreatment cervical punch biopsies.
METHODS:
This was a retrospective cohort study of women having had a single cervical treatment for CIN2 or CIN3 on pretreatment cervical punch biopsies between 2010 and 2011. The cure rates were defined as the absence of any dyskaryosis (mild/moderate/severe) on cytology tests during follow-up and were determined at 6 and 12 months after treatment.
RESULTS:
We identified 411 women having had cervical treatment with 178 cases of cold-coagulation and 233 cases of LLETZ. The cure rates at 6 months following cold-coagulation and LLETZ treatment were 91.6 versus 97.1% (p = 0.02), whereas at 12 months, they were 96.5 versus 97.3% (p = 0.76). Multivariable analysis showed that after adjusting for confounding factors, there was a fourfold higher cure rate with LLETZ in comparison with cold-coagulation at 6 months after treatment (adjusted OR 4.50, 95% CI 1.20-16.83; p = 0.026), with this difference disappearing at 12 months. The lower cure rates with cold-coagulation were due to its higher rates of mild dyskaryosis cytology tests at 6 months. The rates of moderate/severe dyskaryosis cytology tests were similar between the two treatment methods at 6 and 12 months.
CONCLUSION:
We found that women with CIN2 or CIN3 on pretreatment cervical punch biopsies, after adjusting for multiple confounding factors, had higher cure rates when treated with LLETZ versus cold-coagulation at 6 months, with this difference disappearing at 12 months.

The spectrum of renal allograft failure (2016)

Type of publication:
Journal article

Author(s):
*Chand S. , Atkinson D., Collins C., Briggs D., Ball S., Sharif A., Skordilis K., Vydianath B., Neil D., Borrows R.

Citation:
PLoS ONE, September 2016, vol./is. 11/9(no pagination)

Abstract:
Background: Causes of “true” late kidney allograft failure remain unclear as study selection bias and limited follow-up risk incomplete representation of the spectrum. Methods: We evaluated all unselected graft failures from 2008-2014 (n = 171; 0-36 years post-transplantation) by contemporaryclassification of indication biopsies “proximate” to failure, DSA assessment, clinical and biochemical data. Results: The spectrum of graft failure changed markedly depending on the timing of allograft failure. Failures within the first year were most commonly attributed to technical failure, acute rejection (with T-cell mediated rejection [TCMR] dominating antibody-mediated rejection [ABMR]). Failures beyond a year were increasingly dominated by ABMR and ‘interstitial fibrosis with tubular atrophy’ without rejection, infection or recurrent disease (“IFTA”). Cases of IFTA associated with inflammationin non-scarred areas (compared with no inflammation or inflammation solely within scarred regions) were more commonly associated with episodes of prior rejection, late rejection and nonadherence, pointing to an alloimmune aetiology. Nonadherence and late rejection were common in ABMR and TCMR, particularly Acute Active ABMR. Acute Active ABMR and nonadherence were associated with younger age, faster functional decline, and less hyalinosis on biopsy. Chronic and Chronic Active ABMR were more commonly associated with Class II DSA. C1q-binding DSA, detected in 33% of ABMR episodes, were associated with shortertime to graft failure. Most non-biopsied patients were DSA-negative (16/21; 76.1%). Finally, twelve losses to recurrent disease were seen (16%). Conclusion: This data from an unselected population identifies IFTA alongside ABMR as a very important cause of true late graft failure, with nonadherence-associated TCMR as a phenomenon in some patients. It highlights clinical and immunological characteristics of ABMR subgroups, and should inform clinical practice and individualised patient care.

Link to more details or full-text: http://search.proquest.com/docview/1821784851/F5FCCBF39FE8431CPQ/4?accountid=49082