Outcomes of free vascularised fibular graft reconstruction in upper limb trauma-a systematic review.

PURPOSE: To evaluate existing literature describing the use of free fibular flaps in upper extremity trauma and summarise flap outcomes. Secondary objectives are to evaluate patient demographics and flap characteristics. METHODS: EMBASE, PubMed, MEDLINE and the Cochrane Database were searched for eligible studies published from 1975 to January 2019. Primary outcome measures collected were rate of union, graft survival rate, and complication rates. Patient demographics and flap characteristics were also collected. Statistical analysis was performed using SPSS software (SPSS version 25; IBM, Chicago, USA). Pooled data were presented as mean and standard deviation or median and range. Categorical variables were assessed by chi-squared test. Quality of studies were assessed using the National Institutes of Health (NIH) Quality Assessment Tool for case series studies. RESULTS: Initial search yielded 1070 articles. A total of 25 studies (151 cases) met the inclusion criteria. Flap survival was 97% (147/151) at time of follow-up, with first union rate of 95% (142/151) and second union rate of 97% (147/151) following bone graft or further procedure. Overall complication rate was 33% (47/140). There was a statistically significant association between recipient flap site and rates of flap fracture (p = 0.049). There was no statistically significant association between flap type, evidence of infection at donor or defect site, or method of flap fixation on outcomes. CONCLUSIONS: Vascularised fibular flaps are a safe and efficacious reconstructive option for upper limb trauma. Further research is required to enable better understanding of the impact of patient and clinical factors on flap outcome measures.

Cohort profile of the Sloane Project: methodology for a prospective UK cohort study of >15 000 women with screen-detected non-invasive breast neoplasia.

PURPOSE: The introduction of breast screening in the UK led to an increase in the detection of non-invasive breast neoplasia, predominantly ductal carcinoma in situ (DCIS), a non-obligatory precursor of invasive breast cancer. The Sloane Project, a UK prospective cohort study of screen-detected non-invasive breast neoplasia, commenced in 2003 to evaluate the radiological assessment, surgical management, pathology, adjuvant therapy and outcomes for non-invasive breast neoplasia. Long-term follow-up and accurate data collection are essential to examine the clinical impact. Here, we describe the establishment, development and analytical processes for this large UK cohort study. PARTICIPANTS: Women diagnosed with non-invasive breast neoplasia via the UK National Health Service Breast Screening Programme (NHSBSP) from 01 April 2003 are eligible, with a minimum age of 46 years. Diagnostic, therapeutic and follow-up data collected via proformas, complement date and cause of death from national data sources. Accrual for patients with DCIS ceased in 2012 but is ongoing for patients with epithelial atypia/in situ neoplasia, while follow-up for all continues long term. FINDINGS TO DATE: To date, patients within the Sloane cohort comprise one-third of those diagnosed with DCIS within the NHSBSP and are representative of UK practice. DCIS has a variable outcome and confirms the need for longer-term follow-up for screen-detected DCIS. However, the radiology and pathology features of DCIS can be used to inform patient management. We demonstrate validation of follow-up information collected from national datasets against traditional, manual methods. FUTURE PLANS: Conclusions derived from the Sloane Project are generalisable to women in the UK with screen-detected DCIS. The follow-up methodology may be extended to other UK cohort studies and routine clinical follow-up. Data from English patients entered into the Sloane Project are available on request to researchers under data sharing agreement. Annual follow-up data collection will continue for a minimum of 20 years.

Pressure-related flow rates for continuous renal replacement therapy in very small children: an in vitro study.

OBJECTIVE: Continuous renal replacement therapy (CRRT) is extremely challenging in very small children, as most CRRT intravascular access devices are too large. We aimed to quantify flow rates through several alternative intravascular devices. DESIGN: Experimental in vitro study simulating CRRT. SETTING: Whole milk and equine blood were used as human blood substitutes due to similar viscosity. Milk under gravity pressure was run through a standard CRRT circuit. Equine blood was run through a working CRRT machine. SUBJECTS: Eight intravenous access devices used in paediatrics, with a variety of connectors. INTERVENTIONS: Devices were tested with milk for flow between 50 and 200 mm Hg pressure, and with blood for pressure at flows between 20 and 50 mL/min. MAIN OUTCOME MEASURES: Flows at each input pressure with milk, and pressures at each flow rate with blood. RESULTS: With both experimental systems, 8Fr and 6.5Fr haemodialysis catheters, and 18G and 20G cannulae allowed excellent low pressure flow rates. 5Fr triple central catheter, 5Fr and 4Fr umbilical venous catheter, and 5Fr haemodialysis catheters did not allow flows at reasonable pressures for CRRT. A three-way tap did not impede flows, but a needle-free valve did. Flows increased with pressure non-linearly, presumably due to increasing turbulence. CONCLUSIONS: In very small patients needing CRRT, where large haemodialysis catheters cannot be used due to the patient size, we advise the use of two 18G cannulae in different sites. A three-way tap can be added, but not any other connectors. In vitro this system gave suitable flow rates with some flexibility for in vivo variations.