Survival outcomes of elderly patients referred to the lower gastrointestinal 2-week wait service.

AIM: The benefit to elderly patients (≥80 years old) of referral to the resource-intensive lower gastrointestinal 2-week wait (LGI-2WW) pathway is unknown. The aim of this study was to investigate the survival outcome of elderly patients referred to a LGI-2WW service. METHOD: This study comprised a retrospective analysis of a prospectively gathered database of patients referred to a single-centre LGI-2WW service and conformed to STROBE guidelines. The primary outcome was all-cause mortality. Statistical analysis was performed with the chi-square test and Kaplan-Meier survival curves compared with the generalized log-rank test. RESULTS: A total of 10 155 patients referred to the LGI-2WW service between 1 January 2015 and 31 December 2018 were analysed; median follow-up was 37.0 months (range 0-66 months). Six hundred and ninety one cancers were diagnosed (6.8% detection rate); 551 (80%) of these were lower GI cancers (LGICas) [517 (75%) colorectal; 34 (5%) anal]. Forty per cent of LGICas were diagnosed via the LGI-2WW service. Patients aged ≥80 years with LGICa were more likely to be treated with palliative intent [age <80 years, 92/360 (26%) vs. age ≥80 years, 105/191 (55%); p < 0.001]. LGICa patients aged <85 years had a survival difference between those treated with curative intent (LGICa-Cur) or palliative intent (LGICa-Pal) (median survival for patients aged 80-84 years: LGICa-Cur 57 months vs. LGICa-Pal 15 months; p < 0.001). Patients aged ≥85 years did not have any survival difference by treatment intent (median survival for patients aged 85-89 years: LGICa-Cur 31 months vs. LGICa-Pal 16 months; p = 0.062; median survival for patients aged ≥90 years: LGICa-Cur 14 months vs. LGICa-Pal 16 months; p = 0.703). CONCLUSION: Patients with LGICa aged ≥85 years have similar survival whether treated with curative or palliative intent. This can inform management discussions with patients and LGI-2WW referral pathway prioritization approaches.

The association of breast surgery ASPIRE: breast pain pathway rapid evaluation project - study protocol.

Background: Breast pain accounts for 20-40% of new referrals to breast units in the UK and these patients have a very low risk of breast cancer. Patients have previously been assessed in resource-intensive, cancer-exclusion, one stop clinics, which are now failing to meet government targets due to excessive demand. UK Breast units are increasingly piloting Breast Pain-only Pathways (BPP) to assess these patients, and there is no consensus for the optimal pathway. The aim of this prospective multicentre study is to assess the safety and patient satisfaction of different BPPs to inform future BPP design and implementation. Methods: All UK breast units will be invited to join the ASPIRE study between January 2023 and December 2023. Units with a BPP are invited to submit their pathway for evaluation; and those without a BPP who see patients with breast pain-only in a one stop clinics setting are also invited to join the study to evaluate the traditional pathway model concurrently. Patient satisfaction assessments will be collected after their initial consultation and patient outcomes, including subsequent cancer diagnosis, will be followed up at 12 months to determine if they have cancer diagnosis after discharge to assess pathway safety.

Vertical Augmentation Mastopexy with Implant Isolation and Tension Management.

BACKGROUND: The increasingly popular vertical method of mastopexy is less commonly the technique of choice in augmentation mastopexy possibly due to concerns raised in the literature. The purpose of this report is to evaluate safety and satisfaction of the author's variation of the vertical method in this combination surgery. It includes unique tension management steps and total implant isolation from cut parenchyma. METHODS: A retrospective analysis was done of 105 consecutive patients treated with the author's method over an 8 year 6 month period. Clinical outcomes were examined, and a Breast-Q survey and Spear's 2004 survey were mailed to all patients who agreed to it by phone. RESULTS: There were no hematomas or delayed healing but one pulmonary embolus treated as an outpatient and one infection appearing 6 weeks postoperatively. There were only 3 grade 3 or 4 capsular contractures. Sixty-seven patients consented to the survey and 36 were returned. With Breast-Q, there was a mean score of 82.78 for outcome satisfaction and 75.94 for satisfaction with breasts. Spear's survey confirmed high satisfaction with 90.9% indicating that they were satisfied or extremely satisfied. Comparison with Spear's own surgical results did not reach statistical significance. CONCLUSIONS: The author's specific adaptation of vertical augmentation mastopexy appears to be very safe and successfully addresses a variety of healing, tension, and exposure concerns mentioned in the literature. Implant isolation may decrease capsular contracture rate. Both Breast-Q survey and Spear's more specific survey indicate high patient satisfaction.

Sustained cardiovascular actions of APJ agonism during renin-angiotensin system activation and in patients with heart failure.

BACKGROUND: To assess cardiovascular actions of APJ agonism during prolonged (Pyr(1))apelin-13 infusion and renin-angiotensin system activation. METHODS AND RESULTS: Forty-eight volunteers and 12 patients with chronic stable heart failure attended a series of randomized placebo-controlled studies. Forearm blood flow, cardiac index, left ventricular dimensions, and mean arterial pressure were measured using bilateral venous occlusion plethysmography, bioimpedance cardiography, transthoracic echocardiography, and sphygmomanometry, respectively, during brief local (0.3-3.0 nmol/min) and systemic (30-300 nmol/min) or prolonged systemic (30 nmol/min) (Pyr(1))apelin-13 infusions in the presence or absence of renin-angiotensin system activation with sodium depletion or angiotensin II coinfusion. During sodium depletion and angiotensin II coinfusion, (Pyr(1))apelin-13-induced vasodilatation was preserved (P<0.02 for both). Systemic intravenous (Pyr(1))apelin-13 infusion increased cardiac index, whereas reducing mean arterial pressure and peripheral vascular resistance index (P<0.001 for all) irrespective of sodium depletion or angiotensin II (0.5 ng/kg per minute) coinfusion (P>0.05 for all). Prolonged 6-hour (Pyr(1))apelin-13 infusion caused a sustained increase in cardiac index with increased left ventricular ejection fraction in patients with chronic heart failure (ANOVA; P<0.001 for all). CONCLUSIONS: APJ agonism has sustained cardiovascular effects that are preserved in the presence of renin-angiotensin system activation or heart failure. APJ agonism may hold major promise to complement current optimal medical therapy in patients with chronic heart failure. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00901719, NCT00901888, NCT01049646, NCT01179061.

Alloplast as an alternative for dorsal augmentation.

With an ever increasing ethnic population in the United States, dorsal augmentation has become a fairly common accompaniment to rhinoplasty. But procurement of adequate graft material of suitable nature and amount persists as a challenge to plastic surgeons. This dilemma has become even more pressing in recent years as a variety of other exceptional graft applications for the patient's limited cartilage bank have become not just an option but also mandatory for our higher expectations. The debate of the past century over alloplast in the dorsum persists in the present. "When and if ever" is the commonly asked question. Surely, no alloplast can match the ideal graft, but no graft is ideal either as it always comes in limited supply. There is now more than 15 years of experience with expanded polytetrafluoroethylene in the nose. It appears that with proper patient selection and technique, expanded polytetrafluoroethylene can be used in the nasal dorsum with relatively low complication rates and high patient satisfaction.

Leave the fat, skip the bolster: thinking outside the box in lower third nasal reconstruction.

Defects of the lower third of the nose often present especially challenging reconstructive dilemmas. The surrounding skin to match is often thick, sebaceous, and sun damaged, none of which characterizes the historically ideal periauricular donor skin for grafting. The surrounding nasal skin is quite stiff, precluding very small local flaps. To avoid the "misplaced patch" appearance of most classic full-thickness grafts to this area or the depressed scar of an elliptical excision, many surgeons turn to larger local or regional flaps. These provide not only skin color and texture match but also the necessary several millimeters of subcutaneous fat necessary for proper tip aesthetics. Many defects of the lower third are small, making many surgeons reluctant to employ these larger flaps with their long scars and potential to twist or distort delicate tip or ala anatomy. The author has sought a means to transport skin and subcutaneous fat for lower third nasal defects outside of flaps. On the basis of the superiority of nasolabial fold scars and a vast positive experience in the literature utilizing skin and fat composite grafts with no bolsters, the author applied these techniques to 33 lower third nasal defects in 29 patients. Of 33 grafts varying in size from 4 mm circular to 17 mm x 16 mm and retaining 1 to 5 mm of fat, no grafts were lost. Four grafts developed a 30 percent area or less of central necrosis resulting in localized depression. Three of these four grafts were in active smokers and the fourth graft was in a former smoker. Aside from these four grafts and one with considerable excess fat early in the series, contour was good to excellent. Hypopigmentation is still common but improves with time. Easily performed composite grafts effectively carry the necessary fat for aesthetic reconstruction and do not risk long scars on the nose and twisting of the tip and ala that can result from flaps. Revisions are infrequent and extremely simple when indicated.