Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) on upper limb (UL) morbidity in breast cancer patients. BACKGROUND: Axillary de-escalation is motivated by a desire to reduce harm of ALND. Understanding the impact of axillary surgery and disparities in operative procedures on postoperative arm morbidity would better direct resources to the point of need and cement the need for de-escalation strategies. METHODS: Embase, MEDLINE, CINAHL, and PsychINFO were searched from 1990 until March 2020. Included studies were randomized-controlled and observational studies focusing on UL morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of UL morbidity comparing SLNB and ALND at <12 months, 12 to 24 months, and beyond 24 months were analyzed. RESULTS: Sixty-seven studies were included. All studies reported a higher rate of lymphedema and pain after ALND compared with SLNB. The difference in lymphedema and pain prevalence between SLNB and ALND was 13.7% (95% confidence interval: 10.5-16.8, P <0.005) and 24.2% (95% confidence interval: 12.1-36.3, P <0.005), respectively. Pooled estimates for prevalence of reduced strength and range of motion after SLNB and ALND were 15.2% versus 30.9% and 17.1% versus 29.8%, respectively. Type of axillary surgery, greater body mass index, and radiotherapy were some of the predictors for UL morbidities. CONCLUSIONS: Prevalence of lymphedema after ALND was higher than previously estimated. ALND patients experienced greater rates of lymphedema, pain, reduced strength, and range of motion compared with SLNB. The findings support the continued drive to de-escalate axillary surgery.

Antihypertensive medication adherence in chronic type B aortic dissection is an important consideration in the management debate.

OBJECTIVE: Early aortic stenting in chronic type B aortic dissection (TBAD) may lead to long-term benefit, although the optimal treatment strategy is hotly debated. A robust comparison to outcomes seen in medically managed patients is challenging as the rate of antihypertensive medication adherence is unknown. The aims of this study were therefore to identify the rate of antihypertensive medication adherence and predictors of adherence in TBAD. METHODS: This was a cross-sectional mixed methods study of patients with TBAD. Medication adherence was assessed by the eight-item Morisky Medication Adherence Scale together with an assessment of demographic, behavioral, and psychological variables and disease-specific knowledge. RESULTS: There were 47 patients (mean age, 59 years; 81% male) who were recruited from a tertiary vascular unit. The mean total number of medications taken was 5.8 (2-14), and the mean number of antihypertensive medications was 1.9 (1-6). Of the 47 patients, 20 (43%) reported high levels of medication adherence, 17 (36%) reported moderate adherence, and 10 (21%) reported low adherence. Previous aortic surgery was associated with higher levels of adherence (ß = 0.332; P = .03), as was taking a greater number of medications (ß = 0.332; P = .026), perceived benefit from treatment (ß = 0.486; P < .001), good memory (ß = 0.579; P < .001), and low fears of side effects (ß = 0.272; P < .014). CONCLUSIONS: Medical management remains the mainstay of treatment in uncomplicated TBAD; however, the majority of patients are poorly adherent to their antihypertensive medications. The merits of thoracic endovascular aortic repair in TBAD are argued, and poor adherence is an important factor in the debate; one cannot robustly compare two strategies when half of a treatment group may not be receiving the stated intervention. To develop an evidence-based treatment strategy for TBAD, we must take into account the direct and indirect effects of medical therapy and thoracic endovascular aortic repair. Further work to improve medication adherence and to understand its impact on disease progression is vital to inform the debate and to deliver the best outcomes for patients.

Patient-level costs of staged unilateral versus immediate bilateral symmetrization mammoplasty in breast-conserving surgery.

BACKGROUND: Following therapeutic mammoplasty (TM), the contralateral breast may require a later balancing procedure to optimize shape and symmetry. The alternative is to offer patients simultaneous TM with immediate contralateral symmetrization via a dual-surgeon approach, with the goal of reducing costs and minimizing the number of subsequent hospital appointments in an era of COVID-19 surges. The aim of this cost-consequence analysis is to characterize the cost-benefit of immediate bilateral symmetrization dual-operator mammoplasty versus staged unilateral single operator for breast cancer surgery. METHOD: A prospective single-centre observational study was conducted at an academic teaching centre for breast cancer surgery in the UK. Pseudonymized data for clinicopathological variables and procedural care information, including the type of initial breast-conserving surgery and subsequent reoperation(s), were extracted from the electronic patient record. Financial data were retrieved using the Patient-Level Information and Costing Systems. RESULTS: Between April 2014 and March 2020, 232 women received either immediate bilateral (n = 44), staged unilateral (n = 57) for breast cancer, or unilateral mammoplasty alone (n = 131). The median (interquartile range (i.q.r.)) additional cost of unilateral mammoplasty with staged versus immediate bilateral mammoplasty was €5500 (€4330 to €6570) per patient (P < 0.001), which represents a total supplementary financial burden of €313 462 to the study institution. There was no significant difference between groups in age, Charlson comorbidity index, operating minutes, time to adjuvant radiotherapy in months, or duration of hospital stay. CONCLUSION: Synchronous dual-surgeon immediate bilateral TM can deliver safe immediate symmetrization and is financially beneficial, without delay to receipt of adjuvant therapy, or additional postoperative morbidity.

Carpal tunnel syndrome in patients with arteriovenous fistula for haemodialysis: A narrative review of the current literature.

The ideal choice of vascular access in patients requiring haemodialysis is an arteriovenous fistula. However, an important often under-reported complication encountered at follow-up is symptoms of tingling or numbness in the hand. This may represent carpal tunnel syndrome, impairment of the median nerve as it traverses through the carpal tunnel at the wrist by focal compression of this nerve. Contributory factors in the presence of an arteriovenous fistula may include venous hypertension and varying steal syndrome phenomena provoking micro-ischaemia. Studies that investigated the evolution of carpal tunnel syndrome in haemodialysis patients with an arteriovenous fistula revealed that the frequency of carpal tunnel syndrome associated with an arteriovenous fistula on haemodialysis ranged from 10.4% to 42.6%. An association between duration of haemodialysis with arteriovenous fistula and carpal tunnel syndrome development was also observed. Surgical release of carpal tunnel provided complete relief of paraesthesia in all treated patients in the examined, demonstrating an alleviation of symptoms and improved function of hand and quality of life in patients with an arteriovenous fistula. However, the aetiology and risk factors for development of carpal tunnel syndrome remain unclear and further studies should attempt to elucidate the pathophysiology of this occurrence in the presence of arteriovenous fistulas.

Outcome reporting in therapeutic mammaplasty: a systematic review.

BACKGROUND: Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set. METHODS: Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools. RESULTS: Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent). CONCLUSION: Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Genetics in chronic venous disease.

Chronic venous disease is highly prevalent in the Western world, with varicose veins being the most common form of clinical manifestation. With recent developments in sequencing technology, clinicians and geneticists alike are embarking on a journey to identify and unravel the genetic candidates of chronic venous disease. There is now currently substantial evidence to suggest the presence of genetic influences in the aetiology and pathology of venous disease. Despite this, the precise nature and profile of the genes involved in chronic venous disease remain a poorly understood entity. Moreover, it is strikingly apparent that the majority of venous genetic studies conducted over the past decade do not adhere to fundamental research principles. The emergence of high-throughput genotyping platforms permits a more systematic search for inherited components of venous disease. Pursuing a genome-wide frontier has the potential to reveal novel critical metabolic pathways and explain the genetic susceptibility of chronic venous disease. An expedited knowledge of the genetic factors in the aetiology of venous disease may translate into better prevention or treatment, which would benefit patients suffering from its clinical sequelae. Researchers should be urged to foster collaborative links and design a genome-wide case-control association study as an international consortium to provide a statistically robust paradigm in the field of chronic venous disease genetics. This will carry promise for clinically relevant progress and represent a first step towards better understanding of the genetics of chronic venous disease aetiology.

The impact of age, sex and socioeconomic deprivation on outcomes in a colorectal cancer screening programme.

BACKGROUND: Population-based colorectal cancer screening has been shown to reduce cancer specific mortality and is used across the UK. Despite evidence that older age, male sex and deprivation are associated with an increased incidence of colorectal cancer, uptake of bowel cancer screening varies across demographic groups. The aim of this study was to assess the impact of age, sex and deprivation on outcomes throughout the screening process. METHODS: A prospectively maintained database, encompassing the first screening round of a faecal occult blood test screening programme in a single geographical area, was analysed. RESULTS: Overall, 395,096 individuals were invited to screening, 204,139 (52%) participated and 6079 (3%) tested positive. Of the positive tests, 4625 (76%) attended for colonoscopy and cancer was detected in 396 individuals (9%). Lower uptake of screening was associated with younger age, male sex and deprivation (all p<0.001). Only deprivation was associated with failure to proceed to colonoscopy following a positive test (p<0.001). Despite higher positivity rates in those that were more deprived (p<0.001), the likelihood of detecting cancer in those attending for colonoscopy was lower (8% most deprived vs 10% least deprived, p = 0.003). CONCLUSION: Individuals who are deprived are less likely to participate in screening, less likely to undergo colonoscopy and less likely to have cancer identified as a result of a positive test. Therefore, this study suggests that strategies aimed at improving participation of deprived individuals in colorectal cancer screening should be directed at all stages of the screening process and not just uptake of the test.