RESUMO
Aesthetic plastic surgery is a consumer-driven industry, subject to influence by financial forces. A changing economic environment may thus impact on the demand for surgery. The aim of this study was to explore trends in demand for bilateral breast augmentation (BBA) in consecutively presenting patients over an 11-year period and to examine if a correlation exists between these trends and changes in Gross Domestic Product (GDP), a key economic indicator. This study revealed a correlation between annual number of breast augmentation procedures performed and GDP values (r 2 = 0.34, p value = 0.059). Additionally, predicted number of BBA procedures, based on predicted GDP growth in Ireland, strongly correlated with actual number of BBA performed (r 2 = 0.93, p value = 0.000001). Predicted GDP growth can potentially forecast future demand for BBA in our cohort allowing plastic surgeons to modify their practice accordingly. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Produto Interno Bruto/tendências , Necessidades e Demandas de Serviços de Saúde/economia , Mamoplastia/economia , Feminino , Previsões , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Irlanda/epidemiologia , Mamoplastia/tendências , Estudos RetrospectivosRESUMO
UNLABELLED: Aesthetic surgery is a rapidly expanding industry and patient safety is a fundamental issue. The need for regulation has been outlined by the Professional Standards for Cosmetic Practice Report, published by the Royal College of Surgeons in January 2013 which highlighted standards of patient care. The aim of this study was to review institutional compliance with these standards. A retrospective chart review of 40 consecutive patients who underwent either bilateral breast augmentation or bilateral breast reduction between November 2012 and November 2013 within our unit was performed. Compliance with standards relating to practice management, patient consultation, patient communication and record-keeping was examined. While details of past medical history were recorded in most cases, few consultations referred to psychiatric history and cosmetic surgical history specifically. Perioperative documentation and compliance with surgical safety processes were excellent. As a self-regulating profession, it is important that plastic surgeons take the lead in auditing their practice against such published standards. We urge all professionals who carry out cosmetic procedures to regularly review their practice, thereby promoting accountability and maintaining the trust of the general public in the aesthetic surgery industry. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Competência Clínica/normas , Fidelidade a Diretrizes/normas , Mamoplastia/normas , Cirurgia Plástica/normas , Estudos de Coortes , Feminino , Humanos , Mamoplastia/métodos , Guias de Prática Clínica como Assunto/normas , Encaminhamento e Consulta , Estudos Retrospectivos , Medição de Risco , Cirurgia Plástica/métodos , Resultado do TratamentoRESUMO
Basal cell carcinoma (BCC) are the commonest cutaneous malignancy and incidence continues to increase. There is a need to expand the therapeutic toolbox to increase options for patients that are unsuitable for or unwilling to undergo the current therapies. Electrochemotherapy (ECT) is a technique where cells are temporarily permeabilized after exposure to a brief pulsed electrical field and combined with low dose chemotherapeutics to ablate malignancies. It is a simple technique causing minimal damage to the surrounding healthy tissue and has the potential to avoid the need for complex reconstruction. ECT is an established treatment for skin metastases but its role as a primary treatment modality is not demonstrated. A prospective randomised control trial evaluating ECT against the gold standard of treatment, Surgery, was performed for patients with primary BCC and patients followed for 5 years. All lesions treated with ECT (n = 69) responded although 8/69 (12%) needed a second treatment to ensure a complete response. All surgical lesions (n = 48) showed histological evidence of complete excision with 2/48 (4%) undergoing a second excision. At 5 years, in the surgical arm there was no evidence of recurrence in 39/40 (97.5%) lesions with 1/40 (2.5%) confirmed recurrence. In the ECT arm there was no evidence of recurrence in 42/48 lesions (87.5%). There was 5 confirmed recurrences. These groups show statistical equivalence in this non inferiority study design (p = 0.33). ECT is an effective and durable treatment option for primary BCC and should be considered as part of the armamentarium of options available.
Assuntos
Antibióticos Antineoplásicos/administração & dosagem , Bleomicina/administração & dosagem , Carcinoma Basocelular/terapia , Procedimentos Cirúrgicos Dermatológicos/métodos , Eletroquimioterapia/métodos , Neoplasias Cutâneas/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Basocelular/patologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Reoperação , Retratamento , Neoplasias Cutâneas/patologia , Carga Tumoral , Adulto JovemRESUMO
INTRODUCTION: The importance of postoperative drain fixation cannot be overemphasised. There are numerous described techniques for drain fixation. However, to our knowledge, there is no evidence-based comparison between the various techniques of drain fixation used in postoperative management. We describe a new method and compare its reliability with four other commonly used methods. MATERIALS AND METHODS: Five methods were chosen for testing based on current trends in clinical practice: centurion sandal with plastic locking ties, centurion sandal or lattice method, centurion sandal with half-inch Steristrips®, double and multiple looped methods. We used an Instron 8872® tensiometer to apply a measured force to a secured drain. Each fixation method was tested ten times and all fixation methods were performed by the same experienced surgeon. We measured the average number of cycles before failure, the average displacement of the tube at failure and the time needed to apply each fixation method. RESULTS: The number of cycles completed before failure showed that the centurion sandal method, the centurion sandal with plastic ties and the centurion sandal method with Steristrips had the lowest failure rate. The amount of displacement was the least in the centurion sandal with plastic ties followed by the double-loop method and centurion sandal with Steristrips. There was little difference in the time taken to complete the fixation methods (range 21-33 seconds). DISCUSSION: We recommend the use of the centurion sandal with plastic locking ties, centurion sandal with Steristrips followed by the centurion sandal method alone as fixation techniques that are quick to perform, secure and reliable.
Assuntos
Drenagem/métodos , Cuidados Pós-Operatórios/métodos , Tubos Torácicos , Drenagem/instrumentação , Humanos , Cuidados Pós-Operatórios/instrumentação , Padrões de Prática Médica , Inquéritos e QuestionáriosAssuntos
Anastomose Cirúrgica/métodos , Biópsia/métodos , Artéria Femoral/cirurgia , Microcirurgia/métodos , Anastomose Cirúrgica/instrumentação , Biópsia/instrumentação , Cadáver , Desenho de Equipamento , Segurança de Equipamentos , Humanos , Microcirurgia/instrumentação , Equipamentos Cirúrgicos , Procedimentos Cirúrgicos Vasculares/instrumentação , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
BACKGROUND: Merkel cell cancer (MCC) is an uncommon neuroendocrine skin cancer occurring predominantly in elderly Caucasians. It tends to metastasize to regional lymph nodes and viscera and is sensitive to chemotherapy but recurs rapidly. AIM: To report one such case, its response to chemotherapy and briefly review the literature. METHODS: A 73-year-old male with a fungating primary lesion on his left knee and ulcerated inguinal lymph nodes was diagnosed with MCC and treated with chemotherapy. The two largest case series and reviews of case reports were summarised. RESULTS: His ulcer healed after two cycles of carboplatin and etoposide with improvement in quality of life. Overall response rates of nearly 60% to chemotherapy are reported but median survival is only nine months with metastatic disease. CONCLUSIONS: Chemotherapy should be considered for fit elderly patients with MCC who have recurrent or advanced disease.
Assuntos
Antineoplásicos/uso terapêutico , Carboplatina/uso terapêutico , Carcinoma de Célula de Merkel/tratamento farmacológico , Etoposídeo/uso terapêutico , Neoplasias Cutâneas/tratamento farmacológico , Idoso , Carcinoma de Célula de Merkel/diagnóstico , Progressão da Doença , Virilha/patologia , Humanos , Joelho/patologia , Masculino , Estadiamento de Neoplasias , Neoplasias Cutâneas/diagnósticoRESUMO
A case of histologically confirmed Paget's disease of the breast in a 72 year old man, without underlying breast carcinoma, is reported. This report raises questions about the pathogenesis of this condition and suggests that Paget's disease is an independent, intraepidermal carcinoma rather than a direct extension of intraductal carcinoma of the breast to the nipple and areola.
Assuntos
Neoplasias da Mama Masculina/patologia , Doença de Paget Mamária/patologia , Idoso , Epiderme/patologia , Humanos , Masculino , Mamilos/patologiaRESUMO
BACKGROUND: Preliminary studies in this laboratory have shown that treatment with interleukin-12 (IL-12), a cytokine that induces expression of the T-helper-1 lymphocyte phenotype, in an animal model of burn injury increased survival after a septic challenge. The purpose of this study was to define the efficacy of IL-12 therapy and to explore its mechanism of action. METHODS: Adult male A/J mice were subjected to 25% full-thickness scald or sham burn. Starting on day 3 after burn, groups of mice received five daily injections of IL-12, interferon-gamma (IFN-gamma), or saline solution. Some animals received anti-IFN-gamma monoclonal antibody. At day 10 most animals underwent cecal ligation and puncture (CLP) and were observed for survival. Some animals were killed at day 10, and CD4-enriched splenocytes were stimulated with anti-CD3 antibody or concanavalin A and were studied for cytokine production and mRNA expression. RESULTS: IL-12 treatment, 25 ng daily for 5 days, increased survival of the burn group after CLP to that of the sham burn control group. Anti-IFN-gamma antibody, 500 micrograms, administered 1 day before IL-12 treatment, reduced the efficacy of IL-12. IFN-gamma treatment, 7000 units, moderately increased survival. IL-12 had no effect on survival of the sham burn group. At the time of CLP IL-12 therapy had induced a marked decrease in CD4+ lymphocyte IL-4 and a moderate increase in IFN-gamma production and mRNA expression without affecting IL-2. CONCLUSIONS: IL-12 is the most effective therapy so far tested in this burn plus CLP model. It acts at least in part through IFN-gamma. However, IFN-gamma therapy was not as effective as IL-12.
Assuntos
Queimaduras/tratamento farmacológico , Queimaduras/imunologia , Interleucina-12/farmacologia , Animais , Bactérias/imunologia , Queimaduras/mortalidade , Citocinas/biossíntese , Citocinas/genética , Modelos Animais de Doenças , Relação Dose-Resposta a Droga , Imunidade Inata , Interferon gama/farmacologia , Interleucina-4/genética , Masculino , Camundongos , Camundongos Endogâmicos A , Reação em Cadeia da Polimerase , RNA Mensageiro/metabolismo , Análise de SobrevidaRESUMO
In the Western World self-immolation is an uncommon but dramatic method of attempting suicide. In-patients who attempt suicide by fire-setting tend to be female with severe psychopathology. In a previous study from the South of Ireland, seven cases from a psychiatric and prison population were identified in a five year period from 1984 to 1989. This would represent an annual rate of 1.07 per cent of burns treated in the burns unit at Cork University Hospital. In this study 12 cases were identified for the years 1994 and 1995. This represents an increase of 3.5 per cent from 1.07 to 4.6 per cent of all burns treated at the same institution. Ten of these patients had a previous psychiatric history and eight of them were resident on a psychiatric ward when they committed the act. Seven of the patients were found to have a high degree of suicide intent of whom four died of their injuries, which gives a mortality rate for this group of 33 per cent. Effective prevention policies are necessary if this increasing problem is to be curtailed.
Assuntos
Queimaduras/epidemiologia , Transtornos Psicóticos/epidemiologia , Comportamento Autodestrutivo/epidemiologia , Tentativa de Suicídio/estatística & dados numéricos , Adulto , Unidades de Queimados/estatística & dados numéricos , Queimaduras/psicologia , Queimaduras/terapia , Feminino , Seguimentos , Humanos , Incidência , Irlanda/epidemiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Transtornos Psicóticos/diagnóstico , Transtornos Psicóticos/psicologia , Estudos Retrospectivos , Comportamento Autodestrutivo/prevenção & controle , Comportamento Autodestrutivo/psicologia , Suicídio/estatística & dados numéricosRESUMO
The levator claviculae muscle is a vestigal muscle which occurs in less than 2% of humans. The embryological origin of this muscle is controversial. We report a case in which an unusual variant of this muscle was encountered during exploratory surgery following a brachial plexus injury. The anatomical findings in this case suggest that this muscle may arise from either the sternocleidomastoid or trapezius muscles or from the primordial ventrolateral musculature.
Assuntos
Plexo Braquial/lesões , Músculo Esquelético/anormalidades , Adulto , Plexo Braquial/cirurgia , Humanos , Masculino , Músculos do Pescoço/cirurgiaRESUMO
We report our experience of a low-profile mini-plating system in the treatment of fractures of the hand in 57 consecutive patients (five children and 52 adults). Thirteen procedures were performed electively, and 44 procedures were performed on an emergency basis. Indications for plating included fixation of metacarpal (36) and phalangeal (eight) fractures, bony fixation following rotation osteotomy (six) digital replantation (two) or free toe transfer (two). Seventeen patients had postoperative problems, including restricted range of motion (12), rotation deformity (two), significant cold intolerance (two) or fracture (two). Plate removal was required in seven patients, twice as a result of a second injury, and plate removal was unsuccessfully attempted in one other patient. Two patients required extensor tenolysis. We have found this system to be useful for bony fixation in the hand. However, as with other methods of internal fixation in the hand, there may be complications.
Assuntos
Placas Ósseas , Emergências , Fixação Interna de Fraturas/instrumentação , Traumatismos da Mão/cirurgia , Titânio , Adulto , Amputação Traumática/cirurgia , Criança , Feminino , Traumatismos dos Dedos/cirurgia , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Reimplante/instrumentação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
With the advent of laparoscopic cholecystectomy and the impending replacement of open common bile duct exploration, we have reviewed our ten year experience of conventional common bile duct exploration. Open cholecystectomy was performed in 1681 patients and the common bile duct was explored in 325 (19%). Following initial duct exploration, rigid choledo identified residual choledocholithiasis in 58 and periampullary neoplasia in 2 patients. Unexpected retained stones were identified in 3 patients (0.9%). In a further 4 patients, stones which could not be dislodged from the hepatic ducts were confirmed on 10 day T-tube cholangiogram--transduodenal sphincteroplasty had been performed at the time of original surgery in all four. The mortality was 1.9% overall and 1% during the last 5 years. Endoscopic exploration must compare favourably with these data for safe transition to less invasive techniques.
Assuntos
Colecistectomia/métodos , Ducto Colédoco/cirurgia , Doenças da Vesícula Biliar/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ducto Colédoco/patologia , Feminino , Doenças da Vesícula Biliar/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
The increased risk of sepsis in patients following splenectomy has been well documented. Fear of overwhelming post-splenectomy sepsis (OPSI) has resulted in a generalized trend towards splenic salvage among surgeons. However, splenorrhaphy and attempts at splenic salvage may of themselves predispose to significant morbidity, sometimes more serious than increased susceptibility to infection associated with splenectomy. This study aims to assess the risk of splenectomy and subsequent asplenia. We reviewed 246 patients who underwent splenectomy over a 16 year period. Indications for splenectomy were considered under the following headings: haematological (N = 116), trauma (N = 69), visceral carcinoma (N = 28), incidental (N = 13) and miscellaneous (N = 20). There were 28 deaths in the series, primarily among those in the intra-abdominal carcinoma (13) and multiple trauma (13) groups. Two deaths were recorded among patients undergoing elective splenectomy for benign disease. Thrombo-embolic complications were recorded in nine patients; respiratory tract infection in 36 patients and intra-abdominal abscess in two patients. Two cases of post-splenectomy pneumococcal septicaemia were documented, neither of which was fatal. While not an entirely benign procedure, splenectomy can be performed relatively safely, especially when performed for benign disease in an adult population.
Assuntos
Esplenectomia/efeitos adversos , Abscesso Abdominal/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Respiratórias/etiologia , Risco , Sepse/etiologiaRESUMO
Deliberate and recurrent foreign body ingestion is a common problem among institutionalised patients. We review our experience with 36 cases of deliberate foreign body ingestion by prisoners or psychiatric patients, thirty of whom were institutionalised at the time of ingestion. Symptoms were frequently severe in the prison inmate group but, in contrast, psychiatric patients presented with few, if any, symptoms. A majority of objects pass spontaneously or remain in situ without complication. Twenty-four patients were discharged following initial evaluation and without specific treatment. Eight of these were reviewed electively and discharged within one week. Twelve patients were admitted for observation, seven of whom were discharged within 48 hrs. Upper gastrointestinal endoscopy was performed in four patients and an intragastric foreign body identified in two cases. Laparotomy was performed in two cases for unresolving mechanical intestinal obstruction. Management should be conservative when possible, with surgery indicated only for complications.
Assuntos
Sistema Digestório , Corpos Estranhos , Transtornos Mentais , Prisioneiros , Adolescente , Adulto , Idoso , Deglutição , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
A prospective study of the pattern of responses to requests for autopsy in a general surgical unit was performed. Information on the characteristics of the deceased, of the requestee and of the requester was documented in the case of 66 patients who died while in hospital. Permission to perform autopsy was not requested in 39 out of 66 cases and this was the most frequent contributory factor to the low rate of autopsy. Once a decision to grant or refuse autopsy is made by relatives of the deceased, the decision is unlikely to be reversed. Permission to perform autopsy was more likely to be sought when the deceased was male than when deceased was female. The relatives of patients who had recently undergone surgery were more likely to refuse permission for autopsy than were those of patients who had not had recent surgery.
Assuntos
Autopsia , Cirurgia Geral , Hospitais de Condado , Distribuição por Idade , Idoso , Autopsia/normas , Feminino , Humanos , Consentimento Livre e Esclarecido , Masculino , Estudos Prospectivos , Distribuição por SexoRESUMO
A 43-year-old man presented with an abscess on his left ring finger, which recurred despite multiple drainage procedures. Histological examination of the lesion was unhelpful; it was only on histopathological examination of the finger after ray amputation that the diagnosis of cutaneous squamous cell carcinoma was established. This case illustrates the need to consider malignancy when dealing with chronic finger infections.
Assuntos
Abscesso/diagnóstico , Carcinoma de Células Escamosas/diagnóstico , Mãos , Neoplasias Cutâneas/diagnóstico , Adulto , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Humanos , Masculino , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgiaRESUMO
An open randomised prospectively controlled trial was performed to assess the healing efficacy, slippage rate and degree of discomfort on removal of calcium alginate and a silicone-coated polyamide net dressing on split skin graft donor sites. Sixteen patients were randomised to the calcium alginate group and 14 to the silicone-coated group. The donor sites were assessed at days 7, 10, 14 and up to day 21. The mean time to healing in the calcium alginate group was 8.75 +/- 0.78 days (range 7 to 14 days) compared to 12 +/- 0.62 days (range 7 to 16 days) for the silicone-coated group (p < 0.01). Although more silicone-coated dressings slipped (5 versus 1), the difference was not statistically significant. Pain during the first dressing change was assessed using a visual analogue pain scale. Although no significant differences were found between the groups, it was necessary to change the dressing protocol in the silicone-coated arm of the trial after entering the first two patients. Overlaid absorbent gauze adhered to the donor site through the fenestrations in the dressing necessitating the placement of paraffin gauze between the experimental dressing and the overlying cotton gauze. There was one infection in the study, occurring in the alginate group. Based on these results we recommend calcium alginate as the dressing of choice for split skin graft donor sites.
Assuntos
Alginatos/uso terapêutico , Curativos Oclusivos , Silicones/uso terapêutico , Transplante de Pele , Cicatrização , Adulto , Feminino , Ácido Glucurônico , Ácidos Hexurônicos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
A prospective controlled trial was carried out to assess the healing efficacy of calcium alginate and paraffin gauze on split skin graft donor sites. Thirty patients were randomised to the calcium alginate group and 21 to the paraffin gauze group. The donor sites were assessed at 10 days post harvesting to determine if they were completely healed (100%) or not. Twenty one of the 30 patients dressed with calcium alginate were completely healed at day 10, while only 7/21 in the paraffin gauze group were healed (p < 0.05). There were two infections in the study, both occurring in the alginate group while there was no difference in dressing slippage between the two groups. Calcium alginate dressings provide a significant improvement in healing split skin graft donor sites.
Assuntos
Alginatos/uso terapêutico , Bandagens , Transplante de Pele , Cicatrização/efeitos dos fármacos , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Coloides/uso terapêutico , Feminino , Ácido Glucurônico , Ácidos Hexurônicos , Humanos , Masculino , Curativos Oclusivos , Vaselina , Estudos ProspectivosRESUMO
Basal Cell Carcinoma (BCC) affecting the ocular region is potentially problematic due to its ability to infiltrate aesthetic and functional structures. Due to the paucity of local tissue, resection frequently requires reconstruction with skin grafts or local flaps. Surgical treatment may not be suitable for patients with multiple co-morbidities. Electrochemotherapy (ECT) is a technique where cells are temporarily permeabilized after exposure to a brief electrical field and when combined with normally impermeant chemotherapy drugs can resolve cutaneous cancers - even those previously recalcitrant to chemotherapy or radiotherapy. Its particular advantage is its speed of application and the minimal damage to the surrounding healthy tissue structures. We present a series of 3 patients with BCCs in the peri-ocular region and significant co-morbidities deemed unsuitable for surgical resection, who underwent ECT. The lesions were all primary BCC ranging in size from 0.5 cm(2) to 1 cm(2). Two lesions were on the upper eyelid and one on the lower eyelid. ECT was performed using an 8-needle electrode and a CE approved electroporation generator with intra-lesional Bleomycin. All lesions responded to treatment. All BCC's completely resolved, with acceptable scarring. No side effects were reported from the Bleomycin or the electric pulses. ECT for peri-ocular BCC is an adjunct to surgical excision in the management of surgically problematic lesions. This technique could provide a useful initial treatment option for patients who are medically unfit or where resection and would be associated with significant morbidity.
Assuntos
Antineoplásicos/administração & dosagem , Bleomicina/administração & dosagem , Carcinoma Basocelular/tratamento farmacológico , Neoplasias Palpebrais/tratamento farmacológico , Neoplasias Cutâneas/tratamento farmacológico , Idoso de 80 Anos ou mais , Eletroquimioterapia , Feminino , Humanos , Injeções IntralesionaisRESUMO
Post-operative immobilisation following isolated digital nerve repair remains a controversial issue amongst the microsurgical community. Protocols differ from unit to unit and even, as evidenced in our unit, may differ from consultant to consultant. We undertook a retrospective review of 46 patients who underwent isolated digital nerve repair over a 6-month period. Follow-up ranged from 6 to 18 months. Twenty-four were managed with protected active mobilisation over a 4-week period while 22 were immobilised over the same period. Outcomes such as return to work, cold intolerance, two-point discrimination and temperature differentiation were used as indicators of clinical recovery. Our results showed that there was no significant difference noted in either clinical assessment of recovery or return to work following either post-operative protocol, suggesting that either regime may be adopted, tailored to the patient's needs and resources of the unit.