Cutaneous Melanoma and Sentinel Lymph Node Biopsy; An Epidemiology Study of Population Level Data.

Aims Cutaneous melanoma accounts for 90% of all melanoma cases diagnosed. In addition, the incidence of cutaneous melanoma is increasing by approximately 3-7% yearly, and it is the most rapidly increasing cancer diagnosed in white populations worldwide. The aim of this study is to assess the survival benefit of Sentinel Lymph Node Biopsy (SLNB) in cutaneous melanoma in an Irish population. Methods Population based data was obtained from the National Cancer Registry of Ireland (NCRI) on all patients with a cutaneous melanoma diagnosed over a 20-year period 1994-2014 and predictors of Overall Survival (OS) were assessed. Results 13302 patients were identified with a melanoma diagnosis between 1994-2014. OS varied with gender, age, smoking and marital status, anatomical location and TMN stage. 2196 (17%) patients underwent SLNB, which included 710 patients in the stage 1 melanoma category (<11% of this group). Undergoing a SLNB was not an independent predictor of improved OS (p=0.440). However, a positive SLNB result was an independent predictor of OS (0.001). Conclusion This Irish population-based data re-affirms demographic indicators of poorer survival. A positive SLNB result indicates poorer survival; however, the precedent itself is not a predictor of OS.

Electrochemotherapy in the treatment of cutaneous malignancy: Outcomes and subgroup analysis from the cumulative results from the pan-European International Network for Sharing Practice in Electrochemotherapy database for 2482 lesions in 987 patients (2008-2019).

BACKGROUND: Electrochemotherapy (ECT) is a treatment for both primary and secondary cutaneous tumours. The international Network for sharing practices on ECT group investigates treatment outcomes after ECT using a common database with defined parameters. METHODS: Twenty-eight centres across Europe prospectively uploaded data over an 11-year period. Response rates were investigated in relation to primary diagnosis, tumour size, choice of electrode type, route of bleomycin administration, electrical parameters recorded and previous irradiation in the treated field. RESULTS: Nine hundred eighty-seven patients, with 2482 tumour lesions were included in analysis. The overall response (OR) rate was 85% (complete response [CR]: 70%, partial response rate: 15%, stable disease: 11%, and progressive disease: 2%). For different histologies, OR and CR rates for metastases of malignant melanoma were 82% and 64%, basal cell carcinoma were 96% and 85%, breast cancer metastases were 77% and 62%, squamous cell carcinoma were 80% and 63% as well as Kaposi's sarcoma were 98% and 91%, respectively. Variance was demonstrated across histotypes (p < 0.0001) and in accordance with size of lesion treated (dichotomised at diameter of 3 cm (p < 0.0001). Hexagonal electrodes were generally used for larger tumours, but for tumours up to 3 cm, linear array electrodes provided better tumour control than hexagonal electrodes (80%:74%, p < 0.003). For tumours more than 2 cm, intravenous administration was superior to intratumoural (IT) administration (p < 0.05). Current recorded varied across tumour histologies and size but did not influence response rate. In previously irradiated areas, responses were selectively lower for IT administration. CONCLUSIONS: These cumulative data endorse efficiency of ECT across a broad range of histotypes. Analysis of 2482 lesions details subgroup analysis on treatment response informing future treatment choices.

Electrochemotherapy for the treatment of primary basal cell carcinoma; A randomised control trial comparing electrochemotherapy and surgery with five year follow up.

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.

When do we think it is Safe to Drive after Hand Surgery? - Current Practice and Legal Perspective.

Patients recovering from hand surgery frequently ask when it is safe to drive and it is unclear where the responsibility lies; the surgeon, the patient or the insurance company. An eight-question survey looking at various aspects of clinical practice was circulated to consultant and trainee plastic and orthopaedic surgeons in Ireland and the UK. Of the 89 surgeons who replied, (53%) felt the decision when to drive was the patient's compared with the insurance company (40%) and the surgeon (7%). 80% advised patients to contact their insurance company. 87% were unaware of current regulations or guidelines. National guidelines were vague and left the decision with the treating doctor. Similarly, major insurers advise patients to contact their doctor for advice. From a legal standpoint, the patient has a duty of care to other road users to be in full control of his vehicle prior to driving, regardless of any advice received.

The extent of soft tissue and musculoskeletal injuries after earthquakes; describing a role for reconstructive surgeons in an emergency response.

BACKGROUND: Earthquakes are the leading cause of natural disaster-related mortality and morbidity. Soft tissue and musculoskeletal injuries are the predominant type of injury seen after these events and a major reason for admission to hospital. Open fractures are relatively common; however, they are resource-intense to manage. Appropriate management is important in minimising amputation rates and preserving function. This review describes the pattern of musculoskeletal and soft-tissue injuries seen after earthquakes and explores the manpower and resource implications involved in their management. METHODS: A Medline search was performed, including terms "injury pattern" and "earthquake," "epidemiology injuries" and "earthquakes," "plastic surgery," "reconstructive surgery," "limb salvage" and "earthquake." Papers published between December 1992 and December 2012 were included, with no initial language restriction. RESULTS: Limb injuries are the commonest injuries seen accounting for 60 % of all injuries, with fractures in more than 50 % of those admitted to hospital, with between 8 and 13 % of these fractures open. After the first few days and once the immediate lifesaving phase is over, the management of these musculoskeletal and soft-tissue injuries are the commonest procedures required. CONCLUSIONS: Due to the predominance of soft-tissue and musculoskeletal injuries, plastic surgeons as specialists in soft-tissue reconstruction should be mobilised in the early stages of a disaster response as part of a multidisciplinary team with a focus on limb salvage.

Electrochemotherapy for the treatment of ocular basal cell carcinoma; a novel adjunct in the disease management.

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.

Reversal of hand peripheral ischaemia due to extravasation of adrenaline during cardiopulmonary resuscitation.

A 63 year old woman sustained an extravasation of vasopressor during a successful in hospital cardiopulmonary resuscitation resulting in an acutely ischaemic hand. This was treated with multiple washouts of the hand due to incipient recurrence of the ischaemia. Extravasation of vasopressor is exceedingly rare and potentially devastating. This case highlights the specific problems associated with extravasation of vasopressor. We present an algorithm for treatment of these and identify the potential need to use specific antidotes for the vasoconstriction caused by adrenaline extravasation.

Prospective analysis of waiting times for emergency plastic surgery in four units.

INTRODUCTION: Trauma is a significant part of the workload in plastic surgery. There are currently wide variations in the available resource for dealing with these patients. Delays to treatment currently exist and may result in poorer clinical outcomes. METHOD: Data was collected prospectively in 4 centres (Cork University Hospital, John Radcliffe Hospital, Stoke Mandeville Hospital and Salisbury District Hospital) assessing delays to theatre. We assessed time to theatre, both from injury and from review, cancellation rate, starvation time and patient satisfaction. RESULTS: 424 patients were audited over an 8-week period. The average time from review to theatre was 15.7 h and the average injury-to-theatre time was 58.6 h. The average starvation time was 10 h; the mean cancellation rate was 25%. Patients are satisfied overall with the service provided with 83% rating the service as excellent or good, and 63% feeling that there wait was not too long. CONCLUSIONS: Despite an increase in provision of emergency plastic surgery trauma lists, the average wait for emergency plastic surgery is increasing. Despite this patients remain, on the whole, satisfied with the service that they are receiving.

Macrophage-mediated degradation of crosslinked collagen scaffolds.

Biological scaffolds used in tissue engineering are incorporated in vivo by a process of cellular in-growth, followed by host-mediated degradation and replacement of these scaffolds, in which phagocytic cells from the monocyte/macrophage cell lineage play a key role. The chemical degradation of scaffolds with collagenases is well established, but to date this has not been correlated with an in vitro model of cell mediated scaffold degradation. RAW264.7, a murine monocyte/macrophage cell line, was cultured on collagen scaffolds crosslinked either by dehydrothermal treatment (DHT) or by carbodiimide (EDC). These cells attached to collagen scaffolds, proliferated and exhibited macrophage aggregation to form giant cells. Crosslinking the scaffolds by either DHT or EDC increased the resistance of the scaffold to degradation by macrophages. Increasing the amount of crosslinking in the scaffold made them more resistant to degradation by collagenase. However, while EDC increased the scaffolds' thermal and mechanical properties and decreased the swelling ratio, DHT increased the mechanical properties, but decreased the denaturation temperature and swelling ratio. Altering the scaffold properties by crosslinking affects the rate of degradation by macrophages, and this is correlated with chemical degradation (r=0.658, p<0.01). This will help in the design of scaffolds with task-specific profiles for use in tissue engineering.

Pyogenic granuloma - the quest for optimum treatment: audit of treatment of 408 cases.

Pyogenic granuloma is a common, acquired, benign vascular lesion of skin and mucous membranes which may occasionally present intravascularly or subcutaneously. Pyogenic granuloma occur in all age groups and although they may eventually regress, removal of unsightly, bleeding or uncomfortably positioned lesions is usually sought before this takes place. This is a retrospective study of 408 cases of pyogenic granuloma that were analysed by the Stoke Mandeville Histopathology laboratory between 1994 and 2004. This study was carried out to review the sex, age and anatomic distribution of the lesions and to assess the most successful form of treatment on the basis of recurrence risk and other measures such as aesthetic result, acceptability and appropriateness of the procedure with respect to the patient. There was a slight male preponderance especially among children. The exception to this was lesions on mucous membranes, which were more common in women. Head and neck was the most common anatomical location, in particular the cheek and intraoral locations. Fewest recurrences were noted following excision and direct closure although all techniques investigated showed an acceptably low recurrence rate. Whatever technique is used it must yield material for histopathological analysis to ensure the exclusion of differential diagnoses.