'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps.

BACKGROUND: Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes. METHODS: STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis. RESULTS: Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%). CONCLUSIONS: This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Breast implant associated anaplastic large cell lymphoma: The UK experience. Recommendations on its management and implications for informed consent.

BACKGROUND: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, Non-Hodgkin lymphoma arising in the capsule of breast implants. BIA-ALCL presents as a recurrent effusion and/or mass. Tumours exhibit CD30 expression and are negative for Anaplastic Lymphoma Kinase (ALK). We report the multi-disciplinary management of the UK series and how the stage of disease may be used to stratify treatment. METHODS: Between 2012 and 2016, 23 cases of BIA-ALCL were diagnosed in 15 regional centres throughout the UK. Data on breast implant surgeries, clinical features, treatment and follow-up were available for 18 patients. RESULTS: The mean lead-time from initial implant insertion to diagnosis was 10 years (range: 3-16). All cases were observed in patients with textured breast implants or expanders. Fifteen patients with breast implants presented with stage I disease (capsule confined), and were treated with implant removal and capsulectomy. One patient received adjuvant chest-wall radiotherapy. Three patients presented with extra-capsular masses (stage IIA). In addition to explantation, capsulectomy and excision of the mass, all patients received neo-/adjuvant chemotherapy with CHOP as first line. One patient progressed on CHOP but achieved pathological complete response (pCR) with Brentuximab Vedotin. After a mean follow-up of 23 months (range: 1-56) all patients reported here remain disease-free. DISCUSSION: BIA-ALCL is a rare neoplasm with a good prognosis. Our data support the recommendation that stage I disease be managed with surgery alone. Adjuvant chemotherapy may be required for more invasive disease and our experience has shown the efficacy of Brentuximab as a second line treatment.

Automation of an interferon-γ release assay and comparison to the tuberculin skin test for screening basic military trainees for Mycobacterium tuberculosis infection.

We automated portions of the QuantiFERON-TB Gold In-Tube test (QFT-GIT) and assessed its quality when performed concurrently with the tuberculin skin test (TST) among U.S. Air Force basic military trainees (BMTs). The volume of blood collected for QFT-GIT was monitored. At least one of the three tubes required for QFT-GIT had blood volume outside the recommended 0.8- to 1.2-mL range for 688 (29.0%) of 2,373 subjects who had their blood collected. Of the 2,124 subjects who had TST and QFT-GIT completed, TST was positive for 0.6%; QFT-GIT was positive for 0.3% and indeterminate for 2.0%. Among 2,081 subjects with completed TST and determinate QFT-GIT results, overall agreement was 99.5% but positive agreement was 5.6%. Specificity among the 1,546 low-risk BMTs was identical (99.7%). Indeterminate QFT-GIT results were 2.7 times more likely when mitogen tubes contained >1.2 mL blood than when containing 0.8- to 1.2-mL blood. Automation can facilitate QFT-GIT completion, especially if the recommended volume of blood is collected. Mycobacterium tuberculosis infection prevalence among BMTs based on TST and QFT-GIT is similar and low. Selectively testing those with significant risk may be more appropriate than universal testing of all recruits.

Observing the dynamics of supermassive black hole binaries with pulsar timing arrays.

Pulsar timing arrays are a prime tool to study unexplored astrophysical regimes with gravitational waves. Here, we show that the detection of gravitational radiation from individually resolvable supermassive black hole binary systems can yield direct information about the masses and spins of the black holes, provided that the gravitational-wave-induced timing fluctuations both at the pulsar and at Earth are detected. This in turn provides a map of the nonlinear dynamics of the gravitational field and a new avenue to tackle open problems in astrophysics connected to the formation and evolution of supermassive black holes. We discuss the potential, the challenges, and the limitations of these observations.

Suicide burden in the U.S. Air Force: 1990-2004.

OBJECTIVE: To measure indirectly standardized active duty Air Force (ADAF) suicide rates. METHODS: The study period was 1990-2004. ADAF suicide deaths were obtained from the Air Force Mortality Registry. ADAF population counts were obtained from the Defense Manpower and Data Center. Suicide rates for the U.S. general population were obtained from the National Center for Health Statistics. RESULTS: The standardized mortality ratios (SMRs), adjusted for age, gender, and race, were: all enlisted personnel, 0.64 (95% CI: 0.59-0.69) and all officers, 0.14 (95% CI: 0.10-0.20). Adjusted for age and race, the SMRs were: enlisted men, 0.63 (95% CI: 0.58-0.68); enlisted women, 0.95 (95% CI: 0.66-1.33); officer men, 0.12 (95% CI: 0.08-0.17); and officer women, 0.67 (95% CI: 0.27-1.36). CONCLUSIONS: There were significant deficits of suicides in overall enlisted personnel and in overall officers. When analyzed further by gender and rank, there were significant deficits only in enlisted men and officer men. Suicide mortality in enlisted and officer women was not significantly less compared to their general population counterparts.

Motor vehicle driver death and high state maximum speed limits: 1991-1993.

OBJECTIVE: To measure the association between motor vehicle crash (MVC) driver death and high state maximum speed limits. METHODS: This study used a case-control design and assessed driver deaths from three major types of MVCs: non-collision; collision with motor vehicles in transit; and collision with stationary objects. The study period was 1991-1993. For each type of crash, case subject populations of fatally injured drivers were obtained from the U.S. Department of Transportation Fatality Analysis Reporting System. Four control subject populations, each associated with a different cause of death, were obtained from a U.S. national death certificate database (the causes of death were unintentional poisoning, non-Hodgkin lymphoma, drowning, and diabetes mellitus). Subjects were considered exposed if the state in which they crashed (for cases) or died (for controls) had a maximum speed limit greater than 55 mph. Each of the three case subject populations was compared against each of the four control subject populations. Odds ratios (ORs) were adjusted for age and gender. RESULTS: For non-collision driver death, ORs ranged from 3.06 to 6.56, depending on the year and control group; all the ORs were significant. For collision with motor vehicles in transit driver death, ORs ranged from 1.12 to 2.22; all the ORs were significant. For collision with stationary objects driver death, ORs ranged from 0.87 to 1.83. CONCLUSIONS: There was a moderately strong and significant association between non-collision driver death and high state maximum speed limits. For collision with motor vehicles in transit driver death, the association was somewhat milder but still consistent. For collision with stationary objects driver death, the presence of an association was unclear. During 1991-1993, the effects of high state maximum speed limits may have been different for different types of MVCs.

Obesity in civilian adults: potential impact on eligibility for U.S. military enlistment.

OBJECTIVE: This study measures the prevalence in the civilian adult population of obesity for military enlistment. METHODS: The National Health and Nutrition Examination Survey for 2001-2004 was used to obtain a sample of civilian adults 17 to 42 years of age. Weight standards for each branch of service were applied to determine the proportion of subjects who were over maximal weight limits and thus ineligible for enlistment. RESULTS: Depending on the branch of service and the age range, 17.9% to 54.4% of men and 20.8% to 54.9% of women were overweight for enlistment. Generally, there were higher prevalence rates in the older age groups and among women. Prevalence rates for non-Caucasian subjects were not higher among men but were higher among women. CONCLUSION: Large proportions of civilian adults are over the weight limits for military enlistment. The currently increasing prevalence of obesity in the civilian population may pose a challenge for military recruitment programs.

Cancer incidence in the U.S. Air Force: 1989-2002.

BACKGROUND: Cancer incidence in U.S. Air Force active duty (AFAD) personnel is unknown. Defining the epidemiology may support more effective prevention and clinical services. METHODS: Standardized incidence ratios (SIRs) for invasive cancer in AFAD personnel during 1989-2002 were determined using U.S. national incidence rates as the reference. SIRs were adjusted for age and race. Cutaneous squamous and basal cell carcinomas (CAs) were excluded. RESULTS: There were 2750 cases: 1986 in men and 764 in women. The all-cancers SIRs were for men, 0.50 (95% CI: 0.48-0.53), and for women, 0.96 (95% CI: 0.89-1.03). Among men, the 10 most frequent cancers (77.6% of total) were, in descending order: melanoma; testicular CA; prostate CA; non-Hodgkin lymphoma; follicular/papillary thyroid CA; Hodgkin's Disease; colorectal CA; brain neuroepithelial CA; and (tied) bladder CA and oral squamous cell CA. Among women, the 10 most frequent cancers (88.1% of total) were, in descending order: breast CA; cervical CA; follicular/papillary thyroid CA; melanoma; Hodgkin's Disease; colorectal CA; (tied) non-Hodgkin lymphoma and ovarian epithelial CA; vulvar CA; and (tied) brain neuroepithelial CA and oral squamous cell CA. Compared with the U.S. population, cancer type-specific SIRs were significantly increased for cervical CA, prostate CA, and vulvar CA (range, 1.44-3.54). SIRs were significantly decreased for bladder CA (men), brain neuroepithelial CA, colorectal CA (men), Hodgkin's Disease (men), non-Hodgkin lymphoma, oral squamous cell CA (men), and testicular CA (range, 0.31-0.68). The remaining SIRs were not significantly different from unity. CONCLUSIONS: The cancer experience of the AFAD population differs substantially from that of the U.S. population.

A critical evaluation of the electronic surgical logbook.

BACKGROUND: The Association of Surgeons of Great Britain and Ireland (ASGBI) devised the electronic surgical logbook (version 2.4) for higher trainees in General Surgery enabling trainees to compile a uniform data set of their operative and training experience. This is in use by higher surgical trainees (HST) in the United Kingdom. This logbook permits trainees to submit data centrally into a Regional Analysis Database (RAD). With the implementation of the European Working Time Directive (EWTD) there is need for reliable data to assess the effects of the directive on training. In order to draw meaningful conclusions from the database the quality of data needs to be validated. We critically analysed the RAD in the Yorkshire region for a one-year period. METHODS: The RAD from the ASGBI for the Yorkshire region was analysed. Data for the period 01/10/2002-30/09/2003 was identified and interrogated using Microsoft Excel (2000 version). The RAD was compared with information obtained from the Regional Surgical Advisor for Yorkshire with respect to hospitals, surgical consultants and HST's in the region during the study period. RESULTS: There were 13,755 operations entered for the study period. 579 corrections to the data had to be made (4.2%) and a further 1140 entries were deleted (8.2%). Following corrections and deletions 12,615 operative entries were available for analysis. Overall 12.5% of the data required either correction or exclusion from the database prior to analysis. CONCLUSION: The RAD has a large dataset useful to monitor and assess training. However, the quality of the data needs to be verified prior to use. Recommendations have been made to develop the ASGBI logbook, which would eventually translate to improved data reliability of the RAD.

Retrospective review of MEG visual evoked hemifield responses prior to resection of temporo-parieto-occipital lesions.

Visual evoked cortical magnetic field (VEF) waveforms were recorded from both hemifields in 21 patients with temporo-parieto-occipital mass lesions to identify preserved visual pathways. Fifteen patients had visual symptoms pre-operatively. Magnetoencephalographic (MEG) VEF responses were detected, using single equivalent current dipole (ECD), in 17/21 patients studied. Displaced or abnormal responses were seen in 15 patients with disruption of pathway in one patient. Three of 21 patients had alterations in the surgical approach or the planned resection based on the MEG findings. The surgical outcome for these three patients suggests that the MEG study may have played a useful role in pre-surgical planning.

Testicular carcinoma in U.S. Air Force aviators: a case-control study.

BACKGROUND: Previous descriptive studies have suggested an increased risk of testicular carcinoma in military aviators. The association between testicular carcinoma and aviation in the U.S. Air Force was measured using a case-control study design. METHODS: A Department of Defense hospitalization database was used to obtain a set of testicular carcinoma cases (seminomas, embryonal cell carcinomas, teratocarcinomas, and choriocarcinomas) and an unmatched set of male appendicitis controls from October 1988 to February 1999. A centralized U.S. Air Force personnel database was used to obtain demographic and flying history data on the subjects. Multiple logistic regression was used to obtain odds ratios (OR) and confidence intervals (CI) for the following exposure factors: total flight time, rank, crew position, and general type of aircraft. Study subjects were restricted to white active duty officers. RESULTS: For one or more total flight hours, the age-adjusted OR was 1.74 (95% CI 1.04-2.92). Age-adjusted OR's for 1-499, 500-1999, and 2000 or more flight hours were, respectively, 1.37, 1.92, and 1.67. These OR's were not statistically significant. Age- and flight hour-adjusted OR's were increased for the navigator crew position and for bomber/tanker/ transport/reconnaissance type aircraft (2.13 and 1.67, respectively), but the ratios were not statistically significant. OR's were not increased for senior rank, fighter/trainer type aircraft, and rotary-wing aircraft. CONCLUSIONS: There is an association between testicular carcinoma and flight time in U.S. Air Force officers. There was a suggestion of a dose-response effect; however, the OR's were not statistically significant.

Comparative field cage tests of the population suppressing efficiency of three genetic control systems for Aedes Aegypti.

Cycling populations of Aedes aegypti were set up in cages and managed in such a way that the populations had a maximum of threefold recovery potential in response to control measures. Into three such populations daily releases were made of males which had been chemosterilised, or were double translocation heterozygotes (T1T3) or T1T3 with sex ration distortion (DT1T3). Eradication of the populations was achieved with all cases, but the rate of suppression was markedly slower with T1T3 than the other two systems, with which the rates were similar. T1T3 and DT1T3 releases introduced considerable inherited genetic loads into the target populations. The results were in general agreement with computer predictions.

Genetic manipulation of Aedes aegypti: incorporation and maintenance of a genetic marker and a chromosomal translocation in natural populations.

Studies with Aedes aegypti were undertaken to determine if an alien genotype can be (1) incorporated into a natural population and (2) maintained for several generations on its own without any subsequent introductions. Such information is an essential prerequisite for successful application of any genetic control method. Data from a walk-in, field population cage and from field releases of a genetic marker and a chromosomal translocation have demonstrated both genetic incorporation and persistence for at least three successive generations. This is the first demonstration of its type with any vector species.