What are the likely causes of breast implant associated anaplastic large cell lymphoma (BIA-ALCL)?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoma. Where implant history is known, all confirmed cases to date have occurred in patients with exposure to textured implants. The etiopathogenesis of BIA-ALCL is likely to be multifactorial, with current evidence-based theories recognising the combination of chronic infection in setting of textured implants, gram-negative biofilm formation, chronic inflammation, host genetics (e.g. JAK/STAT, p53) and time in tumorigenesis. Proposed triggers for the development of malignancy are mechanical friction, silicone implant shell particulates, silicone leachables and bacteria. Of these, the bacterial hypothesis has received significant attention, supported by a plausible biological model. In this model, bacteria form an adherent biofilm in the favourable environment of the textured implant surface, producing a bacterial load that elicits a chronic inflammatory response. Bacterial antigens, primarily of gram-negative origin, may trigger innate immunity and induce T-cell proliferation with subsequent malignant transformation in genetically susceptible individuals. Future research, investigating BIA-ALCL genetic mutations and immunological modulation with Gram-negative biofilm in BIA-ALCL models is warranted to establish a unifying theory for the aetiology of BIA-ALCL.

Activated protein C to heal pressure ulcers.

Pressure ulcers present a major clinical challenge, are physically debilitating and place the patient at risk of serious comorbidities such as septic shock. Recombinant human activated protein C (APC) is an anticoagulant with anti-inflammatory, cytoprotective and angiogenic effects that promote rapid wound healing. Topical negative pressure wound therapy (TNP) has become widely used as a treatment modality in wounds although its efficacy has not been proven through randomised controlled trials. The aim of this study was to determine the preliminary efficacy and safety of treatment with APC for severe chronic pressure sores with and without TNP. This case presentation describes the history, management and outcome of two patients each with a severe chronic non-healing pressure ulcer that had failed to respond to conventional therapy. TNP was added to conservative management of both ulcers with no improvement seen. Then local application of small doses of APC was added to TNP and with conservative management, resulted in significant clinical improvement and rapid healing of both ulcers, displaying rapid growth of vascular granulation tissue with subsequent epithelialisation. Patients tolerated the treatment well and improvements suggested by long-term follow-up were provided. Randomised placebo-controlled double blind trials are needed to quantify the efficacy, safety, cost-effectiveness, optimal dose and quality of life changes seen from treatment with APC.

Acute Gastric Rupture in a Giant Inguinoscrotal Hernia.

Inguinoscrotal gastric herniation is a rare occurrence and generally presents with obstruction when encountered. We present a case of acute spontaneous gastric rupture in a giant inguinoscrotal hernia which was managed surgically in a one-stage procedure with primary gastric and hernia repair. A subtotal colectomy was performed due to risk of volvulus as well as allowing for primary closure of the abdominal wall. This case illustrates the possibilities in terms of hernia size and contents, in addition to the potential complications that may ensue. Moreover, this case illustrates that adherence to the principles of hernia repair can equip the surgeon to deal with rare and unfamiliar presentations.

Accuracy of burn size estimation in patients transferred to adult Burn Units in Sydney, Australia: an audit of 698 patients.

BACKGROUND: The purpose of this study was to compare burn size estimation between referring centres and Burn Units in adult patients transferred to Burn Units in Sydney, Australia. METHODS: A review of all adults transferred to Burn Units in Sydney, Australia between January 2009 and August 2013 was performed. The TBSA estimated by the referring institution was compared with the TBSA measured at the Burns Unit. RESULTS: There were 698 adults transferred to a Burns Unit. Equivalent TBSA estimation between the referring hospital and Burns Unit occurred in 30% of patients. Overestimation occurred at a ratio exceeding 3:1 with respect to underestimation, with the difference between the referring institutions and Burns Unit estimation being statistically significant (P<0.001). Significant overestimation occurs in the early transfer of burn-injured patients as well as in patients transferred more than 48h after the burn (P<0.005). Underestimation occurs with less frequency but rises with increasing time after the burn (P<0.005) and with increasing TBSA. Throughout the temporal spectrum of transferred patients, severe burns (≥20% TBSA) were found to have more satisfactory burn size estimations compared with less severe injuries (<20% TBSA; P<0.005). CONCLUSIONS: There are significant inaccuracies in burn size assessment by referring centres. The systemic tendency for overestimation occurs throughout the entire TBSA spectrum, and persists with increasing time after the burn. Underestimation occurs less frequently but rises with increasing time after the burn and with increasing TBSA. Severe burns (≥20% TBSA) are more accurately estimated by the referring hospital. The inaccuracies in burn size assessment have the potential to result in suboptimal treatment and inappropriate referral to specialised Burn Units.