Does Mode of Surgical Intervention Based on Oncotype DX Score Influence Disease Recurrence in Early Breast Cancer?

Introduction Routine utilization of multigene assays to inform operative decision-making in early breast cancer (EBC) treatment is yet to be established. In this pilot study, we sought to establish the potential benefits of surgical intervention in EBC based on recurrence risk quantification using the Oncotype DX (ODX) assay. Materials and Methods Consecutive ODX tests performed over a 9-year period from October 2007 to May 2016 were evaluated. Oncotype scores were classified into high (≥31), medium (18-30), or low-risk (0-17) groups. The primary outcome was breast cancer recurrence. Subgroup analysis offered assessment of the recurrence effect of mode of surgical intervention for patient groups as defined by the oncotype score. Results In total 361 patients underwent ODX testing. The mean age and follow-up were 55.25 (± 10.58) years and 38.59 (± 29.1) months, respectively. The majority of patients underwent wide local excision (86.7%) with 8.9 and 4.4% patients having a mastectomy or wide local excision with completion mastectomy, respectively. Fifty-one percent of patients fell into the low risk ODX category with a further 40.2 and 8.5% deemed to be of intermediate and high risk. Five patients (1.38%) had disease recurrence. Comparative analysis of operative groups in each oncotype group revealed no difference in recurrence scores in the low- ( p = 0.84) and high-risk groups ( p = 0.92) with a statistically significant difference identified in the intermediate risk group ( p = 0.002). Conclusion To date we have been unable to definitively identify a role for ODX in guiding surgical approach in EBC. There is, however, a need for larger studies to examine this hypothesis.

Five-year follow-up of patients treated with intra-dermal botulinum toxin for axillary hyperhidrosis.

BACKGROUND: Axillary hyperhidrosis is a common complaint affecting 5% of the general population. It can significantly impact quality of life (QOL) and may be extremely debilitating. Administration of intra-dermal botulinum toxin type-A (Botox) has been proven to be effective in managing axillary hyperhidrosis; however, to date, no long-term data has assessed its efficacy. AIM: We aim to assess long-term (> 5 years) QOL outcomes in this patient cohort. METHODS: In this single-centre series, all patients attending for axillary botox, with five or more years of follow-up, were prospectively included. QOL was assessed in all patients using the validated assessment tool, the modified Dermatology Life Quality Index (DLQI). Standard statistical methods were utilised with data reported as mean (± standard deviation). Subgroup analysis utilising previously published departmental data allowed for further assessment of change in QOL over time. RESULTS: A total of 75 patients (83% female) met the inclusion criteria with 67% completing the DLQI assessment. Follow-up ranged from 5 to 10 years with a mean age of 37.6 years (± 8.82). The mean number of treatments over the study period was 12 (± 3.1). Mean overall post-treatment DLQI score was 1.6 (± 2.01). This represented a significant improvement in patient QOL (p = < 0.0001) associated with long-term botox application. This statistical significance was identified consistently across all components of the DLQI tool. CONCLUSION: These data suggest that the established early QOL benefits associated with intra-dermal botox administration for AH are sustained in the long term. This benefit was seen across all subsets of the DLQI tool.

Meta-analysis of the impact of progesterone receptor status on oncological outcomes in oestrogen receptor-positive breast cancer.

BACKGROUND: Assessment of the oestrogen receptor (ER) provides important prognostic information in breast cancer. The impact of progesterone receptor (PgR) status is less clear. Standardization of immunohistochemical analysis of these receptors has reduced interstudy heterogeneity. The aim of this meta-analysis was to evaluate the impact of PgR negativity on outcomes in ER-positive (ER+) breast cancer. METHODS: This study was performed according to PRISMA and MOOSE guidelines. PubMed, Embase and the Cochrane Library were searched systematically to identify studies comparing disease-free survival as the primary outcome and overall survival as secondary outcome between PgR-positive (PgR+) and PgR-negative (PgR-) status in ER+ breast cancer. A meta-analysis of time-to-effect measures from included studies was undertaken. RESULTS: Eight studies including 13 667 patients, 11 838 in the ER+PgR+ group and 1829 in the ER+PgR- group, met the inclusion criteria. Treatment characteristics did not differ significantly between the two groups. Patients in the ER+PgR- group had a higher risk of disease recurrence than those who had ER+PgR+ disease (hazard ratio (HR) 1·57, 95 per cent c.i. 1·38 to 1·79; P < 0·001). This hazard was increased in patients with human epidermal growth factor receptor 2-negative tumours (HR 1·62, 1·37 to 1·93; P < 0·001). A similar result was observed for overall survival (HR 1·69, 1·33 to 2·14; P < 0·001). CONCLUSION: PgR negativity is associated with significant reductions in disease-free and overall survival in ER+ breast cancer. Treatment and surveillance strategies in these patients should be tailored accordingly.

ANTECEDENTES: La evaluación del receptor de estrógenos (oestrogen receptor, ER) proporciona una importante información pronóstica en el cáncer de mama. El impacto de del estado del receptor de la progesterona (progesterone receptor, PgR) está menos claro. La estandarización del análisis inmunohistoquímico de estos receptores ha reducido la heterogeneidad entre los estudios. El objetivo de este metaanálisis fue evaluar el impacto de la negatividad de PgR (PgR-) en los resultados del cáncer de mama ER positivo (ER+). MÉTODOS: Este estudio se realizó de acuerdo con las directrices PRISMA/MOOSE. Se llevó a cabo una búsqueda sistemática en MEDLINE, PubMed y biblioteca Cochrane para identificar estudios que comparasen la supervivencia libre de enfermedad (disease free survival, DFS) como resultado primario y la supervivencia global (overall survival, OS) como resultado secundario entre los estados PgR+ y PgR- en el cáncer de mama ER+. Se realizó un metaanálisis de los estudios incluidos de las medidas de tiempo hasta el efecto. RESULTADOS: Ocho estudios que incluían 13.533 pacientes, 11.724 en el grupo ER+PgR+ y 1.809 en el grupo ER+PgR- cumplieron con los criterios de inclusión. Las características del tratamiento no diferían significativamente entre los dos grupos. Los pacientes en el grupo ER+PgR- presentaron un riesgo más elevado de recidiva de la enfermedad que aquellas que tenían enfermedad ER+PgR+ (DFS, cociente de riesgos instantáneos, hazard ratio, HR 1,57; i.c. del 95% 1,38-1,79; P < 0,001). Este riesgo se incrementó en pacientes que eran HER2 negativo (DFS HR 1,62; i.c. del 95% 1,37-1,93; P < 0,001). Un resultado similar se observó para la OS (HR 1,69; i.c. del 95% 1,33-2,14, P < 0,001). CONCLUSIÓN: La negatividad de PgR se asocia con disminuciones significativas de DFS y OS en el cáncer de mama ER+. En estas pacientes, las estrategias de tratamiento y seguimiento en deberán adecuarse a cada caso particular.

The Use of Arteriovenous Fistulae as an Adjunct to Peripheral Arterial Bypass: A Systematic Review and Meta-analysis.

BACKGROUND: Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass. METHODS: The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles. STUDY ELIGIBILITY: All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed. RESULTS: Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73-2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82-1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80-1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30-0.98). CONCLUSION: Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.

Radiofrequency ablation: an assessment of clinical and cost efficacy.

BACKGROUND: Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. AIMS: The aim of this study was to directly compare RFA and open saphenofemoral ligation. METHODS: This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. RESULTS: During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P = <0.001) when compared with open ligation with a success rate of 98 %. No significant inter-group difference was noted for 30-day readmission (p = 0.203). Focused cohort analysis identified an increase in hospital day case activity (74 vs. 90 %, p = 0.002), which contributed to a reduction in procedural cost (€1,024 vs. €971, p = 0.003) over the study period. CONCLUSIONS: Radiofrequency ablation is a viable alternative to open repair offering excellent efficacy. It is however associated with a higher procedural cost than the open surgical option.

Endovascular versus open repair of ruptured abdominal aortic aneurysm.

INTRODUCTION: Endovascular aneurysm repair (EVAR) is a comparatively less invasive technique than open repair (OR). Debate remains with regard to the benefit of EVAR for patients with ruptured abdominal aortic aneurysm (RAAA). We sought to evaluate and report outcomes of EVAR for RAAA in an Irish tertiary vascular referral centre. METHODS: Patients undergoing emergency surgery for ruptured or symptomatic AAA were identified from theatre logbooks and HIPE database. Retrospective chart review was undertaken. Data were exported to IBM SPSS version 21 for statistical analysis with p < 0.05 considered significant. RESULTS: A total of 41 patients underwent surgery for RAAA. The mean age was 74 years old with a range from 55 to 89 years. The majority (n = 25, 61%) were baseline American Society of Anaesthesiology (ASA) grade 3-4. Of these 56% underwent EVAR with the remaining 44% repaired open. Mortality rate in those undergoing emergency EVAR was 34.8%, compared with 38.9% in those undergoing open surgery. This difference was not statistically significant. The mean overall length of stay was 13 days. With regard to prognostic indicators of patient outcome, increasing patient age was noted to be significantly associated with increased mortality (p = 0.013), as was increased ASA score at time of surgery (p = 0.029). CONCLUSIONS: Mortality rates in those undergoing EVAR for RAAA are comparable with those undergoing open repair. Increasing age and ASA score are significant predictors of mortality in patients with RAAA undergoing intervention.

Prosthodontic rehabilitation of hypophosphatasia using dental implants: a review of the literature and two case reports.

There are reports in the literature of the various dental features of hypophosphatasia, especially where it affects the deciduous dentition. The descriptions include both the manifestations of the disorder and the subsequent patterns of tooth loss. There are fewer descriptions of the effects of hypophosphatasia on the permanent dentition and little information on the subsequent prosthodontic management of these patients, particularly in relation to the use of dental implants. The aim of this paper was to review the literature on the dental effects of hypophosphatasia, present two cases and describe how one of those patients, a young adult, was successfully rehabilitated using dental implants. That latter patient's pattern of tooth loss as well as some histological and scanning electron microscopic findings of root cementum from the other case is also described.

Differences in displayed pump flow compared to measured flow under varying conditions during simulated cardiopulmonary bypass.

Errors in blood flow delivery due to shunting have been reported to reduce flow by, potentially, up to 40-83% during cardiopulmonary bypass. The standard roller-pump measures revolutions per minute and a calibration factor for different tubing sizes calculates and displays flow accordingly. We compared displayed roller-pump flow with ultrasonically measured flow to ascertain if measured flow correlated with the heart-lung pump flow reading. Comparison of flows was measured under varying conditions of pump run duration, temperature, viscosity, varying arterial/venous loops, occlusiveness, outlet pressure, use of silicone or polyvinyl chloride (PVC) in the roller race, different tubing diameters, and use of a venous vacuum-drainage device.

How much heparin do we really need to go on pump? A rethink of current practices.

OBJECTIVES: Patients undergoing myocardial revascularisation using extracorporeal circulation require heparin anticoagulation. We aimed to evaluate the effect of reducing heparin dosage on target activated clotting time (ACT) and postoperative blood loss. METHODS: In a prospective randomised trial, 195 patients undergoing isolated primary CABG were randomised into four groups A, B, C, and D receiving an initial heparin dosage of 100, 200, 250 and 300 iu/kg, respectively. Extra incremental heparin (50 iu/kg) was added if required to achieve a target ACT of 480 s before initiating cardiopulmonary bypass. Postoperative blood loss was measured from the time of heparin reversal to drain removal 24h later. RESULTS: Target ACT was achieved in 0, 63, 68.3 and 82.4% of patients in groups A, B, C and D, respectively, after the initial dose of heparin. In group B, of those not achieving target act a single increment of heparin was sufficient to achieve target ACT in further 18.6%. The mean ACT after the initial dose in groups B, C and D was 482.9, 519 and 588 s, respectively (P<0.05). Postoperative blood loss in millilitre per kilogram was directly proportional to preoperative heparin dose. CONCLUSIONS: Patients receiving lower dose of heparin has lower postoperative blood loss. Of those achieving the target ACT, group B was significantly the closest to the target ACT. A starting dose of 200 iu/kg of heparin and if necessary one 50 iu/kg increment achieved target ACT in 81.5% of patients. The added benefit of significant drop in postoperative blood loss is evident.

A new specifically designed forceps for chest drain insertion.

Insertion of a chest drain can be associated with serious complications. It is recommended that the drain is inserted with blunt dissection through the chest wall but there is no specific instrument to aid this task. We describe a new reusable forceps that has been designed specifically to facilitate the insertion of chest drains.A feasibility study of its use in patients who required a chest drain as part of elective cardiothoracic operations was undertaken. The primary end-point was successful and accurate placement of the drain. The operators also completed a questionnaire rating defined aspects of the procedure. The new instrument was used to insert the chest drain in 30 patients (19 male, 11 female; median age 61.5 years (range 16-81 years)). The drain was inserted successfully without the trocar in all cases and there were no complications. Use of the instrument rated as significantly easier relative to experience of previous techniques in all specified aspects. The new device can be used to insert intercostal chest drains safely and efficiently without using the trocar or any other instrument.

Electrical failure during cardiopulmonary bypass: an evaluation of incidence, causes, management and guidelines for preventative measures.

The incidence of electrical failure during cardiopulmonary bypass (CPB) has been reported to occur in approximately 1 per 1000 cases. While the resultant morbidity and mortality is low, electrical failure is a life-threatening scenario. We report three major electrical failures during CPB in a patient population of 3500 over a 15-year period. These cases involved mains failure and generator shut down, mains failure and generator power surge, and failure of the uninterruptable power supply (UPS), which caused protected sockets to shut down. Protocols for preventative maintenance, necessary equipment, battery backup and guidelines for the successful management of such accidents during CPB are discussed.

The effects of venous cannulation technique and cardioplegia type on plasma potassium concentration and arterial blood pressure during cardiopulmonary bypass.

The cannulation method and cardioplegia solution used during cardiopulmonary bypass (CPB) may both influence plasma potassium concentrations ([K+]) and mean arterial blood pressure (MAP). Bi-caval or right atrial cannulation methods are routinely used in conjunction with crystalloid or blood cardioplegia. We investigated the influence of cannulation method and cardioplegia solutions on plasma [K+] and MAP during cardiopulmonary bypass. Sixty consecutive patients undergoing elective coronary artery bypass grafting (CABG) using CPB were studied. They were randomly divided into three groups of 20 patients. Patients in Group A underwent bi-caval venous cannulation and received crystalloid cardioplegia. Group B patients underwent right atrial cannulation and received crystalloid cardioplegia. Group C patients underwent right atrial cannulation and received blood cardioplegia. In each case. cardioplegia was administered antegrade via the aortic root. Plasma [K+], MAP. and hemoglobin concentration (Hb) were measured over an 8-min period following cardioplegia administration (pilot studies indicated pressure changes occuring post cardioplegia administration up to this time). The combination of bi-caval cannulation and crystalloid cardioplegia (Group A) was associated with the least increase in plasma [K+] and no decrease in MAP. The maximum [K+] for this Group was 4.2 mmol/L (4.6% increase). The minimum mean pressure was 57 mmHg (13.6% increase). Both right atrial cannulation groups (B and C) showed a large rise in plasma [K+] and a decrease in MAP. Group B maximum [K+] was 5.2 mmol/L (27.5% increase). Group C was also 5.2 mmol/L (26.0% increase). Group C showed the largest pressure decrease, the minimum mean pressure was 45 mmHg (21.3% decrease). The Group B minimum mean pressure was 45 mmHg (8.7% decrease). Our results show that patients undergoing CPB operations who are deemed to be at increased risk of suffering adverse effects from hypotensive episodes may benefit from bicaval cannulation and caval snaring, in preference to right atrial cannulation. Crystalloid cardioplegia may be preferable to blood cardioplegia in these cases to maintain the MAP.

Contemporary developments in the utilization of metal-ceramic restorations: a review.

Numerous porcelain systems and techniques are currently available for utilization in full-coverage anterior crown restorations. Significant improvements have been made in the placement of margins and the reduction of the metal framework in order to enhance the optical effects (e.g., illumination, warmth, and vitality) of these porcelain systems. This article presents several recent developments in the fabrication of metal-ceramic crown restorations, and demonstrates the use of these principles in the aesthetic oral rehabilitation.

Long-term clinical outcome following coronary artery bypass grafting for isolated stenosis of the left anterior descending coronary artery.

AIMS: To detail the clinical and angiographic profile, and long-term outcome in consecutive patients with isolated stenosis of the left anterior descending coronary artery undergoing bypass surgery. METHODS: A retrospective study of all patients (n = 301) (January 1984-December 1990) and undergoing coronary artery bypass grafting for isolated left anterior descending disease, in the Irish Republic, was performed. Survival was compared with that of an exact age- and gender-matched cohort. RESULTS: Mean age was 53 (+/- 9.3) years. There were 238 (79%) males. In 241 (80%) patients an internal thoracic arterial bypass graft was used. Operative mortality was 1.3%. Of the 280 (93%) patients alive (16 cardiac deaths) at 7.1 (+/- 1.9) years, 105 (35%) had angina, 26 (9%) suffered an interval myocardial infarction, and repeat revascularization was required on 29 (10%). Female gender (P = 0.002), pre-operative myocardial infarction (P = 0.02), significant diagonal disease (P = 0.04) and postoperative myocardial infarction (P = 0.0001) were independently associated with survival. Females were more likely to develop congestive cardiac failure (P = 0.01) or postoperative angina (P = 0.03) than their male counterparts. CONCLUSIONS: Survivorship (97%) and event-free survival (96%) at 5 years following coronary artery bypass grafting for isolated left anterior descending coronary artery disease is excellent and equivalent to an age-matched and gender-matched cohort.