Prognostic significance of previous tonsillectomy after radical cystectomy for bladder cancer.

Introduction: To examine whether previous tonsillectomy (TE) impacts on survival after radical cystectomy (RC) for bladder cancer (BC).Patients and Methods: A total of 320 patients were staged cM0 and underwent RC for BC between 2002 and 2013. We retrospectively investigated whether patients had undergone TE prior to RC. Chi-square/Fisher-Exact test was carried out to compare clinicopathological features between the TE- and non-TE-group. Kaplan-Meier analysis with log-rank test was used to estimate recurrence-free survival (RFS) and multivariable Cox-regression analysis of risk factors of recurrence. The median follow-up was 31 months (interquartile range: 9-54).Results: A history of TE was present in 18 of the 320 patients (5.6%). All TEs were performed for benign conditions. TE prior to RC was associated with a history of appendectomy (p = 0.045), lower age at RC (p = 0.029), tumor unifocality (p < 0.001), advanced histopathological tumor stage (p = 0.015), non-pure urothelial carcinoma (p = 0.025), lymphovascular invasion (p = 0.035) and receipt of palliative chemotherapy (p = 0.004). The 3-year RFS was 39.2% for patients with previous TE and 62.4% for those without (p = 0.008). In multivariable analysis, adjusted for all significant parameters of univariable analysis, lymph-node tumor involvement (p = 0.017), positive surgical margins (p = 0.047), tumor grade (p = 0.032), advanced tumor stage (≥pT3a; p = 0.049) and a history of TE (p = 0.021) remained independent prognosticators of recurrence.Conclusion: In this series, previous TE was an independent predictor of recurrence after RC for BC. Further studies are needed to assess whether TE induces immunological alterations that might exert adverse effects on cancer progression of patients with invasive BC.

Prognostic impact of tumor-associated immune cell infiltrates at radical cystectomy for bladder cancer.

OBJECTIVES: To assess whether the presence and location of tumor-associated immune cell infiltrates (TAIC) on histological slides obtained from cystectomy specimens impacts on oncological outcomes of patients with bladder cancer (BC). MATERIAL AND METHODS: A total of 320 consecutive patients staged with cM0 bladder cancer underwent radical cystectomy (RC) between 2004 and 2013. The presence of TAIC (either located peritumorally [PIC] and/or intratumorally [IIC]) on histological slides was retrospectively assessed and correlated with outcomes. Kaplan-Meier analyses were used to estimate the impact of TAIC on recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS). Multivariable Cox-regression analysis was carried out to evaluate risk factors of recurrence. The median follow-up was 37 months (IQR: 10-55). RESULTS: Of the 320 patients, 42 (13.1%) exhibited IIC, 141 (44.1%) PIC and 137 (42.8%) no TAIC in the cystectomy specimens. Absence of TAIC was associated with higher ECOG performance status (P = 0.042), histologically advanced tumor stage (≥pT3a; P < 0.001), lymph node tumor involvement (pN+; P = 0.022), positive soft tissue surgical margins (P = 0.006), lymphovascular invasion (P < 0.001), and elevated serum C-reactive protein levels (P < 0.001). The rate of never smokers was significantly higher in the IIC-group (64.3%) compared to the PIC-group (39.7%, P = 0.007) and those without TAIC (35.8%, P = 0.001). The 3-year RFS/CSS/OS was 73.9%/88.5%/76.7% for patients with IIC, 69.4%/85.2%/70.1% for PIC and 47.6%/68.5%/56.1% for patients without TAIC (P < 0.001/<0.001/0.001 for TAIC vs. no TAIC). In multivariable analysis, adjusted for all significant parameters of univariable analysis, histologically advanced tumor stage (P = 0.003), node-positive disease (P = 0.002), and the absence of TAIC (P = 0.035) were independent prognosticators for recurrence. CONCLUSIONS: In this analysis, the presence and location of TAIC in cystectomy specimens was a strong prognosticator for RFS after RC. This finding suggests that the capability of immune cells to migrate into the tumor at the time of RC is prognostically important in invasive bladder cancer.

Radical Cystectomy in Female Patients - Improving Outcomes.

PURPOSE OF REVIEW: To review the methods of improving surgical, oncological, and functional outcomes in women with bladder cancer treated with radical cystectomy. RECENT FINDINGS: Οrthotopic urinary diversion (ONB) is a safe option for well-selected women as it combines high rates of daytime and nighttime continence with exceptional oncologic outcomes. It is considered safe even for patients with limited lymph node disease and trigone involvement, as long as a preoperative biopsy of the bladder neck or an intraoperative frozen section analysis of distal urethral margin rules out malignant disease. Nerve-sparing techniques have shown promising results. For well-selected patients with early invasive disease, sparing of internal genitalia has proven to be oncologically safe. Yet, generally accepted and evidence-based oncological and functional follow-up schemes for women after radical cystectomy are still lacking. Properly designed prospective studies are needed with adequate number of participants in order to safely conclude about a broader use of pelvic organ-sparing cystectomy.

A modified technique of using the dynamic external finger fixation system. Case study.

Fractures of the phalangeal joints of the hand present a challenging problem because of the small size of the fracture fragments, limiting internal fixation, and their articular nature necessitating early mobilisation to ensure good results. We present a case of a patient presenting with an open displaced intraarticular fracture of the metacarpophalangeal joint that was managed with limited internal fixation with a Kirschner wire along with the S-Quattro. The fracture united and the patient returned to his previous occupation with no limitations in his activities of daily living. This is the first instance of S-Quattro being described for the management of an open fracture with the additional use of limited internal fixation. The additional use of limited internal fixation ensured adequate fracture reduction and stabilisation. The S-Quattro application does not require significant soft tissue dissection, making it particularly suited to open fractures.

Inflammatory bowel disease and coronary artery disease.

Chronic inflammation with the presence of excess serum acute-phase proteins, cytokines and cell adhesion molecules is increasingly being implicated in atherosclerosis. The association between inflammatory bowel disease (IBD) and coronary artery disease (CAD) is unstudied. This is a preliminary, thesis-generating cross-sectional study aimed at evaluating the presence of traditional atherosclerotic risk factors in patients with IBD and CAD compared with the control population. The medical records of 42 consecutive IBD patients with CAD from 1999 to 2005 (27 men) were reviewed for the Framingham risk factors. The Framingham risk score (FRS) is calculated based on age, sex, hypertension, diabetes and hyperlipidemia. FRS of patients with IBD and CAD was compared with the FRS of 137 age- and sex-matched (102 men) consecutive patients with CAD (controls). When the Framingham risk score adjusted for group and gender with age as a covariate, the adjusted total FRS score was higher in patients with CAD alone (10.0 [3.75]) as compared to those with; IBD and CAD: (8.1 [3.47]; p = 0.001). FRS is lower in cases (patients with IBD and CAD) when compared with the controls (CAD alone).

Extensive gastrointestinal tract and thyroid involvement with Wegeners granulomatosis.

Wegeners granulomatosis (WG) is a pauci-immune systemic vasculitis involving small to medium sized blood vessels of the respiratory tract and renal vasculature. We report a 34-year-old lady with extensive gastrointestinal tract, pancreas and thyroid involvement. Literature review revealed only two prior reports of esophageal involvement, two reports of pancreatic involvement and few cases of thyroid involvement.

Function Versus Position: A Randomized Controlled Trial of Interfocal Kirschner Wiring of Unstable Distal Radial Fractures.

INTRODUCTION: A randomized, prospective study has been carried out to determine if immobilisation in dorsiflexion following K-wire fixation of unstable distal radial fractures improves functional outcome. METHODS: Sixty patients with unstable fractures of the distal radius were entered into the trial. There were 52 female and 11 male with an average age of 60yrs (17-84). Randomisation was undertaken in theatre using a closed envelope system. The fractures were initially reduced by closed manipulation and interfocal percutaneous K-wires inserted. Patients randomised to group I had their wrists placed in 30 degrees of dorsiflexion and group II had their wrists placed in 30 degrees of palmer flexion. Patients were reviewed with an x-ray at 1, 3, 5, and 17 weeks by a single physician. Dorsal angulation, Radial inclination, Radial length and Radial height were measured. The K-wires were removed in the outpatient clinic at 3 weeks and the plaster at 5 weeks. Blinded functional review was carried out by an Occupational therapist at 5, 8 and 17 weeks post operation. The power and pinch grip was measured using a Jamar dynamometer. Flexion and extension were measured with a goniometer. RESULTS: There was no statistical difference in radiological or functional outcomes in either group. At 17 weeks the mean dorsal angulation was -0.5 and -1.9 degrees. The mean radial shortening was 1.5mm in both groups. The power grip was 86% and 82% and pinch grip was 99% and 101%. Patients regained 76% and 79% of flexion and 94% and 88% of extension compared to the opposite side. CONCLUSIONS: Immobilisation in dorsi-flexion following K-wiring for unstable distal radial fractures does not improve functional outcome. The overall functional results were excellent and we believe that Kwiring still as a place in the treatment of distal radial fractures in the previously defined population.

Fasciectomy and conservative full thickness skin grafting in Dupuytren's contracture. The fish technique.

We reviewed 79 patients with a total of 100 digits affected by Dupuytren's disease, who were treated surgically in our institution between 1990 and 1998. The mean follow-up was 4.4 years with a range of 2 to 10 years. Only patients with PIP joint deformity of more than 30 degrees were included in the study. All patients had radical excision of diseased fascia tissue to the mid axial line and application of a full thickness skin graft over the proximal phalanx without any skin excision. Twenty two rays had two-stage operations involving percutaneous fasciotomy and application of S-Quattro followed by the definitive procedure after an interval of 6-8 weeks. Patients were clinically assessed for recurrence, extension of disease, 2-point discrimination, finger sensation, graft or donor site problem and patient satisfaction. Seven fingers had recurrent disease, none of which crossed the graft. The present study shows that radical excision of Dupuytren's tissue with full thickness graft without excision of involved skin as a primary procedure reduces recurrence. These results are comparable to those for dermofasciectomy, as reported in previous series.

Ischemic colitis revisited: a prospective study identifying hypercoagulability as a risk factor.

BACKGROUND: Although causes for ischemic colitis have been identified, many cases are deemed idiopathic. Some reports suggest an association between ischemic colitis and coagulation disorders. Our purpose was to explore the relationship of ischemic colitis and clotting abnormalities. METHODS: Eighteen patients consented to undergo a hypercoagulability evaluation. Tests included protein C, protein S, activated protein C resistance, factor V Leiden, anticardiolipin antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, antithrombin III, anti-smooth muscle antibody, lupus anticoagulant panel, and prothrombin 20210G/A mutation (in women undergoing hormone replacement therapy). RESULTS: Five of 18 patients tested positive for coagulation abnormalities, including factor V and activated protein C resistance, protein S deficiency, prothrombin 20210G/A mutation, and anticardiolipin antibody. CONCLUSION: To our knowledge, this is the largest series of patients with ischemic colitis studied for coagulation defects in the United States. The prevalence of clotting disorders in our study (28%) was higher than that in the general population (8.4%). Coagulation disorders should be considered in some cases of ischemic colitis that are thought to be idiopathic.