Liposarcoma subtype recurrence and survival: A UK regional cohort study.

BACKGROUND: Clinical outcome data in the United Kingdom, Europe, and the United States have yet to facilitate appropriately specific surveillance for liposarcoma histological subtypes, despite being one of the most common soft tissue sarcomas. Therefore, this study aims to demonstrate histologic-specific differences in liposarcoma recurrence, disease progression, and survival and discuss the implications. METHODS AND FINDINGS: This cohort study involves patients from a regional sarcoma service in the UK who have had a primary surgical excision of liposarcoma between October 2002 and September 2019. The median follow-up is five years. Confirmed histopathological diagnoses of liposarcoma (n = 193) are organised according to the World Health Organisation recognised subtypes: atypical lipomatous tumours (ALT), myxoid, pleomorphic, and dedifferentiated liposarcomas. In addition, retroperitoneal variants (n = 34) are included to illustrate the broader spectrum of phenotypes. The primary outcomes were local recurrence, distant disease progression, and disease-specific death, and compared using Kaplan-Meier analyses and tumour variables using Cox proportional hazard analyses. All three primary outcomes significantly differed (P < 0.0001, n = 193). There were no metastases or disease-specific death in patients with ALT (n = 92) and no metastases of their retroperitoneal counterparts (n = 17). Amongst the metastasising cases of rarer subtypes, there were pulmonary spread of pleomorphic (8/9, n = 20), dedifferentiated (4/5, n = 18), and myxoid (2/3, n = 29) liposarcomas. CONCLUSION: An absence of metastases of ALT should be considered alongside global evidence. Surveillance protocols could better differentiate between these subtypes and, in doing so, save patients a considerable amount of irradiation, time, fear, and anxiety.

Global trends of hand and wrist trauma: a systematic analysis of fracture and digit amputation using the Global Burden of Disease 2017 Study.

BACKGROUND: As global rates of mortality decrease, rates of non-fatal injury have increased, particularly in low Socio-demographic Index (SDI) nations. We hypothesised this global pattern of non-fatal injury would be demonstrated in regard to bony hand and wrist trauma over the 27-year study period. METHODS: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 was used to estimate prevalence, age-standardised incidence and years lived with disability for hand trauma in 195 countries from 1990 to 2017. Individual injuries included hand and wrist fractures, thumb amputations and non-thumb digit amputations. RESULTS: The global incidence of hand trauma has only modestly decreased since 1990. In 2017, the age-standardised incidence of hand and wrist fractures was 179 per 100 000 (95% uncertainty interval (UI) 146 to 217), whereas the less common injuries of thumb and non-thumb digit amputation were 24 (95% UI 17 to 34) and 56 (95% UI 43 to 74) per 100 000, respectively. Rates of injury vary greatly by region, and improvements have not been equally distributed. The highest burden of hand trauma is currently reported in high SDI countries. However, low-middle and middle SDI countries have increasing rates of hand trauma by as much at 25%. CONCLUSIONS: Certain regions are noted to have high rates of hand trauma over the study period. Low-middle and middle SDI countries, however, have demonstrated increasing rates of fracture and amputation over the last 27 years. This trend is concerning as access to quality and subspecialised surgical hand care is often limiting in these resource-limited regions.

Lower extremity flap coverage following trauma.

Lower extremity injuries requiring soft tissue coverage comprises a significant proportion of these injuries worldwide. Reconstruction of the soft tissues overlying fractures is essential for bone union and reduction of infection thus improving function and reducing the rate of limb amputation. A systematic exploration and excision of the wound should be jointly performed by senior surgeons from Orthopaedic and Plastic Surgery. The grading of the injury and subsequent reconstruction of bone and soft tissue should only be planned once a thorough excision of all necrotic tissue has been performed. It is this thorough debridement and early flap coverage that contributes to infection-free bony union. This article explores the options for soft tissue flap coverage for the different zones in the lower limb.

Soft Tissue and Bone Defect Management in Total Sacrectomy for Primary Sacral Tumors: A Systematic Review With Expert Recommendations.

STUDY DESIGN: Systematic review and expert consensus. OBJECTIVE: To address the following two questions: (A) Is there a difference in outcomes after spino-pelvic reconstruction of total sacrectomy defects compared with no reconstruction? (B) What constitutes best surgical technique for soft tissue and bony reconstruction after total sacrectomy? SUMMARY OF BACKGROUND DATA: The management of the soft tissue and bony defect after total sacrectomy for primary sacral tumors remains a challenge due to the complex anatomical relationships and biomechanical requirements. The scarcity of evidence-based literature in this specialized field makes it difficult for the treating surgeon to make an informed choice. METHODS: A systematic literature review was performed (1950-2015), followed by a meeting of an international expert panel. Medline, Embase, and CINAHL databases and Cochrane Libraries were searched. Using the GRADE guidelines, the panel of experts formulated recommendations based on the available evidence. RESULTS: Three hundred fifty-three studies were identified. Of these, 17 studies were included and were case series. Seven were evaluated as high quality of evidence and nine were of low quality. There were a total of 116 participants. Three studies included patients (n = 24) with no spino-pelvic reconstruction. One study included patients (n = 3) with vascularized bone reconstruction. Twelve studies included patients (n = 80) with no soft tissue reconstruction, three studies described patients with a local flap (n = 20), and four studies with patients having regional flap reconstruction (n = 16). Patients with or without spino-pelvic reconstruction had similar outcomes with regards to walking; however, most patients in the nonreconstructed group had some ilio-lumbar ligamentous stability preserved. The wound dehiscence and return to theater rates were higher in patients with no soft tissue reconstruction. CONCLUSION: We recommend spino-pelvic reconstruction be undertaken with soft tissue reconstruction after total sacrectomy. LEVEL OF EVIDENCE: N/A.

Use of Acticoat dressings in burns: what is the evidence?

The virtues of silver as an antimicrobial agent have been known for some time. Various silver containing dressings are currently used for the treatment of wounds. Introduced in the late 1990s, Acticoat is a nanocrystalline silver dressing developed to overcome some shortcomings of the older dressings by providing sustained release of silver up to 7 days. We aim to determine the level of evidence available in the literature in view of recent increased usage of Acticoat. A Medline search was conducted to identify articles evaluating the use of Acticoat in burn wounds. A level of evidence adapted from the Oxford Centre for Evidence-Based-Medicine was assigned to each of these articles. Only one study was considered to be LOE 1, which is a multicentre randomised controlled trial comparing Acticoat against Silver Sulfadiazine. One further randomised control trial was downgraded to LOE 2 due to a wide confidence interval. Twenty studies (66%) were LOE 5 of which 6 were case reports and 14 were in vitro/animal studies. The available LOE 1 study demonstrates that Acticoat has better antimicrobial activity compared to another available silver dressing. Other studies suggest Acticoat has fewer adverse effects and reduces healing times. Its ease of application and low frequency of change makes it an ideal dressing in burn wounds. More well designed and properly reported randomised controlled trials are essential for informed clinical decision-making.

A nonradioactive assay for nitric oxide synthase activity in tissue extracts.

We describe a fluorescence assay for nitric oxide synthase activity based on a new indicator, 4,5-diaminofluorescein (DAF-2). The method offers the advantage of being safer and more convenient than the citrulline radioassay in common use. The rapid and irreversible binding of DAF-2 to oxidized nitric oxide (NO) enables NO production to be measured in real time. The protocol is applied to the measurement of nitric oxide synthase in crude extracts of skeletal muscle.