Complications and survival of conversion to total hip arthroplasty after failed primary osteosynthesis compared to primary total hip arthroplasty in femoral neck fractures.

INTRODUCTION: Surgical treatment options for patients with an intracapsular fracture of the femoral neck (FFN) are primary osteosynthesis as a femoral head-spearing technique or primary (hemi)arthroplasty. The most common complications after primary osteosynthesis, such as avascular necrosis (AVN) or non-union, can result in conversion to Total Hip Arthroplasty (cTHA). Data concerning complications and survival rates of cTHA in comparison to primary Total Hip Arthroplasty (pTHA) after FFN are limited due to the absence of well-designed studies. METHODS: A multicentre retrospective cohort study was conducted in three Dutch hospitals comparing the rate of postoperative dislocations, periprosthetic fractures, prosthetic joint infections, blood loss during surgery (>1000 mL), postoperative cardiac- and pulmonary complications after pTHA and cTHA in the first year after surgery. As a secondary outcome implant survival of pTHA and cTHA in terms of revision rates was evaluated. RESULTS: In total 548 patients were included (pTHA n = 264 and cTHA n = 284) with a mean follow-up of 5 years (±3.5 SD). No significant differences were found in postoperative complications rates. The revision rate in the pTHA group was 7.2% in comparison to 7.7% in the cTHA group (p = 0.81). No difference in the short-term implant survival was found between both groups (p = 0.81). CONCLUSION: This study showed no significant differences in terms of postoperative complication rates in the first year after pTHA and cTHA in patients with FFN. Also, no significant difference in short-term implant survival of primary and conversion total hip arthroplasty was found.

Low conversion rates toward total hip arthroplasty after hemiarthroplasty in patients under 75 years of age.

INTRODUCTION: An intracapsular fracture of the femoral neck is frequent in the elderly. Patients can be treated with either total hip arthroplasty or hemiarthroplasty. There is a continuous discussion about the treatment in elderly patients who are still healthy, active and mentally untroubled. A potential consequence of hemiarthroplasty, especially in the relatively young elderly, could be conversion to total hip arthroplasty. The conversion rate must be acceptable, and clinical outcome must be sufficient to justify the treatment with hemiarthroplasty in this group of patients. This study evaluates the conversion rate of hemiarthroplasty to total hip arthroplasty and clinical outcome in patients under 75 years of age. METHODS: This study identified 248 patients, younger than 75 years at time of operation, with a fracture of the femoral neck treated with hemiarthroplasty. Patient-reported outcome measurements (VAS pain during rest and activity and WOMAC) were assessed by telephone interviews. Furthermore, radiographic evaluation for the presence of acetabular wear was performed. RESULTS: At a follow-up of 5.1 (0.9-9.6) years, the conversion rate was 7.3%. Mean VAS pain in rest was 0.89 (0-10), the mean VAS pain during activity was 2.2 (0-10), and the WOMAC showed a mean of 16.51 (0-64). At time of follow-up, 38.7% of patients had died. Radiographic evaluation of the unrevised group showed in one patient signs of acetabulum wear. CONCLUSION: Hemiarthroplasty in the relatively young elderly after a fracture of the femoral neck demonstrates an acceptable conversion rate. Furthermore, unrevised patients show low complaints of pain. To prevent one conversion to total hip arthroplasty, 13.7 patients should be treated with total hip arthroplasty that will not undergo a conversion at a later stage. Therefore, hemiarthroplasty remains a viable treatment of femoral neck fractures in relatively young patients. There seems to be no space for standardized decision making concerning the choice of treatment. An individual approach is required.

No decline in high patient satisfaction after total hip arthroplasty at long-term follow-up.

INTRODUCTION: Patient satisfaction is gaining popularity as an important outcome parameter in today's healthcare system and in particular in evaluating the outcome of joint arthroplasty. Total hip arthroplasty (THA) is a very successful procedure with reports on high patient satisfaction at short-term follow-up. Commonly used clinical outcome parameters remain good at long-term follow-up; however, whether this also accounts for patient satisfaction remains unclear. This study presents a prospective follow-up of patient satisfaction after THA, and a possible correlation with common outcome parameters was established. METHODS: This study entails a concise follow-up of an earlier study on patient satisfaction 2.5 years after THA. Patient satisfaction was repeatedly measured with a visual analogue scale (VAS) after a mean follow-up of 13.5 (12.6-14.2) years in a prospective cohort of 147 patients (153 THAs). In addition, VAS pain and common clinical outcome parameters (WOMAC, OHS and SF-36) were also reassessed and were compared with short-term results after a mean follow-up of 2.5 (1.3-3.0) years. RESULTS: At a follow-up of 13.5 (12.6-14.2) years, the median VAS for satisfaction was 95 (26-100) compared to a median VAS satisfaction of 98 (0-100) at earlier follow-up (p = 0.781). Overall, the clinical outcome parameters also remained good at long-term follow-up without significant changes. However, a rather low correlation with VAS satisfaction was encountered. Pain during activity showed the highest correlation (- 0.686) with VAS satisfaction. CONCLUSION: Patient satisfaction after THA remains high after prolonged follow-up. Apparently patients do not get used to the successful results of their THA. A rather low correlation with common clinical outcome parameters suggests that patient satisfaction is a separate entity. Since patient satisfaction correlated best with pain during activity, this is probably the most important aspect in patient satisfaction. Measurement of patient satisfaction has additional value and may even replace some of the more commonly used questionnaires.

Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density?

OBJECTIVES: Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible.The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws. MATERIALS AND METHODS: A total of 12 human cadaveric hemipelvises were analysed in a matched pair study design. Bone mineral density of the specimens was 68 mgHA/cm3 (standard deviation (sd) 52). The anterior pelvic ring fracture was fixed with either one 7.3 mm cannulated screw (Group 1) or two 3.5 mm pelvic cortex screws (Group 2). Progressively increasing cyclic axial loading was applied through the acetabulum. Relative movements in terms of interfragmentary displacement and gap angle at the fracture site were evaluated by means of optical movement tracking. The Wilcoxon signed-rank test was applied to identify significant differences between the groups RESULTS: Initial axial construct stiffness was not significantly different between the groups (p = 0.463). Interfragmentary displacement and gap angle at the fracture site were also not statistically significantly different between the groups throughout the evaluated cycles (p ⩾ 0.249). Similarly, cycles to failure were not statistically different between Group 1 (8438, sd 6968) and Group 2 (10 213, sd 10 334), p = 0.379. Failure mode in both groups was characterised by screw cutting through the cancellous bone. CONCLUSION: From a biomechanical point of view, pubic ramus stabilisation with either one large or two small fragment screw osteosynthesis is comparable in osteoporotic bone. However, the two-screw fixation technique is less demanding as the smaller screws deflect at the cortical margins.Cite this article: Y. P. Acklin, I. Zderic, S. Grechenig, R. G. Richards, P. Schmitz, B. Gueorguiev. Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density? Bone Joint Res 2017;6:8-13. DOI: 10.1302/2046-3758.61.BJR-2016-0261.

[Standardization and modeling of surgical processes]. / Standardisierung und Modellierung von Operationsprozessen.

BACKGROUND: Due to the technological developments around the operating room, surgery in the twenty-first century is undergoing a paradigm shift. OBJECTIVE: Which technologies have already been integrated into the surgical routine? How can a favorable cost-benefit balance be achieved by the implementation of new software-based assistance systems? METHODS: This article presents the state of the art technology as exemplified by a semi-automated operation system for otorhinolaryngology surgery. The main focus is on systems for implementation of digital handbooks and navigational functions in situ. RESULTS: On the basis of continuous development in digital imaging, decisions may by facilitated by individual patient models thus allowing procedures to be optimized. The ongoing digitization and linking of all relevant information enable a high level of standardization in terms of operating procedures. This may be used by assistance systems as a basis for complete documentation and high process reliability. CONCLUSION: Automation of processes in the operating room results in an increase in quality, precision and standardization so that the effectiveness and efficiency of treatment can be improved; however, care must be taken that detrimental consequences, such as loss of skills and placing too much faith in technology must be avoided by adapted training concepts.

Cyr61 is a target for heparin in reducing MV3 melanoma cell adhesion and migration via the integrin VLA-4.

The integrin VLA-4 is important for the metastatic dissemination of melanoma cells. We could recently show that heparin can block VLA-4 binding, which contributes, next to blocking P- and L-selectin, to the understanding of antimetastatic activities of heparin. The matricellular ligand Cyr61, secreted by numerous tumours, is responsible for increased tumourigenicity and metastasis. This has been attributed to Cyr61 binding to, and thus activating integrins. However, a VLA-4/Cyr61 axis has not yet been reported. Since Cyr61 possesses heparin binding capabilities, Cyr61 can be supposed as potential target for heparin to indirectly interfere with integrin functions. The present in vitro studies address (i) the existence of a Cyr61/VLA-4 axis and (ii) the functional relevance of heparin interference via Cyr61. The C-terminal module III of Cyr61 could be exposed as nanomolar affine binding site for VLA-4. A shRNA-based knockdown of Cyr61 in MV3 human melanoma cells reduced VLA-4-mediated cell binding to VCAM-1, migration on fibronectin, and integrin signalling functions significantly. Using a biosensor approach we provide insight into heparin interference with this process. The low-molecular-weight heparin tinzaparin, but not the pentasaccharide fondaparinux, binds module IV of Cyr61 with micromolar affinity. But tinzaparin cannot interfere with Cyr61 accumulation onto syndecan-4, indicating different Cyr61 binding sites for heparin and other GAGs. Nonetheless, tinzaparin affects the VLA-4 binding and signalling functions selectively via Cyr61 already at very low concentration most likely by blocking the cellular secreted free Cyr61. This study emphasises Cyr61 as promising, and hitherto not considered target for heparin to selectively influence integrin functions.

Comparison of tenocytes and mesenchymal stem cells seeded on biodegradable scaffolds in a full-size tendon defect model.

In order to investigate cell-based tendon regeneration, a tendon rupture was simulated by utilizing a critical full-size model in female rat achilles tendons. For bridging the defect, polyglycol acid (PGA) and collagen type I scaffolds were used and fixed with a frame suture to ensure postoperatively a functional continuity. Scaffolds were seeded with mesenchymal stem cells (MSC) or tenocytes derived from male animals, while control groups were left without cells. After a healing period of 16 weeks, biomechanical, PCR, histologic, and electron microscopic analyses of the regenerates were performed. Genomic PCR for male-specific gene was used to detect transplanted cells in the regenerates. After 16 weeks, central ossification and tendon-like tissue in the superficial tendon layers were observed in all study groups. Biomechanical test showed that samples loaded with tenocytes had significantly better failure strength/cross-section ratio (P < 0.01) compared to MSC and the control groups whereas maximum failure strength was similar in all groups. Thus, we concluded that the application of tenocytes improves the outcome in this model concerning the grade of ossification and the mechanical properties in comparison to the use of MSC or just scaffold materials.

Higher doses of opioids in patients who need palliative sedation prior to death: cause or consequence?

BACKGROUND: Palliative sedation (PS) is necessary in a significant percentage of patients dying on an acute palliative care unit (PCU). Common indications are terminal restlessness, pain and dyspnoea. On our PCU, terminal restlessness was the main indication for PS but pain was the most prevalent symptom during admission. Because delirium is often drug induced in terminal cancer patients and opioids are amongst the most frequently implicated drugs, we hypothesised that the underlying pain problem and its treatment might have been related to the need for sedation. PATIENTS AND METHODS: To test this hypothesis, we did a retrospective analysis on the use of medication with potential cognitive side-effects, focusing on analgesics, in 68 patients who died on the PCU after PS and 89 patients who died without PS. RESULTS: Ultimately sedated patients used opioids in significantly higher doses; they were more often treated with a rotation to another opioid and with amitriptyline. The dose of opioids used at various time points between admission and death was strongly related to the probability of PS. CONCLUSIONS: Our findings support the hypothesis that, although pain was not the main indication for PS, pain and its treatment might have been primarily related to the need for palliative sedation in this patient cohort.

Therapeutic surgical management of palpable melanoma groin metastases: superficial or combined superficial and deep groin lymph node dissection.

BACKGROUND: Management of patients with clinically detectable lymph node metastasis to the groin is by ilioinguinal or combined superficial and deep groin dissection (CGD) according to most literature, but in practice superficial groin dissection (SGD) only is still performed in some centers. The aim of this study is to evaluate the experience in CGD versus SGD patients in our center. METHODS: Between 1991 and 2009, 121 therapeutic CGD and 48 SGD were performed in 169 melanoma patients with palpable groin metastases at our institute. Median follow-up was 20 and, for survivors, 45 months. RESULTS: In this heterogeneous group of patients, overall (OS) and disease-free survival, local control rates, and morbidity rates were not significantly different between CGD and SGD patients. However, CGD patients had a trend towards more chronic lymphedema. Superficial lymph node ratio, the number of positive superficial lymph nodes, and the presence of deep nodes were prognostic factors for survival. CGD patients with involved deep lymph nodes (24.8%) had estimated 5-year OS of 12% compared with 40% with no involved deep lymph nodes (p=0.001). Preoperative computed tomography (CT) scan had high negative predictive value of 91% for detection of pelvic nodal involvement. CONCLUSIONS: This study demonstrated that survival and local control do not differ for patients with palpable groin metastases treated by CGD or SGD. Patients without pathological iliac nodes on CT might safely undergo SGD, while CGD might be reserved for patients with multiple positive nodes on SGD and/or positive deep nodes on CT scan.

Orientation and detachment dynamics of Bacillus spores from stainless steel under controlled shear flow: modelling of the adhesion force.

Shear-flow induced spore detachment was performed under well-controlled laminar flow conditions, in a specially-designed shear stress flow chamber. By comparing detachment profiles of a panel of four strains, belonging to the B. cereus group (B. cereus and B. thuringiensis) and to less related Bacillus species (B. pumilus), it was shown that the spore ability of attaching to stainless steel, probed under dynamic conditions, was mainly affected by the presence (and number) of appendages. Adhesion force between the B. cereus 98/4 strain and stainless steel was quantified at nanoscale. To this aim, detachment results were combined with a theoretical modelling, based on the balance of hydrodynamic forces and torque exerted over a simplified spore model with a spherical form. The wall shear stress, required to remove 50% of the spores initially attached to stainless steel, was determined. On this basis, an adhesion force of 930 ± 390 pN was obtained. Real-time re-orientation of B. cereus 98/4 spores was experimentally established, by using a high-speed camera for tracking the motions of individual spores with high temporal and spatial resolution. Even though tethered to stainless steel without any detachment occurring, spores kept mobile on the substratum, probably due to the existence of discrete bonds or local clusters of anchoring sites, and tended to re-orientate in the flow direction, for minimizing hydrodynamic forces and torque exerted by fluid flow. A significant heterogeneity within the population was also observed, with the co-existence of both moving and immobile spores.

A randomized phase II study comparing two schedules of the 21-day regimen of gemcitabine and carboplatin in advanced non-small cell lung cancer.

PURPOSE: Carboplatin area under the curve (AUC) 5 ml/min on day 1 with gemcitabine 1,250 mg/m(2) on day 1 and day 8 is a widely used regimen in advanced non-small cell lung cancer. Grade 3-4 thrombocytopenia and neutropenia are frequent. The aim of this study is to investigate whether toxicity of gemcitabine/carboplatin could be reduced by administering carboplatin on day 8 instead of day 1 without a decrease in response rate (RR). METHODS: Patients received gemcitabine 1,250 mg/m(2) on days 1 and 8, carboplatin AUC 5 on day 1 (arm A) or day 8 (arm B). Drugs were administered over a 21-day cycle. Toxicity and RR were evaluated weekly and every second cycle, respectively. RESULTS: 71 patients were enrolled into the study. We found 79% (95% CI 61-91%) grade 3-4 toxicity (neutropenia and thrombocytopenia) in arm A and 50% (95% CI 32-68%) in arm B; 66% grade 3-4 thrombocytopenia in arm A and 26% in arm B. We observed 30% grade 4 hematological toxicity in arm A and 3% in arm B. In arm A an overall RR of 20% (95% CI 7.7-38.6%) was seen, and 18.2% (95% CI 7-35.5%) in arm B. CONCLUSIONS: Although the study was prematurely closed, the current data are of interest. The schedule with carboplatin on day 8 is associated with substantially lower grade 3-4 neutropenia and thrombocytopenia with comparable dose intensity and RR.

Circulating endothelial cells, circulating tumour cells, tissue factor, endothelin-1 and overall survival in prostate cancer patients treated with docetaxel.

PURPOSE: We investigated whether serum markers of angiogenesis endothelin-1 (ET-1) and tissue factor (TF), and/or markers of vascular damage such as circulating endothelial cells (CECs), or their relative changes during treatment, were prognostic for overall survival (OS) in castration resistant prostate cancer (CRPC) patients. Additionally, we combined these markers with circulating tumour cells (CTCs) to construct a predictive nomogram for treatment outcome. PATIENTS AND METHODS: One hundred and sixty two CRPC patients treated with a docetaxel containing regimen had blood drawn before and at 2-5 weeks and 6-8 weeks after treatment start. Prospectively determined CTC and CEC levels, and retrospectively measured serum concentrations of ET-1 (pg/mL) and TF (pg/mL) were evaluated to determine their prognostic value for OS. RESULTS: Baseline CEC, TF and ET-1 were not prognostic for OS. A > or = 3.8-fold increase in CEC 2-5 weeks after treatment initiation was associated with decreased OS (median 10.9 versus 16.8 months; P=0.015), as was any decrease in TF levels compared to baseline levels (median 11.9 versus 21.5 months; P=0.0005). As previously published, baseline and CTC counts > or = 5 at 2-5 weeks were also predictive of decreased OS. Combining CTC with changes in TF and CEC 2-5 weeks after treatment initiation yielded four groups differing in OS (median OS 24.2 versus 16.0 versus 11.4 versus 6.1 months; P<0.0001). CONCLUSION: CEC, CTC and TF levels alone and combined can predict early on OS in CRPC patients treated with docetaxel-based therapy. A prospective study to confirm the use of these markers for patient management is needed.

Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision.

OBJECTIVES: To determine whether a transverse incision is an alternative to a midline incision in terms of incisional hernia incidence, surgical site infection, postoperative pain, hospital stay and cosmetics in cholecystectomy. Incisional hernias after midline incision are commonly underestimated but probably complicate between 2 and 20% of all abdominal wall closures. The midline incision is the preferred incision for surgery of the upper abdomen despite evidence that alternatives, such as the lateral paramedian and transverse incision, exist and might reduce the rate of incisional hernia. A RCT was preformed in the pre-laparoscopic cholecystectomy era the data of which were never published. METHODS: One hundred and fifty female patients were randomly allocated to cholecystectomy through midline or transverse incision. Early complications, the duration to discharge and the in-hospital use of analgesics was noted. Patients returned to the surgical outpatient clinic for evaluation of the cosmetic results of the scar and to evaluate possible complications such as fistula, wound dehiscence and incisional hernia after a minimum of 12 months follow-up. RESULTS: Two percent (1/60) of patients that had undergone the procedure through a transverse incision presented with an incisional hernia as opposed to 14% (9/63) of patients from the midline incision group (P = 0.017). Transverse incisions were found to be significantly shorter than midline incisions and associated with more pleasing appearance. More patients having undergone a midline incision, reported pain on day one, two and three postoperatively than patients from the transverse group. The use of analgesics did not differ between the two groups. CONCLUSIONS: In light of our results a transverse incision should, if possible, be considered as the preferred incision in acute and elective surgery of the upper abdomen when laparoscopic surgery is not an option.

Crop plants versus energy plants--on the international food crisis.

The recent price explosion of important agricultural commodities has lead to an international food crisis. The price rise is attributed to fundamental factors, such as the rising demand for dairy and meat products in China and the development of the bioenergy branch as well as on short-term factors such as the behaviour of speculators. Mobilising the worldwide supply can held to overcome the demand driven shortage of food this can be achieved through a proper design of the agricultural policy both in developed and developing countries.

Oral UFT, etoposide and leucovorin in recurrent non-small cell lung cancer: a non-randomized phase II study.

BACKGROUND: Oral treatment regimens with few side effects are appealing in the 2nd or 3rd line treatment of non-small cell lung cancer (NSCLC) patients. PURPOSE: The aim was to investigate the efficacy and toxicity of the oral combination etoposide, Uracil-Tegafur (UFT) and leucovorin in 2nd or 3rd line in Caucasian patients with advanced NSCLC. METHODS: Etoposide 50 mg/m(2), UFT 250 mg/m(2) and leucovorin 90 mg (fixed dose) were dosed in 3 gifts approximately 8h apart for 14 days followed by 1 week rest every 3 weeks until progressive disease (PD). Primary endpoint was response rate (RR), secondary endpoints toxicity and time to progression (TTP). RESULTS: The median number of cycles was 3.5 (95% CI 2-5); 9 patients received > or =6 cycles, 4>10 cycles. The median dose intensities for etoposide and UFT were 223 mg/m(2)/week (95% CI 213-232) and 1092 mg/m(2)/week (95% CI 1032-1167), the relative dose intensities 92% and 90%, respectively. Grade 3/4 neutropenia was observed in 12% (4/32), grade 3/4 thrombocytopenia in 15% (5/32), without febrile neutropenia. Non-hematological toxicity grade 3 included hepatic toxicity (6%), lethargy (15%), diarrhea (3%) and nausea (3%). One patient developed grade 4 arterial ischemia. Fourteen percent (95% CI 4-33%) (4/28) had a confirmed partial response, 57% (95% CI 44-81%) (16/28) stable disease and 28% (95% CI 19-56%) (8/28) progressive disease. The median TTP was 3 months (95% CI 1.3-4.4), the median overall survival 6.7 months (95% CI 4.0-9.3). CONCLUSION: The combination of UFT, etoposide and leucovorin is active in 2nd or 3rd line therapy of Caucasian NSCLC patients and because of its favourable toxicity profile this treatment warrants further investigation.

Outcomes of first-line chemotherapy in patients with advanced or metastatic leiomyosarcoma of uterine and non-uterine origin.

Although leiomyosarcomas (LMSs) form the largest subgroup of soft tissue sarcomas (STSs), the efficacy of chemotherapy in this group is largely unclear, partly because older studies are contaminated with gastrointestinal stromal tumors (GISTs). In this retrospective study we investigated the outcome of first line chemotherapy in 65 patients with unresectable or metastatic LMS. The overall response rate (ORR) was 18%; and the median progression-free (PFS) and overall survival (OS) were 3.8 and 9.7 months respectively. No statistically significant differences in outcomes for uterine and non-uterine LMS were found. In non-uterine LMS, however, the PFS and OS seemed to be longer for females than for males, potentially negatively affecting outcomes in this group. If our observations are confirmed in other series, they would suggest that studies performed in STS patients should not only stratify for histological subtype but also for uterine versus non-uterine LMS and for gender.

Electron microscopic detection and activity of glucosyltransferase B, C, and D in the in situ formed pellicle.

OBJECTIVE: Glucosyltransferases (GTFs) represent a virulence factor of mutans streptococci. The aim of the present in situ study was to investigate the distribution of different GTF-isoforms in the pellicle. DESIGN: Bovine enamel slabs were fixed on buccal and palatal sites of individual splints worn by five subjects for 30 and 120 min to allow pellicle formation. Pellicle specimens were processed for transmission electron microscopy (TEM) and field emission in-lens scanning electron microscopy (FEI-SEM). Gold-immunolabelling was used for detection of GTF-isoforms B, C and D. Furthermore, glucosyltransferase activity of 3-, 30- and 120-min pellicles was tested via determination of fructose release. RESULTS: All isoforms of the enzyme were found to be randomly distributed within all layers of the pellicle. In cross-sections (TEM), GTF D was the most abundant isoform. More labelled molecules were detected on buccal sites compared with palatal surfaces, the number of molecules detected increased with time. The amount of GTF B, C and D found on the pellicle surface by FEI-SEM showed no correlation with pellicle formation time or localisation in the oral cavity. Overall, GTF D was detected more frequently on the surface than GTF B and C. All pellicles tested showed GTF-activity. CONCLUSION: The study shows for the first time the presence of the GTF-isoforms B, C and D within all layers of the in situ formed pellicle. This emphasises the impact of streptococcal products on the composition of the pellicle and illustrates a mechanism used by bacteria to colonize dental surfaces.

Multivariable analysis comparing outcome after sentinel node biopsy or therapeutic lymph node dissection in patients with melanoma.

BACKGROUND: Sentinel node (SN) status is the most important prognostic factor for overall survival in stage I or II melanoma. Yet SN-positive tumours with submicroscopic involvement of the SN (clusters of cells smaller than 0.1 mm) have shown a distant recurrence rate of only 9 per cent at 5 years, as good as that in SN-negative patients. This study compared the outcome after completion lymph node dissection (CLND) in SN-positive tumours with elective total lymph node dissection (TLND) in patients with palpable nodes. METHODS: A total of 188 patients were identified; 124 had TLND and 64 had CLND. Median follow-up was 56 and 37 months respectively. There were no significant differences between the groups regarding tumour Breslow thickness, ulceration and site of the primary tumour. Survival rates were calculated from date of primary excision. All patients with primary melanomas on extremities or trunk were included. RESULTS: On univariable analysis, the site of the primary tumour (extremity versus trunk) (P < 0.001), Breslow thickness (P = 0.005) and ulceration (P < 0.001) were prognostic for overall survival. There was a non-significant 13 per cent difference in overall survival at 5 years between CLND and TLND (P = 0.115). Excluding 15 patients who had SN disease with submicrometastases reduced the difference to 6 per cent (P = 0.415). CONCLUSION: This study showed no significant survival benefit for SN-positive CLND compared with TLND, especially when patients with nodes containing submicrometastases were excluded.

Morbidity and prognosis after therapeutic lymph node dissections for malignant melanoma.

Melanoma patients with clinically evident regional lymph node metastases are treated with therapeutic lymph node dissections (TLNDs). The aim of this study was to evaluate morbidity and mortality following TLND in our institution. Moreover, disease-free (DFS) and overall (OS) survival were evaluated and factors that influence prognosis after TLND were assessed. Between 1982 and 2005, 236 patients underwent a TLND. Patients, who received a palliative LND or a sentinel node procedure, were not included. The median Breslow thickness was 2.4mm. Ulceration was present in 23% of patients and unknown in 66%. 37 patients had unknown primary tumors. There were 129 ilio-inguinal, 50 axillary and 61 cervical dissections performed. 37% of the patients experienced at least one operation related complication. The most frequently seen complications were wound infections/necrosis and chronic lymph edema. Ilio-inguinal dissection patients experienced significantly more complications and a longer duration of hospitalization compared to axillary or cervical patients. The duration of hospitalization has been reduced in recent years from 12 to 5days. The mean follow-up was 29months. Kaplan-Meier estimated 5-year regional control was 79%, 5-year DFS was 19% and 5-year OS was 26%. The number of positive lymph nodes, the site of the primary tumor and extra capsular extension (ECE) were independent prognostic factors for DFS and only site and ECE for OS. In conclusion, TLND for stage III melanoma is accompanied with considerable short-term complications, and can achieve regional control and potential curation in approximately one in every four patients.