Surgery for giant tumours of the breast: a 15 year review.

BACKGROUND: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes. METHODS: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement. RESULTS: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12-49 years (y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10-45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21 patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%. CONCLUSION: Benign giant tumours (> 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction.

Two step reconstruction of traumatic ear skin avulsion using Integra graft.

Treatment of traumatic ear injuries have always been a challenge. Preservation of the auricular cartilage is key for reconstruction. Many techniques have been reported for the management of exposed ear perichondrium. We present patient who sustained right ear soft tissue avulsion. Initial examination the patient revealed skin avulsion with exposed cartilage from the concha, scapha and antihelix on the right ear. The treatment sequence included debridement and application of Integra graft. This was followed by dressing changes every three days and three weeks. Once adequate vascularization was noted a split thickness skin graft was used for final reconstruction. Integra has been widely used for the management of burns as well as exposed bone and cartilage. However, its use in traumatic ear injuries has not been reported. This technique allowed for the reconstruction of a large skin avulsion from the right ear with minimal donor site morbidity and avoidance of local rotational flaps that could hinder later reconstructions if needed.

Survival and variability over time from out of hospital cardiac arrest across large geographically diverse communities participating in the Resuscitation Outcomes Consortium.

BACKGROUND: The Resuscitation Outcomes Consortium (ROC)epidemiological registry (Epistry) provides opportunities to assess trends in out-of-hospital cardiac arrest treatment and outcomes. METHODS: Patient, event, system, treatment, and outcome data from adult (≥18 years) out-of-hospital cardiac arrest (OHCA) from 10 geographically diverse North American ROC sites over four 12-month epochs, from July 1, 2011 to June 30, 2015, were assessed. Descriptive statistics were used to characterize the sample and logistic regression assessed the association of study epoch and key covariates on survival. RESULTS: Overall, 85,553 patients were assessed by Emergency Medical Services (EMS) and 45,516 (53.2%, site range 30.4%-69.9%) had resuscitation attempted by EMS. Patient and event characteristics were consistent except for increases in bystander CPR (41.3%-44.9%) and bystander AED application (3.9%-5.2%). EMS CPR depth and compression fraction increased while pre-shock pause interval decreased. Targeted temperature management was performed in 51.1% of admitted patients and early coronary angiography in 30.2%. Survival to hospital discharge improved (from 10.9% to 11.3% across epochs) with epoch significantly associated with survival (p < 0.001) showing an increasing trend in survival over time. (p = 0.02). Marked site variation in survival persisted within and across epochs (overall site range: 4.2%-19.8%). Patients with an initially shockable rhythm (VT/VF) had an overall survival of 32.2% (site range: 11.9%-47.1%) while survival in bystander witnessed VT/VF was 35.8% (site range: 12.9%-53.1%). CONCLUSIONS: Survival from adult OHCA in multiple large geographically-separate sites improved over the study period. Marked site differences in survival persist and addressing this variation is essential to improve outcomes from OHCA across North America.

Surgery for giant tumours of the breast: a 15 year review

Background: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes.Methods: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement.Results: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12­49 years(y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10­45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%. Conclusion: Benign giant tumours (> 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction

Advanced Marjolin's ulcer of the scalp in a 13-year-old boy treated by excision and free tissue transfer: Case report and review of literature.

Marjolin's ulcer originates in chronic scars and wounds of diverse origin. This relatively rare tumour is most commonly a squamous cell carcinoma. The reason for malignant transformation is not well understood. The burn scar is a common predilection. We present the youngest patient in the literature, a 13-year-old male with a locally advanced squamous cell carcinoma of the scalp with intracranial extension following an unhealed burn injury at the age of three. Bilateral cervical lymphadenopathy was also noted. The tumour was excised and the large defect overlying the brain was covered by free latissimus dorsi musculocutaneous flap. At four weeks a therapeutic bilateral selective neck dissection was done. Adjuvant chemotherapy was administered. This report reiterates the importance of early diagnosis. Free tissue transfer further enhances our ability to cover complex defects associated with excision of advanced lesions.

Nostril stenosis corrected by release and serial stenting.

BACKGROUND: The treatment of nostril stenosis is difficult. The aim is to restore facial profile and balance and an adequate airway that is not prone to restenosis. METHODS: Fourteen patients with an age distribution of 18 months to 71 years are presented. The management of the patients involved a surgical release of the nose and creation of a nostril. The nostril was reconstructed by one of a number of methods: (a) The scar was cored out and the passage either lined with skin graft or allowed to re-epithelialise. (b) The nostril opening was increased in size by z plasty technique. (c) The nostril was created by a local flap. The aim of the surgery was to create a nostril opening of adequate size to fit a nasal stent. The nasal stent was then serially upgraded in size to expand the opening of the nostril and the surrounding tissue. The upgrade in the size of the nostril was discontinued when it matched for age or the size of the contralateral one. RESULTS: The results obtained were more than satisfactory. There was adequate long term maintenance of the nostril size in all except one of the patients. Overall, the serial upgrade in the size of the stent helped emulate the growth of the lower third of the nose in a growing child. CONCLUSION: The advocated management appears to a good solution to a very difficult problem. But continual use of the stent and patient compliance can be a drawback.

Clinical experience and analysis of length gain with the use of seven-flap plasty in burn contractures.

BACKGROUND: The seven-flap plasty despite its excellent surgical properties in the release of burn contractures is not widely adopted by surgeons. It is likely that the surgeons may have misgivings about its reliability, its ability to release a contracture and the length gain that can be obtained. SUBJECT AND METHODS: A sponge model is described to determine the gain in length obtained from the seven-flap plasty. It also helps to understand the physical mechanics. Our clinical series of 55 release procedures with the use of seven-flap plasty is described. The anatomical regions include the neck, axilla, cubital fossa, hand, perineum, popliteal fossa and the foot. Forty-nine procedures were assessed for the immediate gain in length obtained post-release. RESULTS: The sponge model demonstrated a length gain of 80%. The length of the contractures to be released ranged from 1 to 14 cm. The immediate length gain obtained in the clinical series ranged from 60 to 233% (average=105%). CONCLUSION: The theoretical length gain in z-plasty is of little clinical significance. A host of factors such as lateral laxity, number of flaps, angle at the tips, the anatomic region, and the cause of the contracture determine the actual clinical length gain obtained following a seven-flap plasty release procedure.

Vaginal malignant melanoma: a case report and literature review.

Vaginal melanomas are rare genital malignancies occurring mainly in the 6th and 7th decades of life. In general, they have a worse prognosis than cutaneous melanomas. In the past, various treatment modalities have been recommended including radical pelvic surgery. However, the prognosis is poor in spite of such radical approaches. More recently, more conservative treatment in the form of wide local excision combined with adjuvant chemotherapy, high-dose radiotherapy, and immunotherapy seem to have promising results. We describe a patient with vaginal malignant melanoma treated with conservative local excision as well as adjuvant radiotherapy, chemotherapy, and interferon.

Reduction mammoplasty in cases of giant fibroadenoma among adolescent females. Case reports and literature review.

Giant tumours of the breast cause massive enlargement of the breast resulting in asymmetry. Simple excision of the tumour fails to restore symmetry, and in some cases leaves the patient with a secondary deformity. We present two cases of giant fibroadenoma in adolescent females. Both patients underwent a one-stage excision of the giant fibroadenoma and reduction mammoplasty. Relevant operative details and results are presented together with a review of the literature.

Recreation of the natal cleft by reverse Z-plasty.

The use of Z-plasties in the closure of elliptical or circular defects is not uncommon. We present a patient in whom a double Z-plasty was performed in order to close a sacral pressure sore. The patient returned 21 years later seeking aesthetic improvements of the resultant obliteration of the natal cleft and the soft tissue and skin redundancy in the central inferior aspect of the buttocks. We met this challenge with a practical solution. The triangular flaps of the Z-plasties were returned to their original positions. This resulted in a natural shortening of the central portion of the buttock and the recreation of the natal cleft. The postoperative result was aesthetically pleasing. We report this unusual case and discuss the geometry behind the reversal of the Z-plasties as the solution to this problem. In addition, a novel interpretation of Z-plasties is presented.

Factors that influence personal perceptions of the risk of an acute myocardial infarction.

Personal risk perceptions of acute myocardial infarction (AMI) affect people's preventive health behaviors as well as their beliefs during a heart attack episode. The authors investigated factors that are associated with personal risk perceptions of having an AMI. A random-digit-dial survey was conducted among 1294 respondents, aged 18 years or older, in 20 communities across the nation as part of the Rapid Early Action for Coronary Treatment (REACT) trial. Results of two mixed-model linear regression analyses suggested that worse perceived general health, more risk factors, and greater knowledge were associated with greater perception of AMI risk. The results also showed that women who answered, incorrectly, that heart disease is not the most common cause of death for women in the United States reported significantly lower risk perceptions than women who answered this question correctly. The findings in this study suggest that interventions need to target specific misconceptions regarding AMI risk.

Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Rapid Early Action for Coronary Treatment (REACT) study.

BACKGROUND: Empirical evidence suggests that people value emergency medical services (EMS) but that they may not use the service when experiencing chest pain. This study evaluates this phenomenon and the factors associated with the failure to use EMS during a potential cardiac event. METHODS AND RESULTS: Baseline data were gathered from a randomized, controlled community trial (REACT) that was conducted in 20 US communities. A random-digit-dial survey documented bystander intentions to use EMS for cardiac symptoms in each community. An emergency department surveillance system documented the mode of transport among chest pain patients in each community and collected ancillary data, including situational factors surrounding the chest pain event. Logistic regression identified factors associated with failure to use EMS. A total of 962 community members responded to the phone survey, and data were collected on 875 chest pain emergency department arrivals. The mean proportion of community members intending to use EMS during a witnessed cardiac event was 89%; the mean proportion of patients observed using the service was 23%, with significant geographic differences (range, 10% to 48% use). After controlling for covariates, non-EMS users were more likely to try antacids/aspirin and call a doctor and were less likely to subscribe to (or participate in) an EMS prepayment plan. CONCLUSIONS: The results of this study indicate that indecision, self-treatment, physician contact, and financial concerns may undermine a chest pain patient's intention to use EMS.

Association between prepayment systems and emergency medical services use among patients with acute chest discomfort syndrome. For the Rapid Early Action for Coronary Treatment (REACT) Study.

STUDY OBJECTIVE: Cost concerns may inhibit emergency medical services (EMS) use. Novel tax-based and subscription prepayment programs indemnify patients against the cost of EMS treatment and transport. We determine whether the presence of (or enrollment in) prepayment plans increase EMS use among patients with acute chest discomfort, particularly those residing in low-income areas, those lacking private insurance, or both. METHODS: This study uses a subset of baseline data from the REACT trial, a multicenter, randomized controlled community trial designed, in part, to increase EMS use. The sample includes 860 consecutive noninstitutionalized patients (>30 years old) presenting with nontraumatic chest discomfort to hospital emergency departments in 4 Oregon/Washington communities. The association between prepayment systems and EMS use was analyzed using multivariable logistic regression. RESULTS: Overall EMS use was 52% (n=445). Among EMS users, 338 (75%) were subsequently admitted to the hospital and 110 (25%) were released from the ED. Prepayment was not associated with increased EMS use in the overall patient sample. However, patients residing in low-income census block groups (median annual income <$30,000) were 2.6 times (95% confidence interval [CI] 1.4 to 4.8) more likely to use EMS when a prepayment system was available than when no system was present. No association was noted among higher-income block group residents. Among low-income block group residents lacking private insurance, prepayment systems were associated with 3.8 times (95% CI 1.2 to 13.4) greater EMS usage. CONCLUSION: Economic considerations may affect EMS system utilization among underinsured and low-income patients experiencing a cardiac event. Prepayment systems may increase EMS utilization among these groups.

Unintentional pediatric superwarfarin exposures: do we really need a prothrombin time?

OBJECTIVE: To determine whether routine follow-up coagulation studies are useful in children with accidental exposures to rodenticides containing superwarfarin compounds. DESIGN: Retrospective review of poison center charts involving pediatric superwarfarin exposures occurring in two 2-year periods. SETTING: An American Association of Poison Control Centers-certified regional poison control center with an annual call volume of 55 000 calls per year from a 2-state area with a combined population of 4 million people. OUTCOME MEASURES: Prothrombin times and/or international normalized ratios and reported clinical signs of excessive anticoagulation after exposure. RESULTS: Of 542 children in 4 years of data collection, follow-up prothrombin times and/or international normalized ratios measurements did not detect any significant coagulation abnormalities. No child developed bleeding complications. No child required or received antidotal treatment with vitamin K. CONCLUSION: Normal preschool-aged children with unintentional acute exposures to superwarfarin rodenticides do not require any routine follow-up laboratory studies and do not require any medical intervention.

Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction.

To inform intervention development in a multisite randomized community trial, the Rapid Early Action for Coronary Treatment (REACT) project formative research was undertaken for the purpose of investigating the knowledge, beliefs, perceptions, and usual practice of health care professionals. A total of 24 key informant interviews of cardiologists and emergency physicians and 15 focus groups (91 participants) were conducted in five major geographic regions: Northeast, Northwest, Southeast, Southwest, and Midwest. Transcript analyses revealed that clinicians are somewhat unaware of the empirical evidence related to the problem of patient delay, are concerned about the practice constraints they face, and would benefit from concrete suggestions about how to improve patient education and encourage fast action. Findings provide guidance for selection of educational strategies and messages for health providers as well as patients and the public.