Comparing 200,000 Breast Implants and 85,000 Patients over Four National Breast Implant Registries.

BACKGROUND: Growing awareness about breast implant-related adverse events has stimulated the demand for large, independent data resources. For this, data from breast implant registries could be combined. However, that has never been achieved yet. METHODS: Real-world data from four currently active national breast implant registries were used. All permanent breast implants from the Australian, Dutch, Swedish, and American registries were included. A subpopulation present across all registries between 2015 and 2018 was subsequently selected, including only permanent breast implants inserted during primary surgery for breast reconstruction or augmentation in patients without previous breast device surgery. Nationwide coverage, patient and implant characteristics, infection control measures, and revision incidences were analyzed. RESULTS: A total of 207,189 breast implants were registered. Nationwide coverage varied between 3% and 98%. The subpopulation included 111,590 implants (7% reconstruction, 93% augmentation). Across the registries, mean patient age varied between 41 and 49 years ( P < 0.001) for reconstruction and 31 and 36 years ( P < 0.001) for augmentation. Variation was observed in implant preferences across the countries and over the years. Infection control measures were most frequently registered in Australia. Cumulative revision incidence at 2 years ranged from 6% to 16% after reconstruction and from 1% to 4% after augmentation. CONCLUSIONS: For the first time, independent, national, registry-based data from four breast implant registries were combined. This is a powerful step forward in optimizing international breast implant monitoring, evidence-based decision-making, and patient safety.

Anaesthesia and epilepsy.

Epilepsy is the most common serious neurological disorder, with a prevalence of 0.5-1% of the population. While the traditional antiepileptic drugs (AEDs) still play a significant role in treatment of seizures, there has been an influx of newer agents over the last 20 yr, which are now in common usage. Anaesthetists are frequently faced with patients with epilepsy undergoing emergency or elective surgery and patients suffering seizures and status epilepticus in the intensive care unit (ICU). This review examines perioperative epilepsy management, the mode of action of AEDs and their interaction with anaesthetic agents, potential adverse effects of anaesthetic agents, and the acute management of seizures and refractory status epilepticus on the ICU. Relevant literature was identified by a Pubmed search of epilepsy and status epilepticus in conjunction with individual anaesthetic agents.

Sarcomatoid carcinoma of the hand: a clinical case with an aggressive and uncommon presentation.

Cutaneous sarcomatoid carcinoma is a high-grade malignancy. We describe a clinical case of an aggressive sarcomatoid carcinoma in an 87-year-old woman, who presented to the outpatients department with a haemorrhagic nodule on the dorsum of her right hand. By the time of excision 3 weeks later, the nodule had enlarged to 100 × 90 × 65 mm in size. On histological examination, a poorly differentiated carcinoma was seen, with both carcinomatous and sarcomatous elements, in keeping with a sarcomatoid carcinoma. The tumour was positive for cytokeratin, epithelial, smooth-muscle actin, and vimentin stains. Two months later, the patient presented with a recurrent growth on the excised scar along with numerous large right axillary lymph nodes. A right axillary dissection along with excision of the growth confirmed tumour recurrence with metastasis to lymph nodes. Soon after, the patient developed cerebral metastasis, which proved fatal. This case thus highlights the aggressive potential of sarcomatoid carcinoma.

COVID-19 and the tsunami of information.

Coronavirus disease-2019 (COVID-19) is the infectious disease caused by the recently discovered coronavirus, SARS-CoV2. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019. The number of publications with regard to COVID-19-related information is exponentially increasing, but there are also some retracted papers appearing on PubMed, including those retracted from The Lancet Global Health and the New England Journal of Medicine. In a PubMed search for "COVID," there were 1595 articles by April 1, 2020. As of June 30, the number of articles has now reached 25,913. In this editorial, 4 specific areas of information are looked at but the principles apply to many other areas of medicine. The specifics looked at are PPE for tracheostomy, testing for COVID-19, pregnancy and COVID-19, and surgical expectations during redeployment. We must make no mistake that we are seeing a disease that modern medicine has never encountered before. This article is not aimed at belittling or dismissing any of the advice of the Royal Colleges' or PHE advice, but it demonstrates the tsunami of information and the ambiguity that surgeons are experiencing throughout the UK right now. This is unlikely to be the end of progression regarding healthcare planning and development for unencountered viruses9. In the next few months and beyond, there are likely to be adaptions and revisions of more documents advising on various aspects of healthcare with regard to COVID-19 management and for possible future viruses not yet seen by the modern world before.

High risk device registries: Global value, costs, and sustainable funding.

BACKGROUND: Well-designed implant registries have been shown to be a worthwhile investment, from both a health and economic perspective. However, many registries do not attain desirable capture rates or lack sufficient funding, potentially leading to premature termination. This study aims to provide information about rarely discussed, yet pivotal topics regarding the long-term survival of implant registries, focusing on costs, funding models, and the role of stakeholders. METHODS: Worldwide, relatively recently developed breast device (BD) registries were compared to long-standing, orthopaedic (OD) and cardiovascular device (CD) registries. A standardised questionnaire was sent to the registries' designated representatives with key positions, discussing start-up costs, costs of maintenance, value of investment, governance, stakeholders, funding, and sustainability. RESULTS: Thirteen registries were included, originating from nine countries (seven BD registries, five OD registries, one CD registry). In general, start-up costs were comparable, and younger registries were more expensive to maintain. Numerous stakeholders showed interest in registry outcomes. However, only 50% of the registries reported a sustainable funding structure. CONCLUSION: This study provides a global perspective on implantable device registries. All registries provided important information, serving three unique purposes by evaluating the quality of healthcare provided, the quality of all registered devices, and processing recall information. Yet, only half of the registries were certain of sustainable funding, and thus their future existence. It is of utmost importance to bring this to the attention of all parties involved.

Eccrine porocarcinoma.

We present an unusual case of eccrine porocarcinoma in that diagnosis was delayed for many years after the initial lesion appeared, resulting in relatively large tumor.

Amiloride inhibits arginine vasopressin-induced decrease in fetal lung liquid secretion.

The effects of arginine vasopressin (AVP) and amiloride were studied in 16 unanesthetized fetal sheep (129-135 days of age) with indwelling catheters. Secretion was measured by an impermeant tracer technique. Control fetuses showed no change in lung liquid secretion over a 5-h period with an average secretion rate of 3.6 +/- 0.31 ml.kg-1.h-1. Infusion of AVP (23.4 +/- 2.23 mU.kg-1.min-1) in seven fetuses (134-140 days of age) produced significant decreases (from control) in the secretion rate over a 5-h period: the secretion rate decreased by 68% in the last hour. Amiloride placed in the lung liquid during infusion of AVP, but after AVP effects had taken place, reversed the AVP-induced decrease in lung liquid secretion. AVP in conjunction with other hormones that are elevated during the stress of birth (epinephrine and cortisol) may be important in the removal of lung fluid at birth.

Estimation of lung liquid production in fetal sheep with blue dye dextran and radioiodinated serum albumin.

Lung liquid production and reabsorption rates and lung volumes were measured in 99 fetal sheep (119-148 days of gestation) by indicator-dilution methods with the simultaneous use of blue dye dextran (BDD) and radioiodinated serum albumin (RISA). There were no significant differences between rates of lung liquid production or reabsorption by the two methods (n = 71 pairs; paired t-test; Wilcoxon test; ANOVA); this was equally true for rates in milliliters per hour or milliliters per kilogram body weight per hour and was independent of age. Volumes measured by both methods showed a close linear relationship (r = 0.97; for slope P < 0.0001; n = 99), whether expressed as milliliters or milliliters per kilogram body weight. Either method could give the higher volume. Values differed by only approximately 4%, independent of age or parameter (ml or ml/kg body wt; volumes regressed to original volume, or as measured in untreated control hours). However, this small difference was significant by paired t-test or Wilcoxon test when all data were combined irrespective of age; it was not significant after allowance for gestational age (two-way ANOVA). Both indicators showed the same increase in lung volume toward birth and the same fall when related to body weight (slopes significant P = 0.0003-0.0004; r = 0.93). Two-way ANOVA showed that the declines were significant (P = 0.003). The data suggest that 1) there was no significant difference in production or reabsorption rates measured by BDD or RISA, 2) differences in volumes measured by the two indicators were only significant if gestational age was ignored and were too small to have physiological importance, and 3) although BDD and RISA each may have methodological weaknesses, for purposes of measuring lung liquid volumes both are sufficiently accurate and reproducible to obtain meaningful physiological results.

Alpha-adrenoreceptor influences on liquid movements by in vitro lungs from fetal guinea pigs.

Lungs from near-term fetal guinea pigs (60 +/- 2 days of gestation) were supported in vitro for 3 h; lung liquid production was monitored by a dye-dilution method. Studies of 30 fetuses showed that untreated preparations produced fluid at 1.34 +/- 0.21 ml.h-1.kg body wt-1, but epinephrine at concentrations known at delivery (10(-8) and 10(-7) M) produced significant reductions or fluid reabsorption (analysis of variance, regression analysis); at high levels (10(-6) and 10(-5) M, epinephrine had no effect. Maximal responses from 10(-7) M epinephrine involved alpha-adrenoreceptors, since they were abolished by 10(-6) M phentolamine (alpha-antagonist) but were unaffected by 10(-6) M propranolol (beta-antagonist; n = 36). Activation was through alpha2-adrenoreceptors, since responses were abolished by 10(-4) M yohimbine (alpha-antagonist; n = 24) but were resistant to 10(-5) M prazosin (alpha 1-antagonist; n = 24). At high levels of epinephrine (10(-5) M), where responses did not normally occur, reductions in lung liquid production were large if prazosin was also present (n = 24), and increases were significant if yohimbine was included (n = 24). In guinea pigs, epinephrine appears to activate lung fluid reabsorption through alpha 2-adrenoreceptors; at high concentrations only, it can also increase production through alpha 1-adrenoreceptors. Therefore, species differences appear to exist.

Regulation of lung liquid secretion in immature fetal sheep: hormonal interaction.

The present studies were designed to test the hypothesis that arginine vasopressin (AVP) can interact with hydrocortisone and 3,5,3'-triiodothyronine (T3) to induce maturation of lung liquid reabsorptive processes in fetal sheep < 130 days gestation. Lung liquid production rates were measured in chronically catheterized thyroidectomized fetal sheep during eight different experimental treatments. Each experiment consisted of a 2-h control period followed by a 5-h treatment period. Net secretion or reabsorption of lung liquid was measured by using impermeant marker dilution techniques. AVP alone (50 mU/kg bolus plus 5.0 mU.kg-1.min-1 i.v. infusion) does not alter lung liquid secretion in fetal sheep 125 +/- 0.72 (SE) days gestation. In contrast, AVP (same dose as above) with T3 (30 micrograms) and hydrocortisone (6.94 mg/min) depressed lung liquid secretion and caused reabsorption of fluid. T3 alone, T3 and hydrocortisone, T3 and AVP, hydrocortisone alone, hydrocortisone and AVP, and saline did not result in net lung liquid reabsorption over a 5-h treatment period. These investigations demonstrate that AVP, T3, and hydrocortisone interact to cause lung liquid reabsorption in immature fetal lungs.

Effects of glucagon on in vitro liquid production by lungs from fetal guinea pigs.

BACKGROUND: Lung liquid reabsorption in newborns with respiratory distress syndrome can be deficient. Respiratory distress syndrome is often seen in infants of diabetic mothers, in whom the neonatal surge of glucagon is suppressed. AIM: To investigate the possible effects of glucagon on lung liquid reabsorption. METHODS: Lungs from near term fetal guinea pigs (62 (2) days gestation; term = 67 days) were supported in vitro for three hours; lung liquid production and reabsorption were monitored by a dye dilution method. RESULTS: Untreated control preparations produced fluid at 1.75 (0.33) ml/h per kg body weight, and did not change significantly in three hours; those immersed in 10(-12) M glucagon during the middle hour showed no significant change, but those given higher concentrations all showed significant reductions in fluid production or even reabsorption (65.6 (10.3)% fall at 10(-11) M, 70.0 (6.3)% fall at 10(-10) M, and 90.6 (11.1)% fall at 10(-9) M; based on 54 preparations). At 10(-9) M glucagon, 12 out of 30 preparations reabsorbed fluid. The linear log dose-response curve (r(2) = 0.94) gave a theoretical threshold at 4 x 10(-15) M glucagon. Responses appeared to involve the amiloride sensitive Na(+) based reabsorptive system: responses to 10(-9) M glucagon appeared to be reduced by 10(-6) M amiloride, and were abolished by 10(-5) M amiloride (based on 72 preparations). CONCLUSIONS: The results suggest that the surge of glucagon at birth may help to drain the lungs of fluid. As glucagon liberates cAMP, which also stimulates surfactant, glucagon is worth consideration for possible use in neonatal respiratory distress.

Effects of lung expansion on lung liquid production in vitro by lungs from fetal guinea-pigs. I. Basic studies and the effects of amiloride and propranolol.

Lungs from near-term fetal guinea-pigs were supported in vitro for 3 h; lung liquid production was measured by a dye-dilution method using Blue Dextran 2000 (fetuses 62 +/- 2 days of gestation, 97.6 +/- 19.0 (SD) g body weight; n = 134). Untreated control preparations produced fluid at 1.30 +/- 0.22 ml/kg body weight per h, and showed no significant changes during incubation (n = 30). After 1 h of incubation, experimental lungs were expanded with Krebs-Henseleit saline in volumes estimated to be below or approximating those of the first breath (n = 30; first breath, 0.6-1.2 ml). Expansions were graded at 18 +/- 4%, 31 +/- 4%, 43 +/- 3%, 50 +/- 3% and 72 +/- 2% of lung volume (volumes used for expansion at the maximal level, 0.64 +/- 0.25 ml). All expansions of 31% or above produced reductions in fluid production significant by analysis of variance (P < 0.01-0.001); production halted at 50% expansion, and there was strong reabsorption at 72% expansion (-0.87 +/- 0.45 ml/kg body weight per h by the final hour). There was an exponential relationship between percentage expansion and percentage fall in production (r = 1.00). There was no evidence for excessive pressure, and no evidence for lung damage as judged by electron microscopy or entry of intracellular materials into the fluid (lactic dehydrogenase, protein, K+). In studies based on 36 preparations, 10(-6) M amiloride present in the lung lumen (apically) abolished the reabsorptions seen at 70 +/- 3% expansion, but not the arrest of production; it had no effect on control preparations. Studies based on 24 preparations showed that responses to 72 +/- 2% expansion were not affected by 10(-7) M propranolol placed in the outer saline. In studies of 14 fetuses of widely different body weights (68.3-124.9 g), responses to 74 +/- 2% expansion showed an exponential increase with increasing body weight (r = 0.96). Although caution is needed, the results suggest that expansion of the lungs at birth may induce fluid reabsorption by an action independent of tissues outside the lungs, probably involving both activation of a Na(+)-based reabsorptive system and arrest of production, but not requiring beta-receptor activation. The probability that the responses are maximal at birth is discussed, and it is suggested that the effect of expansion may be a specialization of the perinatal lung.

Effects of lung expansion on lung liquid production in vitro by lungs from fetal guinea-pigs. II. Evidence for generation of an inhibitory factor.

Lungs from near-term fetal guinea-pigs were supported in vitro for 3 h; lung liquid production was measured by a dye-dilution method using Blue Dextran 2000 [fetuses 63 +/- 2 days of gestation, 97.6 +/- 19.8 (SD) g body weight]. Preparations were incubated in pairs taken from the same mother. Twenty lungs incubated in pairs without treatment (controls) showed no significant changes in fluid production throughout incubation (analysis of variance; regression analysis); rates in successive hours were: first lung, 1.36 +/- 0.39, 1.09 +/- 0.34 and 1.27 +/- 0.42 ml/kg body weight per h; second lung, 1.46 +/- 0.52, 1.09 +/- 0.41 and 1.18 +/- 0.43 ml/kg body weight per h. Twenty lungs were incubated similarly in pairs, but after one hour one lung from each pair was expanded with Krebs-Henseleit saline in volumes approximating those of the first breath (68 +/- 10% of lung volume). The expanded lungs began to reabsorb fluid immediately after expansion; the untreated lungs also stopped production or reached reabsorption by the final hour. Rates in successive hours were: expanded lungs; before expansion, 1.00 +/- 0.21, after expansion, -0.23 +/- 0.17 and 0.14 +/- 0.09 ml/kg body weight per h; unexpanded lungs, 1.27 +/- 0.49, 0.02 +/- 0.01 and -0.01 +/- 0.004 ml/kg body weight per h. The decrease in production was significant for each type of lung. The effects persisted in both expanded and unexpanded lungs in the presence of 1.78 x 10(-5) M phentolamine (n = 12; 70 +/- 2% expansion). The results suggest that expansion of the lungs at birth may release an unknown inhibitory factor, provisionally termed Expansion Factor (EF), within the lungs; this agent, probably not a catecholamine, can change lung fluid production into reabsorption and may partly account for the failure of beta-antagonists to prevent fluid reabsorption at delivery.

Tissue expansion in the lower limbs of children and young adults.

We report the successful use of tissue expansion in the lower limbs of five children and one young adult. It was possible to replace dense adherent skin grafts by expanded skin and subcutaneous tissue. Such expansion needs to be undertaken slowly, but expanded tissue matches the normal local tissue and has normal sensation. These qualities were particularly important in three amputations which were revised.

Solitary median maxillary central incisor, short stature, choanal atresia/midnasal stenosis (SMMCI) syndrome.

This article describes a series of 21 consecutive cases, each involving a solitary median maxillary central incisor; the patients were seen in the Department of Dentistry or the Victorian Clinical Genetics Unit, Murdoch Institute, at the Royal Children's Hospital, Melbourne, from 1966 to 1997. The spectrum of anomalies and associated features present in these cases--solitary median maxillary central incisor, choanal atresia, and holoprosencephaly--is described, and the literature related to the features, including genetic studies in these conditions, is reviewed. We relate our findings in these cases to current knowledge of developmental embryology. It is hoped that the findings, together with our interpretation of them, will help to clarify understanding of solitary median maxillary central incisor syndrome. This syndrome was previously considered a simple midline defect of the dental lamina, but it is now recognized as a possible predictor of holoprosencephalies of varying degrees in the proband, in members of the proband's family, and in the family's descendants.

An unusual complication of Vacuum Assisted Closure in the treatment of a pressure ulcer.

A patient with a non-healing sacral pressure ulcer underwent exploratory surgery. During the procedure a piece of polyurethane sponge was found to have been left in situ. This unusual case highlights the importance of vigilance at dressing changes.

Airway fire during tracheostomy: prevention strategies for surgeons and anaesthetists.

Airway fires are an uncommon but real and devastating complication of tracheostomy. One such fire in a 31-year-old man is described. Surgical fires are discussed, and 15 reported cases of tracheostomy fire are reviewed. A tracheostomy protocol, adopted by our department and designed to avoid this life-threatening complication, is described. Surgeons and anaesthetists involved in tracheostomy must understand the fire hazard and how to avoid it.

Respite care innovations for carers of people with dementia.

The importance of family carers to making a reality of community care policy is now widely recognized. The central role of carers was recently confirmed by the launch of 'The Carers' National Strategy' (Department of Health (DoH), 1999). In his foreword to this document, the Prime Minister, Tony Blair, acknowledged carers as the 'unsung' heros of British life' and pledged to raise the level and quality of the support that carers receive. Although the primary responsibility for meeting carers' needs still rests with local authorities the strategy charges everyone involved in the caring services with paying greater attention to supporting family members. In allocating monies to move the strategy forward the Government identified the provision of short breaks as one of the major priorities. This article describes the development of an innovative service for people with dementia and their carers in Sheffield. The service evolved following a research study on the views of carers and of people with dementia which identified the need for the provision of short breaks which were flexible, responsive and person-centred.