Extensor indicis transfer versus palmaris longus transplantation in reconstruction of extensor pollicis longus tendon: a protocol for a systematic review.

This review will provide an overview of published data comparing transposition of the extensor indicis pollicis (EIP) tendon and palmaris longus (PL) tendon grafting in thumb extension reconstruction following loss of the extensor pollicis longus (EPL) tendon function. We will consider all studies comparing EIP and PL utilized to reconstruct thumb extension after injury/rupture of the EPL tendon. Only studies published in the English and German literature will be included. A systematic literature research will be performed across relevant health databases including the Cochrane Library, MEDLINE, and Google Scholar using the following keywords: ((extensor pollicis longus) OR EPL) AND ((extensor indicis) OR EIP OR (tendon transposition)) AND ((palmaris longus) OR (free tendon graft) OR (tendon transplantation)). Central tendencies will be reported in terms of means and standard deviations where necessary. If not reported, the standard deviation will be calculated from the standard error of the mean. Risk ratios will be calculated where possible. All calculations will be performed with a 95% confidence interval. Statistical significance will be set at P < 0.05. Adjusted effect estimates will be analyzed in preference to the unadjusted estimates, using inverse-variance weighted average. Pooled estimates will only be presented after consideration of both clinical and methodological heterogeneity of included studies. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. SYSTEMATIC REVIEW REGISTRATION: The protocol was registered on PROSPERO CRD42019135735: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=135735.

Temporal artery biopsy in the diagnosis of giant cell arteritis: Bigger is not always better.

OBJECTIVE: Accurate early giant cell arteritis (GCA) diagnosis can be established through temporal artery biopsy (TAB). We herein investigate the relationship between specimen length and positive TAB result in a tertiary-care hospital in Germany during a 8-year period. Secondarily, we studied the relationships of specific epidemiological and laboratory parameters with positive TABs. METHOD: We retrospectively reviewed the medical records of all patients with suspected GCA, who underwent TAB in our institution. RESULTS: The total sample consisted of 116 patients with a mean age of 76.1 (SD 7.7) years. Mean specimen length post-fixation was 0.94 cm (SD 0.49). The TAB(+) group consisted of 64 patients (55.2%). The specimen length was comparable in the two groups (0.96 cm vs 0.91 cm, p = 0.581). Twenty six TAB(+) patients (41%) had a post-fixation specimen longer than 1 cm, comparable with the respective percentage in the TAB(-) group (42%, p = 1). All laboratory tests performed were statistically significantly different in the two groups. CONCLUSION: We conclude that TAB length is not associated with the TAB diagnostic yield in patients with clinical suspicion of GCA.

Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland.

INTRODUCTION: There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates. METHODS: A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies. RESULTS: A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin. CONCLUSION: There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.

The Treatment of Critically Ill Patients With Acute Cholecystitis.

BACKGROUND: Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking. METHODS: In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included. RESULTS: Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10). CONCLUSION: The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.

Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review.

BACKGROUND: Acute cholecystitis is a common diagnosis. However, the heterogeneity of presentation makes it difficult to standardize management. Although surgery is the mainstay of treatment, critically ill patients have been managed via percutaneous cholecystostomy. However, the role of percutaneous cholecystostomy in the management of such patients has not been clearly established. This systematic review will compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy to those of similar patients managed with cholecystectomy. METHODS/DESIGN: Systematic searches will be conducted across relevant health databases including the Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Embase, and Scopus using the following keywords: (acute cholecystitis OR severe cholecystitis OR cholecystitis) AND (cholecystectomy OR laparoscopic cholecystectomy OR open cholecystectomy) AND (Cholecystostomy OR percutaneous cholecystectomy OR gallbladder drain OR gallbladder tube OR transhepatic gallbladder drain OR transhepatic gallbladder tube OR cholecystostomy tube). The reference lists of eligible articles will be hand searched. Articles from 2000-2014 will be identified using the key terms "acute cholecystitis, cholecystectomy, and percutaneous cholecystostomy". Studies including both interventions will be included. Relevant data will be extracted from eligible studies using a specially designed data extraction sheet. The Newcastle-Ottawa scale will be used to assess the quality of non-randomized studies. Central tendencies will be reported in terms of means and standard deviations where necessary, and risk ratios will be calculated where possible. All calculations will be performed with a 95 % confidence interval. Furthermore, the Fisher's exact test will be used for the calculation of significance, which will be set at p < 0.05. Pooled estimates will be presented after consideration of both clinical and methodological heterogeneity of included studies. Both interventions would be compared with regard to in-hospital mortality, 30-day mortality, procedure-dependent complications, re-intervention, length of intensive care unit (ICU) stay, length of hospital stay, re-admission, and cost of treatment. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. DISCUSSION: This systematic review aims at identifying and evaluating the clinical value of percutaneous cholecystostomy in the management of critically ill patients with acute cholecystitis. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015016205.

Nuclear grade plus proliferation grading system for invasive ductal carcinoma of the breast: validation in a tertiary referral hospital cohort.

OBJECTIVES: For patients with invasive breast cancer, management decisions are informed by tumor grade according to the Nottingham Grading System (NGS), either on its own or as part of the Nottingham Prognostic Index (NPI). A system retaining the nuclear grade element but substituting the two subjective components, mitosis count and tubule formation, of the NGS with a proliferation index based on Ki-67 (MIB-1) has been proposed (nuclear grade plus proliferation [N+P] grading). METHODS: We validated the prognostic value of this grading system on a population of 322 women. RESULTS: N+P grading resulted in more grade I tumors (47.9% vs 4.5%) and fewer grade II (32% vs 51.5%) and grade III (20.1% vs 44%) tumors compared with NGS. The NPI calculated based on N+P grade had a similar association with survival (P < .001; odds ratio, 1.729) as the NPI calculated on the basis of the NGS grade (P < .001; odds ratio, 1.668). CONCLUSIONS: The N+P system seems equivalent to the NGS system.

Temporal artery biopsy size does not matter.

This study aimed to clarify whether positive temporal artery biopsies had a greater sample length than negative biopsies in temporal arteritis. It has been suggested that biopsy length should be at least 1 cm to improve diagnostic accuracy. A retrospective review of 149 patients who had 151 temporal artery biopsies was conducted. Twenty biopsies were positive (13.3%), 124 negative (82.1%) and seven samples were insufficient (4.6%). There was no clinically significant difference in the mean biopsy size between positive (0.7 cm) and negative samples (0.65 cm) (t-test: p = .43 NS). Ninety-four patients fulfilled all three ACR criteria prior to biopsy (62.3%) and four patients (2.6%) changed ACR score from 2 to 3 after biopsy. Treatment should not be delayed in anticipation of the biopsy or withheld in the case of a negative biopsy if the patient's symptoms improve.