Reconstructive trends following mastectomies in Scotland: A comparison with England.

INTRODUCTION: In England there has been a substantial increase in the use of immediate implant-based reconstruction, accounting for over half of all immediate reconstructions (IR). Less than one third of patients in England undergo autologous reconstruction IR. Our aim was to examine IR trends in Scotland. METHODS: Data was extracted from the Scottish Morbidity Record held at the Information Services Division of the NHS National Services Scotland. All patients discharged from Scottish hospitals between 2011 and 2016 who had a diagnosis of breast cancer including DCIS and underwent mastectomy were identified. Patients undergoing IR were identified by coding at the time of mastectomy to identify who had IR and what method was used. RESULTS: Between 2011 and 2016, 7358 patients underwent a mastectomy for breast cancer. 1845 patients (25%) had an IR. The percentage of patients undergoing IR increased from 22% in 2011 to 26% in 2016. The dominant annual procedure type was autologous reconstruction (free flap and pedicled flaps), accounting for 58% in 2011 and 54% in 2016. Pedicled flaps alone decreased from 40% in 2011 to 28% in 2016 and free flaps increased from 18% in 2011 to 26% in 2016. Implant based reconstruction rates were broadly consistent, 37% in both 2011 and 2016. Pedicled flaps with implant reconstruction decreased from 13% in 2011 to 5% in 2016. CONCLUSIONS: Autologous reconstruction (with increasing trend for free flaps procedures) remains a constant preferred technique for IR in Scotland, accounting for over half of IR performed.

Interpreting Evidence of Torture.

The Istanbul Protocol provides a scheme for giving evidence of signs of torture. This scheme does not conform with the principles of logical inference, revolving as it does round the concept of 'consistency'. The shortcomings of the Protocol are explained using the evidence given in the recent case of KV(Sri Lanka) and the logical approach to such evidence explained.

Pilomatrix carcinoma: 12-year experience and review of the literature.

Pilomatrix carcinoma is a rare, locally aggressive tumor with a tendency to recur. Distant metastases have been reported, with pulmonary lesions being the most frequent manifestation. Similar to pilomatrixoma, pilomatrix carcinoma typically presents as a nontender, firm dermal swelling and is found most commonly in the head and neck region. Although pilomatrixomas and pilomatrix carcinoma are well-recognized lesions, clinically they are frequently misdiagnosed as other skin conditions. By reviewing the literature over the past 10 years, the aims of this review are to analyze the cause, clinical presentation, histopathologic features, management and outcomes of pilomatrix carcinoma amongst children and adults.

Management of Incompletely Excised Skin Tumors: Our Experience.

BACKGROUND: Current British Association of Dermatologists guidelines recommend that Mohs micrographic surgery should be considered for incompletely excised basal cell carcinomas and squamous cell carcinomas. Units that perform Mohs surgery are limited. In Teesside, the skin cancer multidisciplinary team discusses all incompletely excised skin tumors, considers all treatment options, provides recommendations, and initiates the agreed management plan. OBJECTIVE: To assess the outcome and appropriateness of local surgical macroexcision for incompletely excised skin tumors. METHODS: The authors performed a retrospective analysis of the local skin multidisciplinary team notes from July 2010 to July 2012 identifying all incompletely excised skin cancers. A total of 46 basal cell carcinomas and 27 squamous cell carcinomas were incompletely excised. Case note and pathology report review was used to identify the recommended management option and subsequent outcome. RESULTS: Fifty-four of the 73 incompletely excised tumor identified underwent further surgical excision locally. Fifty-one of 54 patients (94.4%) had successful completion of excision with a single procedure. The remaining 3 patients' required further surgery, performed locally, to completely excise their tumor. Average follow-up was 35 months with 1 (1.9%) recurrence. CONCLUSION: In the authors' region, local surgical management of incompletely excised skin tumors has yielded results comparable to Mohs surgery. Mohs surgery remains a viable option in specific cases.

Pilomatrixoma: A Comprehensive Review of the Literature.

INTRODUCTION: Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a superficial benign skin tumor that arises from hair follicle matrix cells. Although pilomatrixomas are well-recognized lesions, clinically they are frequently misdiagnosed as other skin conditions. By reviewing all the literature over the past 10 years, the aims of this article are to analyze the cause, clinical presentation, management, and outcome of pilomatrixoma among children and adults to gain a more complete understanding of this lesion in today's clinical context. METHODS: A MEDLINE and EMBASE search was conducted from January 2005 to February 2015 using a combination of the terms: "child," "childhood," "adult," and keywords: "pilomatrixoma," "pilomatricoma," and "calcifying epithelioma of Malherbe." A total of 150 articles were reviewed. RESULTS: The lesions occurred most commonly in the first and second decades (mean age 16 years and 7 months). The commonest presentation was of an asymptomatic, firm, slowly growing, mobile nodule. Only 16% were accurately diagnosed on clinical examination. Imaging in the form of ultrasound, computed tomography, and magnetic resonance imaging has been reported. Pathological diagnosis was achieved through incision, punch, and shave biopsies. Pathological findings are discussed and summarized in this review. CONCLUSION: Pilomatrixomas are thought to arise from mutation in the Wnt pathway and has been linked to several genetic conditions. It is commonly misdiagnosed preoperatively; however, with better awareness of the lesion, it can be appropriately treated while avoiding unnecessary diagnostic tests. Complete surgical excision with clear margins is almost always curative.

'Step-port' laparoscopic cystgastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis.

BACKGROUND: Post-acute pancreatic collections (PAPCs) may require intervention when persistent, large or symptomatic. An open cystgastrostomy is an effective treatment option particularly for larger, solid predominant collections. A laparoscopic cystgastrostomy (LCG) as initially described, could be technically challenging. This report describes the evolution of the operative technique and the results from LCG in a tertiary referral centre. METHODS: Retrospective analysis of the unit's prospectively populated database was conducted. All patients who underwent a surgical cystgastrostomy (SCG) were identified. Patient demographics, outcome and complications were collected and analysed. RESULTS: Forty-four patients underwent SCG: 8 open and 36 laparoscopic. Of the 36 LCG, 6 required open conversion, although with evolution of the technique all of the last 17 cases were completed laparoscopically. The median interquartile range (IQR) length of stay in patients completed laparoscopically was 6 (2-10) compared with 15.5 days (8-19) in those patients who were converted (P = 0.0351). The only peri-operative complication after a LCG was a self-limiting upper gastrointestinal bleed. With a median (IQR) follow-up of 891 days (527-1495) one patient required re-intervention for a residual collection with no recurrent collections identified. CONCLUSION: LCG is a safe and effective procedure in patients with large, solid predominant PAPCs. With increased experience and technical expertise conversion rates can be lowered and outcome optimized.

A simple solution to a complex position in cleft surgery.

Correct positioning of the surgeon and patient in palate surgery is a problem often faced by the craniofacial surgeon. To achieve the best result, it is essential that the surgeon has direct visualization and sufficient access to the field. We describe a simple solution to this complex problem, which has been used by Dr. Ian Jackson for the last 20 years. We believe the Jackson method of positioning offers good visualization of both anterior and posterior parts of the palate, while minimizing the strain associated with neck extension during conventional positioning in cleft surgery.

Endotracheal tube fixation methods for optimal stability: a comparison of adhesive tape, suture, and tape-suture fixation.

Accidental extubation of an intubated patient is a serious consideration in the surgical patient. Adequate fixation in the intubated patient is essential to prevent potentially life-threatening complications. Several methods of endotracheal tube fixation have been described in the literature. In this study, we examine 3 common methods of fixation: adhesive tape alone, suture, and tape-suture. Testing occurred in a laboratory setting with 2 fresh cadavers. Endotracheal tubes were inserted, using the methods of fixation in question. We subjected each fixation technique to progressively increasing weight to determine which technique is most resistant to accidental removal. We found that fixation of the tube by combining tape around the tube with a suture through the tape is the best noninvasive technique of the 3 methods evaluated in cases where movement of the head is anticipated.

A review of likelihood ratios in forensic science based on a critique of Stiffelman "No longer the Gold standard: Probabilistic genotyping is changing the nature of DNA evidence in criminal trials".

Stiffelman [1] gives a broad critique of the application of likelihood ratios (LRs) in forensic science, in particular their use in probabilistic genotyping (PG) software. These are discussed in this review. LRs do not infringe on the ultimate issue. The Bayesian paradigm clearly separates the role of the scientist from that of the decision makers and distances the scientist from comment on the ultimate and subsidiary issues. LRs do not affect the reasonable doubt standard. Fact finders must still make decisions based on all the evidence and they must do this considering all evidence, not just that given probabilistically. LRs do not infringe on the presumption of innocence. The presumption of innocence does not equate with a prior probability of zero but simply that the person of interest (POI) is no more likely than anyone else to be the donor. Propositions need to be exhaustive within the context of the case. That is, propositions deemed relevant by either defense or prosecution which are not fanciful must not be omitted from consideration.

A response to "Likelihood ratio as weight of evidence: A closer look" by Lund and Iyer.

Recently, Lund and Iyer (L&I) raised an argument regarding the use of likelihood ratios in court. In our view, their argument is based on a lack of understanding of the paradigm. L&I argue that the decision maker should not accept the expert's likelihood ratio without further consideration. This is agreed by all parties. In normal practice, there is often considerable and proper exploration in court of the basis for any probabilistic statement. We conclude that L&I argue against a practice that does not exist and which no one advocates. Further we conclude that the most informative summary of evidential weight is the likelihood ratio. We state that this is the summary that should be presented to a court in every scientific assessment of evidential weight with supporting information about how it was constructed and on what it was based.

A comment on the PCAST report: Skip the "match"/"non-match" stage.

This letter comments on the report "Forensic science in criminal courts: Ensuring scientific validity of feature-comparison methods" recently released by the President's Council of Advisors on Science and Technology (PCAST). The report advocates a procedure for evaluation of forensic evidence that is a two-stage procedure in which the first stage is "match"/"non-match" and the second stage is empirical assessment of sensitivity (correct acceptance) and false alarm (false acceptance) rates. Almost always, quantitative data from feature-comparison methods are continuously-valued and have within-source variability. We explain why a two-stage procedure is not appropriate for this type of data, and recommend use of statistical procedures which are appropriate.

Girdlestone procedure for avascular necrosis of the hip in an intravenous drug user.

The Girdlestone procedure is an excision arthroplasty of the hip. Rarely used nowadays, it was required in a young patient following discovery of avascular necrosis of the femoral head as a result of septic emboli from infective endocarditis in an intravenous drug user. This procedure was deemed necessary based on poor cardiac function and anaesthetic risk. During this case report we will discuss investigations performed, the procedure and post-procedure course.

The World Health Organization's 'Surgical Safety Checklist': should evidence-based initiatives be enforced in hospital policy?

OBJECTIVES: To assess the awareness and voluntary usage of the World Health Organization's Surgical Safety Checklist (WHO SSC), just prior to its mandatory implementation. DESIGN: Questionnaire-based, prospective, telephone survey. SETTING: Patients are exposed to systematic risks and principles of surgical safety are inconsistently applied even in sophisticated settings. The evidence-based WHO SSC addresses shortfalls to promote patient safety. It was formally introduced in the United Kingdom in January 2009 and became a mandatory preoperative requirement in all hospitals from February 2010. PARTICIPANTS: Two hundred and thirty-eight hospitals, both private and government-run, in the UK. MAIN OUTCOME MEASURES: Appreciation among senior theatre personnel as to the existence, implementation and usage of the WHO SSC concept. RESULTS: Almost all had heard of the SSC, but in only two-thirds of hospitals was its use mandatory. Where the SSC was not compulsory, 80% were using it informally or sporadically. One-quarter of senior theatre personnel in hospitals without compulsory use indicated they did not know or that their department did not plan on using the checklist in the next six months, despite the deadline for implementation. CONCLUSIONS: If the SSC is to optimize safety, then greater education and awareness is required.