Single-stage nasal reconstruction with the islanded forehead flap

BACKGROUND AND PURPOSES

Multi-staged forehead flaps are a well-recognised reconstructive workhorse for subtotal and total nasal defects. It carries the disadvantage of repeated trips to theatre for revisional surgery, which is not suited to all patient cohorts. The single-stage islanded forehead flap eliminates this need. We detail our indications and outcomes of using this flap to highlight the maintained versatility of the technique without significant compromise on reconstructive and patient outcome.

SUBJECTS STUDIED AND METHODS

A prospective surgical database was collated where patients were categorised as partial or total reconstruction. We detail surgical technique and review of rationale of patient selection. Patient demographics, perioperative data and follow-up course were recorded.

MAIN FINDINGS

A total of 22 patients were recorded from both the U.K. and Ethiopia via working with the charity Facing Africa. Defects occurred from a mixture of trauma, Noma and cancer resections. Thirteen were total nasal reconstructions and nine partial. The mean follow-up period was 2.25 years. We experienced two major complications which required minor revision in the theatre and two minor complications, all resolved satisfactorily.

CONCLUSIONS

We demonstrate good outcomes and safety of the procedure in this first report of a varied cohort of nasal reconstructions in a heterogenous cohort of patients. We advocate the use of this flap in the multi-morbid patient where recovery can be expedited or those who have limitations from economical restraints.

The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy

Pre-operative anaemia is associated with poor outcomes after elective surgery but its relationship with outcomes after emergency surgery is unclear. We analysed National Emergency Laparotomy Audit data from 1 December 2013 to 30 November 2017, excluding laparotomy for haemorrhage. Anaemia was classified as 'mild' 129-110 g.l-1; 'moderate' 109-80 g.l-1; or 'severe' ≤ 79 g.l-1. The primary outcome was 90-day mortality. Secondary outcomes were 30-day mortality, return to theatre and postoperative hospital stay. The primary outcome was available for 86,763 patients, of whom 45,306 (52%) were anaemic. There were 12,667 (15%) deaths at 90 postoperative days and 9246 (11%) deaths at 30 postoperative days. Anaemia was associated with increased 90-day and 30-day mortality, odds ratio (95%CI): mild, 1.15 (1.09-1.21); moderate, 1.44 (1.36-1.52); and severe, 1.42 (1.24-1.63), p < 0.001 for all; mild, 1.07 (1.00-1.12), p = 0.030; moderate, 1.30 (1.21-1.38), p < 0.001; and severe, 1.22 (1.05-1.43), p = 0.010, respectively. All categories of anaemia were associated with prolonged hospital stay, adjusted coefficient (95%CI): mild, 1.31 (1.01-1.62); moderate, 3.41 (3.04-3.77); severe, 2.80 (1.83-3.77), p < 0.001 for all. Moderate and severe anaemia were associated with increased risk of return to the operating theatre, odds ratio (95%CI): moderate 1.13 (1.06-1.21), p < 0.001; and severe 1.23 (1.06-1.43), p = 0.006. Pre-operative anaemia is common in patients undergoing emergency laparotomy and is associated with increased postoperative mortality and morbidity.

Obsessive compulsive Personality Disorder and Autism Spectrum Disorder Traits in the Obsessive-compulsive Disorder Clinic

Introduction

Obsessive Compulsive Personality Disorder (OCPD) is a common, highly co-morbid disorder. Subjected to comparatively little research, OCPD shares aspects of phenomenology and neuropsychology with obsessive-compulsive spectrum disorders and neurodevelopmental disorders such as autism spectrum disorder (ASD). A greater understanding of this interrelationship would provide new insights into its diagnostic classification and generate new research and treatment heuristics.

Aims

To investigate the distribution of OCPD traits within a cohort of OCD patients. To evaluate the clinical overlap between traits of OCPD, OCD and ASD, as well as level of insight and treatment resistance.

Method

We interviewed 73 consenting patients from a treatment seeking OCD Specialist Service. We evaluated the severity of OCPD traits (Compulsive Personality Assessment Scale; CPAS), OCD symptoms (Yale–Brown Obsessive Compulsive Scale; Y-BOCS), ASD traits (Adult Autism Spectrum Quotient; AQ) and insight (Brown Assessment of Beliefs Scale; BABS).

Results

Out of 67 patients, 24 (36%) met DSM-IV criteria for OCPD, defined using the CPAS. Using Pearson's test, CPAS scores significantly (P < 0.01) correlated with total AQ and selected AQ domains but not with BABS. Borderline significant correlation was observed with Y-BOCS (P = 0.07). OCPD was not over-represented in a highly resistant OCD subgroup.

Conclusion

Disabling OCPD traits are common in the OCD clinic. They strongly associate with ASD traits, less strongly with OCD severity and do not appear related to poor insight or highly treatment-resistant OCD. The impact of OCPD on OCD treatment outcomes requires further research.

Disclosure of interest

This work did not receive funding from external sources. Over the past few years, Dr. Fineberg has received financial support in various forms from the following: Shire, Otsuka, Lundbeck, Glaxo-SmithKline, Servier, Cephalon, Astra Zeneca, Jazz pharmaceuticals, Bristol Myers Squibb, Novartis, Medical Research Council (UK), National Institute for Health Research (UK), Wellcome Foundation, European College of Neuropsychopharmacology, UK College of Mental Health Pharmacists, British Association for Psychopharmacology, International College of Obsessive-Compulsive Spectrum Disorders, International Society for Behavioural Addiction, World Health Organization, Royal College of Psychiatrists.

Survival analysis of carboplatin added to an anthracycline/taxane-based neoadjuvant chemotherapy and HRD score as predictor of response-final results from GeparSixto

Background

In the neoadjuvant GeparSixto study, adding carboplatin to taxane- and anthracycline-based chemotherapy improved pathological complete response (pCR) rates in patients with triple-negative breast cancer (TNBC). Here, we present survival data and the potential prognostic and predictive role of homologous recombination deficiency (HRD).

Patients and methods

Patients were randomized to paclitaxel plus nonpegylated liposomal doxorubicin (Myocet®) (PM) or PM plus carboplatin (PMCb). The secondary study end points disease-free survival (DFS) and overall survival (OS) were analyzed. Median follow-up was 47.3 months. HRD was among the exploratory analyses in GeparSixto and was successfully measured in formalin-fixed, paraffin-embedded tumor samples of 193/315 (61.3%) participants with TNBC. Homologous recombination (HR) deficiency was defined as HRD score ≥42 and/or presence of tumor BRCA mutations (tmBRCA).

Results

A significantly better DFS (hazard ratio 0.56, 95% CI 0.34-0.93; P = 0.022) was observed in patients with TNBC when treated with PMCb. The improvement of OS with PMCb was not statistically significant. Additional carboplatin did not improve DFS or OS in patients with HER2-positive tumors. HR deficiency was detected in 136 (70.5%) of 193 triple-negative tumors, of which 82 (60.3%) showed high HRD score without tmBRCA. HR deficiency independently predicted pCR (ypT0 ypN0) [odds ratio (OR) 2.60, 95% CI 1.26-5.37, P = 0.008]. Adding carboplatin to PM significantly increased the pCR rate from 33.9% to 63.5% in HR deficient tumors (P = 0.001), but only marginally in HR nondeficient tumors (from 20.0% to 29.6%, P = 0.540; test for interaction P = 0.327). pCR rates with carboplatin were also higher (63.2%) than without carboplatin (31.7%; OR 3.69, 1.46-9.37, P = 0.005) in patients with high HRD score but no tmBRCA. DFS rates were improved with addition of carboplatin, both in HR nondeficient (hazard ratio 0.44, 0.17-1.17, P = 0.086) and HR deficient tumors (hazard ratio 0.49, 0.23-1.04, P = 0.059).

Conclusions

The addition of carboplatin to neoadjuvant PM improved DFS significantly in TNBC. Long-term survival analyses support the neoadjuvant use of carboplatin in TNBC. HR deficiency in TNBC and HRD score in non-tmBRCA TNBC are predictors of response. HRD does not predict for carboplatin benefit.

Overlap of obsessive-compulsive personality disorder and autism spectrum disorder traits among OCD outpatients: an exploratory study

Background: Whereas the phenomenology of obsessive-compulsive personality disorder (OCPD) shows similarities to that of obsessive compulsive and related disorders (OCRDs) as well as with autism spectrum disorder (ASD), the relationship between these disorders is poorly understood.Aims: Within a clinical sample, we aimed to investigate the distribution of OCD, OCPD and ASD symptoms and traits and their interrelationship, as well as to evaluate insight and treatment refractoriness.Methods: Consecutive adult OCD outpatients were assessed for OCPD traits (Compulsive Personality Assessment Scale (CPAS)), OCD symptoms (Yale-Brown Obsessive Compulsive Scale (Y-BOCS)), ASD traits (Autism Spectrum Quotient (AQ)), insight (Brown Assessment of Beliefs Scale (BABS)) and treatment resistance (clinical records). Those scoring highly on the AQ underwent a diagnostic interview for ASD.Results: Sixty-seven consenting individuals completed the CPAS, BABS and AQ, and 65 completed the Y-BOCS. Twenty-four patients (35.8%) were diagnosed with OCPD. Patients with OCPD were less likely to be employed (p=.04). They demonstrated elevated AQ scores (p=.004) and rates of ASD diagnosis (54.2%) (p <.001). OCPD traits (CPAS) showed a highly significant correlation with ASD traits (AQ) (p<.001), and no association with Y-BOCS, BABS or treatment resistance.Conclusions: In an OCD cohort limited by small size, OCPD associated strongly with unemployment and ASD, with implications for diagnosis, treatment and outcome.KEY POINTSClinicians should exercise a high level of vigilance for OCPD and ASD in patients presenting with obsessive compulsive symptoms.The presence of OCPD may indicate a likelihood of disabling ASD traits, including cognitive inflexibility, poor central coherence and poor social communication.These neuropsychological factors may require separate clinical intervention strategies.

Measuring pain in dogs and cats using structured behavioural observation

The contemporary approach to pain measurement in people and animals seeks to measure the affective (emotional) component of the pain experience using structured questionnaires with formal scoring methodology. Chronic pain has wide-ranging impacts which affects the quality of life (QOL) of the individual, whether that is a person or an animal. Accordingly instruments to measure chronic pain are designed to measure its impact on QOL and are called health-related quality of life (HRQL) instruments. In veterinary science instruments to measure pain are based on behavioural observation by the veterinary surgeon/nurse in the case of acute pain and by the owner in the case of chronic pain. The development of HRQL instruments is an expanding field in veterinary science, not just for the measurement of pain, but for other chronic diseases, and it has a wide application in pharmaceutical research and clinical practice to improve patient care. This review highlights the challenges involved in creating such measures for dogs and cats, seeking to provide the reader with an understanding of their development process. It then provides an overview of the current status with regard to acute and chronic pain measurement.