The routine use of post-operative drains in thyroid surgery: an outdated concept

The use of surgical drains in patients undergoing thyroid surgery is standard surgical teaching. Life-threatening complications, arising from post-operative haematomas, mandates their utilization. There is increasing evidence to suggest that this is an outdated practice. This paper determines whether thyroid surgery can be safely performed without the routine use of drains. A retrospective review of patients undergoing thyroid surgery, over a three year period was performed and post-operative complications documented. One hundred and four thyroidectomies were performed. 63 (60.6%) patients had a partial thyroidectomy, 27 (25.9%) had a total thyroidectomy and 14 (13.5%) had a sub-total thyroidectomy. Suction drains were not inserted in any patient. A cervical haematoma did not develop in any patient in this series and no patient required re-operation. There is no evidence to suggest the routine use of surgical drains following uncomplicated thyroid surgery reduces the rate of haematoma formation or re-operation rates and indeed is now unwarranted.

The obesity epidemic: implications for recruitment and retention of defence force personnel

The primary purpose of fitness and body composition standards in the military has always been to select individuals best suited to the physical demands of military service. Obesity has reached epidemic proportions globally, and may have adverse consequences for the military: a worsening prevalence of obesity in young civilian adults could hinder the recruitment and maintenance of military manpower. This review explores the impact of obesity on suitability for employment in defence force careers and any potential impact on long-term occupational health. Studies containing data on obesity and the military were identified from an electronic database. Thirty-eight papers were identified and 17 were included in this review. There is a limited body of evidence available to ascertain whether or not obese individuals are suitable for employment in the military. There are a number of key issues that need to be addressed before a definitive conclusion can be drawn. These include the future health of obese personnel recruited into the military and subsequent implications for health services, costs to the organization and military readiness, and the ability of an obese person to be an active member of the military workforce. Future research should be targeted towards these areas in order to determine the implications of obesity for recruitment and retention of defence force personnel.

Evolution of breast cancer management in Ireland: a decade of change

BACKGROUND

Over the last decade there has been a paradigm shift in the management of breast cancer, subsequent to revised surgical oncology guidelines and consensus statements which were derived in light of landmark breast cancer clinical trials conducted throughout the latter part of the 20th century. However the sheer impact of this paradigm shift upon all modalities of treatment, and the current trends in management of the disease, are largely unknown. We aimed to assess the changing practices of breast cancer management over the last decade within a specialist tertiary referral Breast Cancer Centre.

METHODS

Comparative analysis of all aspects of the management of breast cancer patients, who presented to a tertiary referral Breast Cancer Centre in 1995/1996 and 2005/2006, was undertaken and measured against The European Society for Surgical Oncology guidelines for the surgical management of mammographically detected lesions [1998].

RESULTS

613 patients' case profiles were analysed. Over the last decade we observed a dramatic increase in incidence of breast cancer [>100%], a move to less invasive diagnostic and surgical therapeutic techniques, as well as increased use of adjuvant therapies. We also witnessed the introduction of immediate breast reconstruction as part of routine practice

CONCLUSION

We demonstrate that radical changes have occurred in the management of breast cancer in the last decade, in keeping with international guidelines. It remains incumbent upon us to continue to adapt our practice patterns in light of emerging knowledge and best evidence.

Effect of moderate-intensity exercise session on preprandial and postprandial responses of circulating ghrelin and appetite

Responses of plasma total ghrelin and appetite were investigated during preprandial and postprandial stages of recovery from a moderate-intensity cycling session. Healthy recreationally active men underwent one exercise and one control trial. In the exercise trial, subjects exercised for approximately 60 minutes, while in the control trial they rested quietly for the same duration. After the intervention, subjects rested for 120 minutes and then consumed a test meal. Measurements were obtained immediately and 120 minutes after the intervention and then during 180 minutes of the postprandial period. The post-intervention concentration of total ghrelin was lower (p<0.05) in the exercise than in the control trial. The modulating effect of exercise was related to the reduction in the postprandial rather than preprandial concentration. Post-intervention scores of appetite were not different between the two trials, but when preprandial and postprandial responses were considered separately, postprandial hunger and desire to eat was higher (p<0.05) in the exercise trial. In summary, during recovery from moderate-intensity exercise, total ghrelin does not respond in a compensatory manner to disturbances in energy balance. Thus, an exercise-induced increase in appetite during the later stages of recovery coinciding with the postprandial state cannot be explained by changes in the plasma concentration of total ghrelin.

Prospective evaluation of quality of life in patients with localized oesophageal cancer treated by multimodality therapy or surgery alone

BACKGROUND

Health-related quality of life (HRQL) outcomes are important in assessing new approaches to the treatment of cancer. Neoadjuvant therapy is being used increasingly before surgery in patients with localized oesophageal cancer. This prospective non-randomized study evaluated HRQL in patients treated by preoperative chemotherapy and radiation therapy followed by surgery (multimodal therapy) or by surgery alone.

METHODS

Data from European Organization for Research and Treatment of Cancer quality of life questionnaires QLQ-30 and QLQ-OES24 were collected prospectively. Questionnaires were completed at diagnosis, after chemoradiotherapy where applicable, and at 3, 6 and 12 months after surgery.

RESULTS

The study included 202 consecutive patients with oesophageal cancer considered suitable for curative (R0) resection at the time of staging. Eighty-seven patients received chemotherapy combined with external-beam radiotherapy before surgery. At baseline, 75 (86 percent) of 87 patients in the multimodal group completed questionnaires, compared with 72 (62.6 percent) of 115 in the surgery-alone group. There were no significant differences in baseline global HRQL scores between groups. Preoperative chemoradiotherapy significantly reduced physical (P=0.004) and role (P=0.007) functioning before surgery, despite a significant (P=0.043) improvement in the dysphagia score. Oesophageal resection had a negative impact on global, functional and symptom HRQL scores at 3 months in both groups. Most variables had recovered by 6 months in the two groups, but at 12 months physical and role functioning remained impaired in the surgery-alone group, and social functioning and financial worries in the multimodal group.

CONCLUSION

Although the multimodal regimen had a negative impact on HRQL before surgery, postoperative quality of life in patients who had multimodal therapy was similar to that in those who had surgery alone.

Spontaneous activity responses to exercise in males and females

OBJECTIVE

This study examines the impact of a short-term exercise programme, prescribed on the basis of current exercise recommendations, on energy balance in males and females to assess whether this type of exercise induces compensatory changes in spontaneous activity energy expenditure (SAEE) and energy intake (EI).

DESIGN

Individuals were monitored for 16 days, 8 days of habitual physical activity (C) and 8 days when exercise was imposed (E). Total energy expenditure (TEE) was calculated from individual relationships of VO2 and VCO2 to heart rate (HR) records of HR and physical activity obtained during waking hours of the C and E periods and basal metabolic rate (BMR) measurements (Deltatrac System, Datex Instrumentation). Changes in nude body mass (BM) were estimated by using a digital scale (Sartorius AG, Gottigen, Germany).

SETTING

Laboratory and free-living.

SUBJECTS

Eight lean females (body fat: 17.5+/-4.5%) and eight males of similar percentage body fat participated in this study. All subjects were Caucasian and aged between 20 and 25 years.

INTERVENTION

During the E period, a supervised exercise session was conducted every second day, each consisting of a total net energy expenditure of 2092 kJ+BMR at 90% lactate threshold.

RESULTS

During the E period, TEE was higher than C in males and females (exercise: 95.2+/-13.9, 78.3+/-15.9 MJ; control: 82.4+/-10.4, 68.8+/-16.7 MJ, respectively; P<0.00; P=0.02). SAEE, calculated as TEE minus the energy expended during exercise, was not significantly different between C (males: 82.4+/-4.8 MJ; females: 68.8+/-7.6 MJ) and E (males: 86.8+/-6.3 MJ; females: 70.0+/-7.2 MJ) periods in either gender. Males showed no change in BM over the C (pre-intervention: 83.4+/-7.2 kg; post-intervention: 83.1+/-6.8 kg) or E (pre-intervention: 83.4+/-6.8 kg; post-intervention: 83.4+/-6.8 kg) periods. Females' BM over the C period did not alter (pre-intervention: 63.3+/-2.8 kg; post-intervention 63.7+/-3.1 kg); however, there was a significant decrease (P<0.00) in BM over the E period (pre-intervention: 63.0+/-2.7 kg; post-intervention: 62.4+/-2.7 kg).

CONCLUSION

The exercise programme was achieved in males and females without any impact on SAEE. Therefore, differences between genders in relation to BM reduction can be explained by differences in the EI response to exercise.

Emergency department ultrasound (EDU): clinical adjunct or plaything?

BACKGROUND

Emergency department ultrasound (EDU) is a physician performed ultrasound service aimed at improving patient flow and diagnosis in the emergency department.

METHODS

This paper describes the initial phase of the introduction of EDU with three illustrative case reports and a discussion on the pitfalls and benefits of EDU.

RESULTS AND DISCUSSION

In three cases discussed here, the use of EDU facilitated treatment and reduced the need for formal radiological scanning. While there are drawbacks to EDU, we believe these are far outweighed by the advantages, and in a recent survey of emergency medicine consultants throughout Ireland, the vast majority were in favour of its introduction.

CONCLUSION

EDU has become a routine part of our clinical practice, and although we are still on a learning curve with regard to its use, we have experienced significant benefits in patient care. With technological advances (such as improved image resolution and teleradiology) the potential for EDU will continue to expand, but training, practice, accreditation, and audit are essential.

Comparative prospective study of foreign body removal from external auditory canals of cadavers with right angle hook or cyanoacrylate glue

OBJECTIVES

Foreign bodies of the external auditory canal are a relatively common problem in emergency departments. Repeated attempts at removal with standard instrumentation can lead to significant ear injury. Recent case reports of using cyanoacrylate impregnated cotton buds suggest this is less traumatic and well tolerated by patients. No studies on this method have been performed. The objectives of this study were to identify whether there were significant differences in success rate, duration and injury caused by extracting beads from the external auditory canals of adult cadaveric ears using two different methods. This is the first study in a planned series of anatomical and clinical studies relating to foreign body extraction from the external auditory canal.

METHODS

In this study the success rate, time taken and injury rate were assessed for removal of impacted spherical foreign bodies in the external auditory canals of cadavers using both a blunt right angle hook and cotton buds impregnated with cyanoacrylate glue. This process was performed by a specialist registrar in otolaryngology and repeated by a specialist registrar in emergency medicine.

RESULTS

It was shown that both methods had a statistically similar success rate (two tailed binomial test p=0.5) and no injury was identified for either method. In addition the median extraction time for a right angle hook was 6 seconds and 42 seconds for cyanoacrylate. It was also noted that failed extraction was associated with a poor view of the foreign body in the external canal. This was caused by hair, a large tragus or tortuous external canal.

CONCLUSIONS

The authors feel that cyanoacrylate impregnated cotton buds are as effective at removing impacted foreign bodies as a right angle hook but the process takes longer. It is believed that patients could tolerate this longer time as the cyanoacrylate method is in theory less traumatic.

The prognostic significance of CD44s and CD44v6 expression in stage two breast carcinoma: an immunohistochemical study

AIMS

Expression of the v6 variant isoform of CD44 has been causally associated with the development of metastases. This study, using immunohistochemical techniques, examined the prognostic significance of CD44s and CD44v6 expression.

METHODS

A cohort of 109 women presenting with stage 2 breast cancer, with a minimum follow-up of 5 years, were assessed.

RESULTS

Eighty percent of patients demonstrated CD44v6 expression on immunohistochemical studies. CD44v6 expression in tissue sections was found to be independent of age, tumour size, grade, and lymph-node status. No significant association was demonstrated between CD44v6 expression and either disease-free or overall survival. Similar findings were observed for CD44s.

CONCLUSIONS

CD44s and CD44v6 do not appear to be useful as prognostic indicators in early breast cancer. The increased expression of variant CD44 isoforms seen in breast neoplasia may merely be a marker for loss of control of alternative splicing within tumour tissue.

Preoperative treatment with recombinant human growth hormone prevents ischemia reperfusion-induced diaphragmatic dysfunction

BACKGROUND

Respiratory complications continue to be a major cause of morbidity and mortality following major vascular surgery. The recent UK Small Aneurysm Trial cited preoperative respiratory function as the major predictor of outcome following elective aortic surgery.

AIM

The aim of this study was to investigate the effect of aortic clamping and revascularization on diaphragmatic muscle function in a small animal model and to evaluate the role of preoperative treatment with recombinant human growth hormone (rhGH) in preventing diaphragmatic muscle dysfunction.

METHODS

Male Sprague-Dawley rats (n = 18) were randomized into one of three groups: control (n = 6) underwent laparotomy only; IR (n = 6) had a laparotomy with infrarenal cross-clamping for 30 min followed by lower torso revascularization for 2 h; IR + rhGH (n = 6) were treated with rhGH (Genotropin 0.3 IU/kg/day) for 5 days before laparotomy and aortic cross-clamping for 30 min followed by lower torso revascularization for 2 h. Diaphragmatic muscle contractile function was assessed ex vivo using electrical field stimulation in a tissue bath.

RESULTS

Two hours of IR injury resulted in a significant impairment in diaphragmatic twitch (Control, 242.01 + 38.45 g; IR, 108.55 + 7.15 g). This impairment was prevented by pretreatment with rhGH (rhGH, 319.14 + 30.71 g; P < 0.01). Tetanic function was also significantly impaired by ischemia reperfusion injury (control, 605 + 77.63 g; IR, 228.12 + 14.38 g). Again, pretreatment with rhGH prevented this deterioration (IR + rhGH, 704.39 + 45.69 g; P < 0.05) compared with controls.

CONCLUSION

The results of this study suggest that preoperative administration of rhGH may have a role in preventing the diaphragmatic dysfunction associated with infrarenal aortic cross-clamping and revascularization.

Complete genome sequence of an M1 strain of Streptococcus pyogenes

The 1,852,442-bp sequence of an M1 strain of Streptococcus pyogenes, a Gram-positive pathogen, has been determined and contains 1,752 predicted protein-encoding genes. Approximately one-third of these genes have no identifiable function, with the remainder falling into previously characterized categories of known microbial function. Consistent with the observation that S. pyogenes is responsible for a wider variety of human disease than any other bacterial species, more than 40 putative virulence-associated genes have been identified. Additional genes have been identified that encode proteins likely associated with microbial "molecular mimicry" of host characteristics and involved in rheumatic fever or acute glomerulonephritis. The complete or partial sequence of four different bacteriophage genomes is also present, with each containing genes for one or more previously undiscovered superantigen-like proteins. These prophage-associated genes encode at least six potential virulence factors, emphasizing the importance of bacteriophages in horizontal gene transfer and a possible mechanism for generating new strains with increased pathogenic potential.

Prognostic implications of p53 and bcl-2 expression in 108 women with stage two breast cancer

BACKGROUND

The mortality and morbidity of patients with breast cancer can vary even between individuals with similar histological stage at diagnosis. Identification of those individuals with prognostically poorer tumours is an essential prerequisite in planning adjuvant therapies. Some prognostic indices of tumour size, grade, oestrogen receptor status and nodal status are well established.

AIM

The aim of this study was to examine the prognostic role of information relating to proto-oncogene and tumour suppressor gene expression.

METHODS

108 women with stage II breast cancer were studied. Tumour expression of p53 and bcl-2 were scored and then correlated with recurrence and mortality.

RESULTS

We have shown that individuals poorly expressing bcl-2 in their tumours have a poorer disease-free and overall survival than those who express bcl-2. When p53 was strongly expressed, it was associated with poorer disease-free and overall survival.

CONCLUSION

The profiling of individual tumour genetic expression of proto-oncogenes may allow for more specific identification of patients at higher risk of recurrence in breast cancer.

The role of apoptotic cell death in cardiovascular disease

BACKGROUND

Programmed cell death, or apoptosis, is a distinct, managed form of cell death. It is fundamentally different from necrosis. It is a genetically controlled, energy-dependent method of cellular deletion without inflammation. In the cardiovascular system, apoptosis occurs as a primary and secondary event in disease pathogenesis. This review addresses our current understanding of the initiation, propagation and significance of apoptosis in the cardiovascular system, as well as assessing therapeutic potentials arising therefrom.

METHODS

A Medline search was performed and relevant publications reviewed. Further articles were obtained from the references of these publications.

RESULTS

and conclusions Apoptotic cell death is a key element in the pathogenesis and progression of ischaemia-reperfusion (IR) injury, cardiac failure, myocardial infarction, atherosclerosis, endothelial dysfunction and the clinical syndromes which these situations produce. Our increased understanding of the role of apoptosis in the pathogenesis of cardiovascular disease offers potential to develop new therapeutic strategies.

Management of chronic osteoarthritic pain

Osteoarthritis is a common cause of chronic pain in small animals. Although there is currently no known cure, the disease can often be palliated by a combination of weight control, regulated exercise, anti-inflammatory medications, and disease-modifying osteoarthritic agents. The diagnosis, recommended treatments, and many of the newer drugs and disease-modifying agents are discussed in this article.

Melanotic neuroectodermal tumor of infancy (MNTI) of the hard palate: presentation and management

OBJECTIVE

To discuss the presentation and management of melanotic neuroectodermal tumor of infancy (MNTI) of the hard palate.

METHOD

Case presentation and literature review.

CASE

A 6-month-old girl presented with a slow growing, non-tender anterior oral hard palate mass. Radiologic imaging revealed a well-circumscribed cystic lesion containing teeth. After excision, histopathologic and electron microscopic evaluation revealed MNTI. No recurrence was seen at 12-month follow-up.

CONCLUSIONS

This case and a review of the literature reveal MNTI to be a rare, benign hard palate tumor, which may present as a smooth, firm, painless, slow-growing anterior palatal lesion. Imaging reveals a well-circumscribed cystic lesion. Complete excision should be curative. Management requires attention to the potential need for palatal reconstruction, orthodontic care and correction of secondary nasal deformities.

Taurine protects against early and late skeletal muscle dysfunction secondary to ischaemia reperfusion injury

OBJECTIVE

To assess the efficacy of the cytoprotective B-amino acid taurine in prevention of skeletal muscle dysfunction secondary to ischaemia-reperfusion (IR) injury.

DESIGN

Randomised controlled animal study.

SETTING

Biomedical research laboratory, teaching hospital, Republic of Ireland.

ANIMALS

96 Sprague Dawley rats.

INTERVENTIONS

Rats were randomised into three groups (n = 24/group): control (sham); ischaemia-reperfusion (untreated); and ischaemia-reperfusion + taurine. A further 24 rats were given taurine alone. The rat cremaster skeletal muscle model of four hours of ischaemia followed by reperfusion was used. Taurine 4%wt/vol was given in the animals' water throughout the experiment, beginning 48 hours before the ischaemia was initiated.

OUTCOME MEASURES

8 rats were killed from each group and muscle contractile function was assessed using electrical field stimulation in a tissue bath at 24 hrs, 48 hrs and 7 days.

RESULTS

Ischaemia followed by 24 hours, 48 hours or 7 days of reperfusion resulted in significant reduction in both muscle twitch and tetanic contractile function (p < 0.05). This was reversed by taurine, which resulted in significant preservation of twitch and tetanic contractility at all time points including one week of reperfusion (p < 0.05). There was no difference in muscle function between muscle treated with taurine after ischaemia-reperfusion and control muscle, with the same operation but without ischaemia, from 48 hours onwards.

CONCLUSIONS

These data show that pharmaceutical use of the endogenous amino acid taurine, unlike many-other agents, protects electrophysiological function in skeletal muscle against both early and late ischaemia-reperfusion injury.

Characterization of chimeric lipopolysaccharides from Escherichia coli strain JM109 transformed with lipooligosaccharide synthesis genes (lsg) from Haemophilus influenzae

Previously, we reported the expression of chimeric lipopolysaccharides (LPS) in Escherichia coli strain JM109 (a K-12 strain) transformed with plasmids containing Haemophilus influenzae lipooligosaccharide synthesis genes (lsg) (Abu Kwaik, Y., McLaughlin, R. E., Apicella, M. A., and Spinola, S. M. (1991) Mol. Microbiol. 5, 2475-2480). In this current study, we have analyzed the O-deacylated LPS and free oligosaccharides from three transformants (designated pGEMLOS-4, pGEMLOS-5, and pGEMLOS-7) by matrix-assisted laser desorption ionization, electrospray ionization, and tandem mass spectrometry techniques, along with composition and linkage analyses. These data show that the chimeric LPS consist of the complete E. coli LPS core structure glycosylated on the 7-position of the non-reducing terminal branch heptose with oligosaccharides from H. influenzae. In pGEMLOS-7, the disaccharide Gal1--> 3GlcNAc1--> is added, and in pGEMLOS-5, the structure is extended to Gal1-->4GlcNAc1-->3Gal1-->3GlcNAc1-->. PGEMLOS-5 LPS reacts positively with monoclonal antibody 3F11, an antibody that recognizes the terminal disaccharide of lacto-N-neotetraose. In pGEMLOS-4 LPS, the 3F11 epitope is apparently blocked by glycosylation on the 6-position of the terminal Gal with either Gal or GlcNAc. The biosynthesis of these chimeric LPS was found to be dependent on a functional wecA (formerly rfe) gene in E. coli. By using this carbohydrate expression system, we have been able to examine the functions of the lsg genes independent of the effects of other endogenous Haemophilus genes and expressed proteins.