Reconstruction of perineo-scrotal defects from Fournier’s gangrene with the adipofascial anterolateral thigh flap

Objective:

To present a small case series of a novel solution, using pedicled adipofascial anterolateral thigh (ALT) flaps for skin grafting, for the reconstruction of perineo-scrotal defects following Fournier’s gangrene (a complex surgical problem). Many options are described. We believe that this procedure overcomes the contracture complications of skin grafting alone and that it is a more supple reconstruction in the Western population.

Patients:

We performed pedicled adipofascial ALT flaps on three patients, for the reconstruction of complex perineo-scrotal wounds with exposed testes, following Fournier’s gangrene. Patients were of male gender, aged 38 – 56 years old and otherwise healthy. The adipofascial ALT flap was raised based on the lateral circumflex femoral artery and was inset with split-thickness skin graft coverage.

Results:

Study outcomes were time-to-healing and complications. Follow-up was between 6 months to 4 years. At routine outpatient follow-up, all three patients had healed wounds; and at long-term follow-up, all three patients were satisfied with their wound reconstruction. There were no surgical complications.

Conclusion:

This study demonstrated that the pedicled adipofascial ALT flap is a reliable flap that is straightforward to raise, of an appropriate bulk, and has pliability for the neo-scrotum. The authors recommend this procedure as a good treatment option for reconstructing complex perineo-scrotal wounds following Fournier’s gangrene.

Factors influencing treatment failure in HIV positive adult patients on first line antiretroviral therapy

BACKGROUND

Risk factors for treatment failure in HIV positive adults have not been studied extensively in Zimbabwe.

AIM

To investigate socio-demographic, psychosocial and antiretroviral drug related factors as possible risk factors for treatment failure.

OBJECTIVE

To compare the accuracy and reliability of CD4 count results in diagnosing treatment failure versus viral load results.

DESIGN

A descriptive cross-sectional survey.

SETTING

Harare Central Hospital adult opportunistic infections clinic.

PARTICIPANTS

One hundred and eighteen (118) HIV positive participants on 1st line antiretroviral therapy (any 1 of stavudine, tenofovir or zidovudine combined with lamivudine and nevirapine or efavirenz) for at least 1 year. Participants were conveniently sampled.

MAIN OUTCOME MEASURES

First line treatment failure as defined according to World Health Organisation (WHO) 2010 guidelines.

RESULTS

Factors associated with higher odds of treatment failure were severe depression [OR 3.7; p-value 0.002; 95% CI 1.6-8.5] and discontinuing ART [OR 4.4; p-value 0.02; 95% CI 1.3-14.7]. Factors associated with lower odds of treatment failure were age = 42 [OR 0.3; p-value 0.007; 95% CI 0.1-0.7], taking ART on time [OR 0.2; p-value 0.02; 95% CI 0.05-0.8], time on ART > 4 years [OR 0.6; p-value 0.02; 95% CI 0.3-0.9] and female sex [OR 0.4; p-value 0.02; 95% CI 0.2-0.8]. There was statistically significant difference between CD4 count and viral load results in diagnosing treatment failure [OR 8.7; p-value 0.0005; 95% CI 3.6-21.2].

CONCLUSION

Severe depression and discontinuing ART predisposed to treatment failure. CD4 counts were not as reliable as viral load measurements in diagnosing treatment failure.

Effects of clonality on the genetic variability of rare, insular species: the case of Ruta microcarpa from the Canary Islands

Many plant species combine sexual and clonal reproduction. Clonal propagation has ecological costs mainly related to inbreeding depression and pollen discounting; at the same time, species able to reproduce clonally have ecological and evolutionary advantages being able to persist when conditions are not favorable for sexual reproduction. The presence of clonality has profound consequences on the genetic structure of populations, especially when it represents the predominant reproductive strategy in a population. Theoretical studies suggest that high rate of clonal propagation should increase the effective number of alleles and heterozygosity in a population, while an opposite effect is expected on genetic differentiation among populations and on genotypic diversity. In this study, we ask how clonal propagation affects the genetic diversity of rare insular species, which are often characterized by low levels of genetic diversity, hence at risk of extinction. We used eight polymorphic microsatellite markers to study the genetic structure of the critically endangered insular endemic Ruta microcarpa. We found that clonality appears to positively affect the genetic diversity of R. microcarpa by increasing allelic diversity, polymorphism, and heterozygosity. Moreover, clonal propagation seems to be a more successful reproductive strategy in small, isolated population subjected to environmental stress. Our results suggest that clonal propagation may benefit rare species. However, the advantage of clonal growth may be only short-lived for prolonged clonal growth could ultimately lead to monoclonal populations. Some degree of sexual reproduction may be needed in a predominantly clonal species to ensure long-term viability.

Cancer incidence and mortality among underground and surface goldminers in Western Australia

Background:

In a cohort of goldminers, we estimated cancer mortality and incidence, for both surface and underground workers, and we examined the hypothesis that (underground) mining may be protective against prostate cancer.

Methods:

Standardised mortality and incidence ratios (SMRs and SIRs) and 95% confidence intervals (CI) were calculated to compare cancer mortality and incidence of former goldminers with that of the general male population. Internal comparisons on duration of underground work were examined using Cox regression.

Results:

During 52 608 person-years of follow-up among 2294 goldminers, 1922 deaths were observed. For any cancer, mortality was increased for the total group of miners (SMR=1.27, 95% CI 1.16–1.39). In the Cox models, lung cancer mortality and incidence were particularly increased among underground miners, even after adjustment for smoking. The SMR for prostate cancer suggested a lower risk for underground miners, whereas incidence of prostate cancer was significantly increased (SIR=1.31, 95% CI 1.07–1.60) among underground miners.

Conclusion:

Overall cancer mortality and incidence was higher among Western Australian goldminers compared with the general male population, particularly for underground mining. This study does not support the hypothesis that miners have a decreased risk of prostate cancer.

No dose-dependent increase in fracture risk after long-term exposure to high doses of retinol or beta-carotene

Uncertainty remains over whether or not high intakes of retinol or vitamin A consumed through food or supplements may increase fracture risk. This intervention study found no increase in fracture risk among 2,322 adults who took a controlled, high-dose retinol supplement (25,000 IU retinyl palmitate/day) for as long as 16 years. There was some evidence that beta-carotene supplementation decreased fracture risk in men.

INTRODUCTION

There is conflicting epidemiological evidence regarding high intakes of dietary or supplemental retinol and an increased risk for bone fracture. We examined fracture risk in a study administering high doses of retinol and beta-carotene (BC) between 1990 and 2007.

METHODS

The Vitamin A Program was designed to test the efficacy of retinol and BC supplements in preventing malignancies in persons previously exposed to blue asbestos. Participants were initially randomised to 7.5 mg retinol equivalents (RE)/day as retinyl palmitate, 30 mg/day BC or 0.75 mg/day BC from 1990 to 1996; after which, all participants received 7.5 mg RE/day. Fractures were identified by questionnaire and hospital admission data up until 2006. Risk of any fracture or osteoporotic fracture according to cumulative dose of retinol and BC supplementation was examined using conditional logistic regression models adjusting for age, sex, smoking, body mass index, medication use and previous fracture.

RESULTS

Supplementation periods ranged from 1 to 16 years. Of the 2,322 (664 females and 1,658 males) participants, 187 experienced 237 fractures. No associations were observed between cumulative dose of retinol and risk for any fracture (OR per 10 g RE=0.83; 95% CI, 0.63-1.08) or osteoporotic fracture (OR per 10 g RE=0.95; 95% CI 0.64-1.40). Among men, cumulative dose of BC was associated with a slightly reduced risk of any fracture (OR per 10 g=0.89; 95% CI 0.81-0.98) and osteoporotic fracture (OR per 10 g=0.84; 95% CI 0.72-0.97).

CONCLUSIONS

This study observed no increases in fracture risk after long-term supplementation with high doses of retinol and/or beta-carotene.

Frequency and consequences of violence in community pharmacies in Ireland

BACKGROUND

Violence in community pharmacies in Ireland is thought to be common but underreported. The frequency and consequences of violence has not been studied previously.

AIMS

To establish the frequency and nature of violence in community pharmacies over 12 months, and to investigate the impact of violence on employees and possible consequence for the industry.

METHODS

A two-part survey was distributed to community pharmacies in Ireland in 2011 (n = 200). The first part related to pharmacy demographics, the frequency of various violent events (verbal abuse, threats etc.), the respondents' worry regarding violence and its impact on their co-workers. The second part concerned individual employees' subjective response to a violent event, using the Impact of Event Scale-Revised (IES-R).

RESULTS

Fifty-seven per cent of the pharmacies responded, with 77% reporting some violent event (verbal or physical), over the past year. Eighteen per cent reported physical assault, and 63% were worried about workplace violence. There was no association between late night opening hours or pharmacy size and violence frequency. Positive statistically significant correlations were present between all types of violence and absenteeism and employee fear levels. An IES-R score could be calculated for 75 respondents; the median IES-R score was 8 with 19% reporting clinically significant scores.

CONCLUSIONS

Violence is common in Irish community pharmacies and impacts on employees and the industry.

Malignant mesotheliomas in former miners and millers of crocidolite at Wittenoom (Western Australia) after more than 50 years follow-up

Background:

To report the number of malignant pleural and peritoneal mesotheliomas that have occurred in former Wittenoom crocidolite workers to the end of 2008, to compare this with earlier predictions, and to relate the mesothelioma rate to amount of exposure.

Methods:

A group of 6489 men and 419 women who had worked for the company operating the former Wittenoom crocidolite mine and mill at some time between 1943 and 1966 have been followed up throughout Australia and Italy to the end of 2008.

Results:

The cumulative number of mesotheliomas up to 2008 was 316 in men (268 pleural, 48 peritoneal) and 13 (all pleural) in women. There had been 302 deaths with mesothelioma in men and 13 in women, which was almost 10% of all known deaths. Mesothelioma rate, both pleural and peritoneal, increased with time since first exposure and appeared to reach a plateau after about 40 to 50 years. The mesothelioma rate increased with amount of exposure and the peritoneal mesotheliomas occurred preferentially in the highest exposure group, 37% compared with 15% overall.

Conclusion:

By the end of 2008, the number of mesothelioma deaths had reached 4.7% for all the male workers and 3.1% for the females. Over the past 8 years the numbers were higher than expected. It is predicted that about another 60 to 70 deaths with mesothelioma may occur in men by 2020.

Primary rectal melanoma

Primary rectal melanoma is rare and only represents up to 4% of anorectal malignancies. The prognosis of such a diagnosis is significantly different to a metastatic melanoma deposit in the anorectal area and therefore differentiation between the two is of the utmost importance with regards to initial treatment and long-term management. Various immunohistochemical markers have been shown to be associated with primary melanoma and strongly aid in diagnosis. Surgical management is still widely disputed and multiple papers have been published comparing wide local excision with abdominoperineal resection. Here a case of primary rectal melanoma is presented with a brief discussion exploring diagnostic techniques, treatment options and prognostic factors.