1448 Photo-Biomodulation(PBM) Therapy In Resistant Chronic Ulcers Caused By Kaposi's Sarcoma - An Effective Adjunct For Wound Healing

Introduction

Photo-biomodulation (PBM), also known as low level Laser therapy (LLLT), is a novel non-pharmacological adjunct for enhancing the healing process of resistant wounds and ulcers. PBM promotes cellular proliferation and activates angiogenesis. We present a novel approach in the treatment of radiotherapy-related ulcer resistant to standard ulcer care.

Case description

A 60-year-old gentleman was referred with a complex left heel ulcer and pain following radiotherapy and chemotherapy post non-HIV related Kaposi's sarcoma resection. Conservative management failed and a below knee amputation was considered. The patient opted for an advanced therapy program. Repeated sessions of PBM were given (660 nm and 810 nm wavelength, 20Hz, 44.6 milliwatt/cm2, 26.76 Joules/cm2). The wound was covered with a novel fish skin xenograft Kerecis™ and supported with PICO™ dressing. A combination of further debridement, PBM, re-application of Kerecis™, PICO™ dressing and long-term antibiotics allowed a new vascularized layer with good pulsatile flow along wound edges to establish within 6 weeks at a rate of 4mm2/week. Achilles tendon was partially excised, and maggots were used. Full coverage of the ulcer bed with a new healthy granulation tissue was achieved in 12 weeks’ time. The pain improved dramatically, opioids were stopped, and the patient managed to mobilize independently again with occasional aids. The wound was allowed to heal with secondary intention.

Conclusions

PBM, Kerecis and best standards of wound care allowed avoiding a major amputation and healing of a malignancy-related and radiotherapy-related ulcer. PBM can be considered as an adjunct in slow / non-healing wounds for skin malignancies and radiotherapy patients.

Oriented Immobilization on Gold Nanoparticles of a Recombinant Therapeutic Zymogen

Direct immobilization of functional proteins on gold nanoparticles (AuNPs) affects their structure and function. Changes may vary widely and range from strong inhibition to the enhancement of protein function. More often though the outcome of direct protein immobilization results in protein misfolding and the loss of protein activity. Additional complications arise when the protein being immobilized is a zymogen which requires and relies on additional protein-protein interactions to exert its function. Here we describe molecular design of a glutathione-S-transferase-Staphylokinase fusion protein (GST-SAK) and its conjugation to AuNPs. The multivalent AuNP-(GST-SAK)n complexes generated show plasminogen activation activity in vitro. The methods described are transferable and could be adapted for conjugation and functional analysis of other plasminogen activators, thrombolytic preparations or other functional enzymes.

Management of concomitant cancer and abdominal aortic aneurysm

Background. The coexistence of neoplasm and abdominal aortic aneurysm (AAA) presents a real management challenge. This paper reviews the literature on the prevalence, diagnosis, and management dilemmas of concurrent visceral malignancy and abdominal aortic aneurysm. Method. The MEDLINE and HIGHWIRE databases (1966-present) were searched. Papers detailing relevant data were assessed for quality and validity. All case series, review articles, and references of such articles were searched for additional relevant papers. Results. Current challenges in decision making, the effect of major body-cavity surgery on an untreated aneurysm, the effects of major vascular surgery on the treatment of malignancy, the use of EVAR (endovascular aortic aneurysm repair) as a fairly low-risk procedure and its role in the management of malignancy, and the effect of other challenging issues such as the use of adjuvant therapy, and patients informed decision-making were reviewed and discussed. Conclusion. In synchronous malignancy and abdominal aortic aneurysm, the most life-threatening lesion should be addressed first. Endovascular aneurysm repair where possible, followed by malignancy resection, is becoming the preferred initial treatment choice in most centres.

Control chart methods for monitoring surgical performance: a case study from gastro-oesophageal surgery

Graphical methods are becoming increasingly used to monitor adverse outcomes from surgical interventions. However, uptake of such methods has largely been in the area of cardiothoracic surgery or in transplants with relatively little impact made in surgical oncology. A number of the more commonly used graphical methods including the Cumulative Mortality plot, Variable Life-Adjusted Display, Cumulative Sum (CUSUM) and funnel plots will be described. Accounting for heterogeneity in case-mix will be discussed and how ignoring case-mix can have considerable consequences. All methods will be illustrated using data from the Scottish Audit of Gastro-Oesophageal Cancer services (SAGOCS) data set.

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes

BACKGROUND

The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre-defined the definition of "high" and "low" volume surgeons.

AIM

To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon's outcomes.

METHODS

All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon's annual case volume and two

OUTCOME MEASURES

in-hospital mortality rate, and hospital stay. The surgeon's outcomes were then analysed with respect to the overall level of activity in their operating centre.

RESULTS

A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (-0.968, p<0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate.

CONCLUSION

Analysis of HES data confirms an inverse relationship between surgeon's caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.

Is there a Minimum Caseload that Achieves Acceptable Operative Mortality in Abdominal Aortic Aneurysm Operations?

BACKGROUND

Studies have shown correlation between operative workload and mortality for major operations. Is there a threshold for case volume that predicts an acceptable mortality for abdominal aortic aneurysm surgery?

METHODS

Hospital Episode Statistics (HES) Data for England between 1997-2002 was analysed using ICD-10 codes I71.x and OPCS-4 codes L16.x-L26.x. Mortality was identified by the method of discharge.

RESULTS

31,078 operations on abdominal aortic aneurysms were studied in 223 NHS Trusts. 6,007 in-hospital deaths were identified in both elective and emergency cases (overall mortality rates 7.7% and 40%, respectively). Trusts with large elective workloads had reduced mortality for both elective and emergency operations. Using parabolic regression and logarithmic transformation, 14 elective operations per Trust per year was identified as a cut-off point above which the decrease in mortality rate with increasing case volume was relatively small. A similar effect was not seen with increasing emergency workload alone.

CONCLUSION

HES data analysis suggests increasing elective workload correlates with lower in-hospital mortality for elective and emergency operations on abdominal aortic aneurysm. Data suggests a range of hospital caseload that correlate with an acceptable elective and emergency mortality rate.

Defining the minimum hospital case-load to achieve optimum outcomes in radical cystectomy

OBJECTIVE

To define 'high-' and 'low-' volume hospitals for radical cystectomy, and the minimum caseload required for a hospital to achieve optimum outcomes, as a relationship between increasing surgical case volume and improved outcomes in radical urological surgery has been suggested in recent North American studies.

METHODS

All cystectomies for urological cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. The data were analysed statistically to describe the relationship between each hospital's annual case volume and two outcome measures: in-hospital mortality rate (MR) and hospital stay.

RESULTS

In all, there were 6317 cystectomies in 210 centres, with an overall MR of 5.6%. There was a significant inverse correlation (-0.733, P < 0.01) between hospital case volume and MR. Applying 95% confidence intervals, the minimum caseload required to achieve optimum outcomes was 11 procedures/year. Increasing the caseload beyond this minimum did not produce a significant reduction in MR.

CONCLUSION

Analysis of HES data confirms an inverse relationship between hospital caseload and mortality for radical cystectomy. A caseload of 11 operations/year is associated with the lowest MR.