'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

The novel combination of dynamic vapour sorption gravimetric analysis and near infra-red spectroscopy as a hyphenated technique

The novel combination of an environmental controlled gas flow microbalance (Dynamic Vapour Sorption, Surface Measurement Systems, UK) with a NIR spectrometer (Foss NIR Systems) is described. The study follows the gravimetric changes and the spectroscopic changes in the amorphous and crystalline states of lactose at 298 K. NIR spectra and gravimetric water sorption were recorded simultaneously for the same sample. Differentiation of the amorphous and crystalline states of lactose was possible from the evaluation of peak intensity and shifts in the known fingerprint regions of the NIR spectra, i.e. 1350-1510 and 1825-1975 nm which correspond to water changes, and 2075-2160 nm which tends to illustrate changes in the organic/structural backbone character. Gravimetric analysis confirmed that the amorphous lactose crystallised, as weight changes can be linked to structural changes. The combined technique maintains the high performance of the DVS microbalance for gravimetric analysis but also provides a preset, regulated and controllable environment for studies using NIR spectroscopy probes, which was previously not possible. The results obtained agree with accepted data, and therefore provide validation for the hyphenation technique. The use of the combined DVS-NIR instrument has indicated two new pieces of information, firstly the amorphous form loses some water before the crystallisation is detectable. This indicates that water desorption may precede crystallisation, rather than the other way around, and secondly, the sample has completed crystallisation before water desorption has ended.

Multiple-dose lorazepam kinetics: shuttling of lorazepam glucuronide between the circulation and the gut during day- and night-time dosing intervals in response to feeding

Lorazepam kinetics were examined in seven healthy males age 18 to 30 years after single- and multiple-dose lorazepam administration and in the presence and absence of neomycin and cholestyramine to block the enterohepatic circulation of the drug. Methods used a simultaneous i.v./p.o. dosing regimen with provision to measure lorazepam clearance during day- and night-time dosing intervals. The day-time steady-state clearance of free lorazepam measured 7.55 +/- 1.95 ml/min/kg (mean +/- S.D.) and was identical to that observed after single-dose administration (7.68 +/- 3.19 ml/min/kg). Neomycin and cholestyramine increased lorazepam clearances 5 to 45% (P < or = .05) as would be expected for interruption of an enterohepatic circulation and in keeping with previous observations under nonsteady-state conditions. Lorazepam clearances were the same during the day as during the night, except in the presence of neomycin and cholestyramine, where night-time clearances were significantly greater (10.16 +/- 3.52 vs. 8.77 +/- 2.43 ml/min/kg, P < or = .05). Urinary recoveries of lorazepam glucuronide, on the other hand, were greater during the day than during the night (114 +/- 11 vs. 77 +/- 15%, P < or = .05) and in all cases were greater than 100% of the administered dose for that interval. Thus, there is a diurnal variation in lorazepam elimination consistent with a fasting-induced increase in hepatic glucuronidation during the night. This, combined with the relative inactivity of the gut during this period, serves to trap the glucuronide and delay its transfer back to the systemic circulation and urine.

Biliobronchial fistula following pyogenic liver abscess

A 65-year-old man with malaise, chills and fever was found to have a pyogenic liver abscess. A fistula from the abscess to the bronchial tree was confirmed by bronchoscopy and thoracotomy. In spite of adequate drainage of the abscess, respiratory function deteriorated and the patient died 1 month after operation. Biliobronchial fistula resulting from a pyogenic liver abscess is rare and has not recently been reported in the English or French literature. Reports dating back to the first published case in 1857 are reviewed. Early supradiaphragmatic excision of the fistulous tract and drainage of the hepatic abscess are recommended.

Ultrastructural pathology in Hashimoto's thyroiditis

Ultrastructural studies of the thyroid tissue in two cases of Hashimoto's thyroiditis demonstrated that the inflammatory cells do not pass through the follicular cells. Indeed these cells travelled between the epithelial cells in a manner similar to the neutrophil emigration (diapedesis) through the vessel wall in acute inflammation. Inflammatory infiltrates were composed of lymphocytes, plasma cells, or transformed lymphocytes that showed features intermediate between those of lymphocytes and plasma cells. These inflammatory cells were observed to travel from the stroma to the follicular lumen in a vectorial manner - similar to neutrophilic chemotaxis in acute inflammation. The basement membrane around the thyroid follicles remained intact around some follicles whereas it was reduplicated or focally increased in thickness around others. The basement membrane material seemed to have been secreted by the follicular cells, and strands of early collagen fiber formation were seen within the excess basement membrane material. The follicular cells showed evidence fo sublethal injury characterized by prominent defects of the rough endoplasmic reticulum or the mitochondria. Cells from areas that appeared as foci of squamous metaplasia by light microscopy showed an increased number of cytoplasmic filaments (120 to 160 A), bundles of tonofilaments, large desmosomes, an increased number of desmosomes, and intracellular desmosomes. The colloid content of the follicles was diminished, and it seemed that instead of secreting the protein colloid, the follicular cells in Hashimoto's thyroiditis were producing either excessive proteinaceous material similar to colloid or other types of proteins such as basement membrane material or keratin.

Tanzania: medicine on a meagre budget

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