Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Aberrant right posterior sectoral duct injury necessitating liver resection

Aberrant insertion of the right posterior sectoral duct is a particularly hazardous variation of biliary anatomy which makes it prone to injury during laparoscopic cholecystectomy. Such injuries are challenging to manage, as multiple therapeutic options are available with no clear consensus in the literature for an optimal approach. Options include conservative management, intraoperative ligation of the injured duct, Roux-en-Y reconstruction and segmental liver resection. Most cases in the literature advocate for nonoperative management or hepaticojejunostomy. We present an unusual case of aberrant right posterior sectoral duct injury in which neither of these approaches was viable, necessitating a bi-segmental liver resection.

Age- and gender-specific variations of the epiphyseal tilt and epiphyseal angle in adolescents without hip pathology

PURPOSE

To determine age-and gender-dependent variation of epiphyseal tilt and epiphyseal angle using CT in adolescents without hip pathology.

METHODS

Pelvic CT scans were obtained in 132 adolescents for evaluation of abdominal pain. Radially oriented planes around the femoral neck were reformatted and the epiphyseal tilt and angle were measured in the anterior, anterosuperior and superior planes. Variations in the tilt angle and epiphyseal angle were assessed by age group from 12 to 18 years and gender by using a linear mixed model analysis.

RESULTS

The epiphyseal tilt did not change (p = 0.97) with increasing age. Male patients exhibited smaller tilt angle in the anterosuperior plane (p = 0.003) but no difference was detected in the anterior (p = 0.17) or superior (p = 0.06) planes. The epiphyseal angle decreased with increasing age in the anterior (p = 0.03), anterosuperior (p = 0.001) and superior (p < 0.001) planes in male patients, with no variation in female patients (p = 0.92). Male patients had larger epiphyseal angles in the anterior (p = 0.02), anterosuperior (p < 0.001) and superior (p = 0.002) planes compared with female patients.

CONCLUSION

We found no age-specific variations in the epiphyseal tilt and no difference in the epiphyseal tilt in male and female patients in the superior and anterior plane. The epiphyseal angle was smaller in female patients, however, the epiphyseal angle decreased with increasing age in male patients which corresponds to an increase in epiphyseal extension. The reference values reported in this study may serve as additional information in the evaluation of adolescents with hip pain and as reference for future studies investigating slipped capital femoral epiphysis and femoroacetabular impingement development.

LEVEL OF EVIDENCE

Level III Diagnostic Study.

An Evaluation of the Value of Group Education in Recently Diagnosed Diabetes Mellitus

Diabetic patients have a 12% to 25% lifetime risk of developing foot complications leading to significant morbidity and mortality. The objective of this study was to assess the effectiveness of group education in improving patient awareness of foot care. The authors evaluated the effect of group size and areas in which knowledge seemed to be most affected. Patients attending a 2-hour teaching session between November 2005 and March 2006 were recruited. Patients filled in an 18-part questionnaire before and after the teaching session to assess knowledge. Fifty-nine patients recently diagnosed with diabetes mellitus or foot complications were recruited for 7 sessions. Analysis of the data showed a statistically significant improvement in foot care knowledge after the teaching session compared with before (69% to 85%,P < .001). Patients in the smaller group (n< 10) had significantly higher scores compared with the bigger groups (n> 10;P < .025). These data show the benefit of group education about foot care for patients with diabetes. Smaller groups benefited more than larger ones did, which could be attributed to the sizes allowing for better interaction between the tutor and patient. As patient knowledge is variable from individual to individual, smaller teaching sessions may allow patients to address specific concerns.

Teleportation as a depolarizing quantum channel, relative entropy, and classical capacity

We show that standard teleportation with an arbitrary mixed state resource is equivalent to a generalized depolarizing channel with probabilities given by the maximally entangled components of the resource. This enables the usage of any quantum channel as a generalized depolarizing channel without additional twirling operations. It also provides a nontrivial upper bound on the entanglement of a class of mixed states. Our result allows a consistent and statistically motivated quantification of teleportation success in terms of the relative entropy and this quantification can be related to a classical capacity.

Pivotal phase III trial of two dose levels of denileukin diftitox for the treatment of cutaneous T-cell lymphoma

PURPOSE

The objective of this phase III study was to determine the efficacy, safety, and pharmacokinetics of denileukin diftitox (DAB389IL-2, Ontak [Ligand Pharmaceuticals Inc, San Diego, CA]) in patients with stage Ib to IVa cutaneous T-cell lymphoma (CTCL) who have previously received other therapeutic interventions.

PATIENTS AND METHODS

Patients with biopsy-proven CTCL that expressed CD25 on > or = 20% of lymphocytes were assigned to one of two dose levels (9 or 18 microg/kg/d) of denileukin diftitox administered 5 consecutive days every 3 weeks for up to 8 cycles. Patients were monitored for toxicity and clinical efficacy, the latter assessed by changes in disease burden and quality of life measurements. Antibody levels of antidenileukin diftitox and anti-interleukin-2 and serum concentrations of denileukin diftitox were also measured.

RESULTS

Overall, 30% of the 71 patients with CTCL treated with denileukin diftitox had an objective response (20% partial response; 10% complete response). The response rate and duration of response based on the time of the first dose of study drug for all responders (median of 6.9 months with a range of 2.7 to more than 46.1 months) were not statistically different between the two doses. Adverse events consisted of flu-like symptoms (fever/chills, nausea/vomiting, and myalgias/arthralgias), acute infusion-related events (hypotension, dyspnea, chest pain, and back pain), and a vascular leak syndrome (hypotension, hypoalbuminemia, edema). In addition, 61% of the patients experienced transient elevations of hepatic transaminase levels with 17% grade 3 or 4. Hypoalbuminemia occurred in 79%, including 15% with grade 3 or 4 changes. Tolerability at 9 and 18 microg/kg/d was similar, and there was no evidence of cumulative toxicity.

CONCLUSION

Denileukin diftitox has been shown to be a useful and important agent in the treatment of patients whose CTCL is persistent or recurrent despite other therapeutic interventions.

Antigen gene transfer to cultured human dendritic cells using recombinant avipoxvirus vectors

Advances in understanding the role of dendritic cells (DCs) as the major antigen (Ag)-presenting cell type of the immune system combined with the recent development of methods for the ex vivo expansion of human DCs have opened the possibility for the transfer of tumor Ags to DCs with a view toward tumor immunotherapy. In this study, we examined the feasibility of Ag transfer to cultured human DCs using the host range-restricted avipoxvirus, fowlpoxvirus (FWPV). FWPV was found to infect and express a lacZ marker gene in a number of mammalian cell lines of fibroblastic, epithelial, and hemopoietic lineage origins. LacZ recombinant FWPV (rFWPV) was found subsequently to infect human DCs that had been cultured ex vivo from peripheral blood monocytes. Using rFWPV containing lacZ under the control of a vaccinia virus (VV) early/late promoter (p7.5K) and a 10 plaque-forming units per cell multiplicity of infection, >80% of cells expressed the lacZ marker gene. Quantitative analysis showed that the level of expression continued to rise for 5 days postinfection, at which point the experiments were terminated. Replication-competent recombinant VV (rVV) was also shown to be capable of transferring the marker gene to primary DC cultures. However, neither rFWPV nor rVV were able to express transgenes under the control of late viral promoters, indicating that both rFWPV and rVV infections are arrested at an early stage in human DCs. Infection of CD83 + DCs by rFWPV was confirmed by double-staining cytochemistry. We conclude that host range-restricted FWPV can be used efficiently to transfer Ag genes to human DCs ex vivo and may have a role in the development of tumor immunotherapy protocols.

Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey

BACKGROUND

Axillary lymph node dissection is commonly performed as part of the primary management of breast carcinoma. Its value in patient management, however, has recently been questioned. Few studies exist that document long term complications.

METHODS

Four hundred thirty-two patients with Stage I or II breast carcinoma who were free of recurrence 2-5 years after surgery were identified. A cross-sectional survey was conducted to determine the prevalence of long term symptoms and complications as perceived by the patient, and patient and treatment factors that may have predicted complications were determined. Three hundred thirty of the 432 (76%) completed a mailed, self-administered questionnaire. In addition, the medical records of the 330 patients were reviewed. Patient and treatment factors were analyzed with logistic regression.

RESULTS

Numbness was reported by 35% of patients at the time of the survey. Pain was noted in 30%, arm swelling in 15%, and limitation of arm movement in 8%. Eight percent reported episodes of infection or inflammation at some point since the diagnosis of breast carcinoma. The majority of symptoms were mild and interfered minimally with daily activities. Younger age (P=0.001) was associated with more frequent reporting of pain. Numbness was more common in younger patients (P=0.004) as well as in those with a history of smoking (P=0.012). There was a positive association of limitation of arm motion with adjuvant tamoxifen therapy (P=0.016). Arm swelling was associated with both younger age (P=0.004) and greater body surface area (P=0.008). Radiation therapy was associated with a higher frequency of infection or inflammation in the arm and/or breast (P=0.001).

CONCLUSIONS

Mild symptoms, especially pain and numbness, are common 2-5 years after axillary lymph node dissection. The frequency of inflammation or infection in patients treated with radiation to the breast or chest wall after an axillary lymph node dissection may be greater than previously appreciated. Severe complications or symptoms that have a major impact on daily activities are uncommon. These findings should help health care providers and their patients with breast carcinoma weigh the pros and cons of axillary lymph node dissection.

Half a loaf is better than waiting for the bread truck. A computerized mini-medical record for outpatient care

We describe a locally developed system for partial computer storage of medical data, called the mini-medical record system. The system produces a typed face sheet prior to each patient visit. The face sheet, which also serves as a progress note, contains patient demographic data, medical problem lists, previous vital signs, allergies, medication profile, and health maintenance reminders. Between regularly scheduled visits, all computerized data are available by computer printout for unscheduled visits to walk-in clinics and the emergency department. Structured reports are generated by the system that describes each resident and faculty members' practice. Quality assurance reports are also available. Since the system draws from several already existing databases, new data entry requirements are modest and cost to the institution is low. Partially computerized systems can be developed inexpensively and are well received in multispecialty practices, where interphysician communication is vital.

Artificial insemination of red deer (Cervus elaphus) with frozen-thawed wapiti semen

Semen collected from wapiti (Cervus elaphus) in Canada in 1983 was frozen in two extenders. In 1988, the semen was used to inseminate 200 red deer hinds on 2 farms in New Zealand. Oestrus was synchronized in the hinds with progesterone-impregnated intravaginal devices (CIDR); 200 iu pregnant mares' serum gonadotrophin was given to each hind on Day 11. The CIDRs were removed on Day 12 at 20/h, as the numbers of the hinds were recorded. On Day 14, 54-56 h after CIDR removal, the hinds were brought into the yards in the same batches and laparoscopically inseminated. Semen from three sires was used. The overall conception rate was 51%. Gestation length ranged from 239 to 247 days. One hind was lost at calving, 3 calves had to be hand raised and there were 2 neonatal calf deaths.

Interleukin-1 is one factor which regulates autocrine production of GM-CSF by the blast cells of acute myeloblastic leukaemia

The role of interleukin-1 (IL-1) as a regulator of the autonomous growth of the blast cells of acute myeloid leukaemia (AML) has been studied on samples isolated from 15 patients. In nine out of 10 patients with evidence of partial autonomous blast cell growth. IL-1 further stimulated cell growth in both suspension culture and in a clongenic assay. IL-1 also stimulated cell growth in two out of three cases with no evidence of autonomous growth whereas no additional stimulation was observed in two cases with totally autonomous growth. In blast cells stimulated by IL-1, synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) was increased and the proliferative response to IL-1 was inhibited by an antibody to GM-CSF. In all samples with evidence of autonomous growth, blast cell conditioned medium (BCCM) contained IL-1 activity (range 0.7-74.2 units ml) and a polyclonal antibody to IL-1 markedly inhibited autonomous growth in four samples. BCCM from three of these four samples contained GM-CSF, the synthesis of which was suppressed when BCCM was prepared in the presence of anti-IL-1. Our data suggests that endogenous IL-1 is an important factor in the regulation of the production of GM-CSF and hence of autonomous growth of AML blasts, but that other mechanisms regulating GM-CSF production may exist.

Endogenous interleukin-1 can regulate the autonomous growth of the blast cells of acute myeloblastic leukemia by inducing autocrine secretion of GM-CSF

We have studied peripheral blood blast cells from a patient with acute myeloblastic leukemia (AML) whose cells proliferated autonomously at high cell density, but only in the presence of adherent cells. At low cell density in suspension culture and in a clonogenic assay, blast cell growth was stimulated by recombinant granulocyte macrophage colony stimulating factor (GM-CSF) and recombinant interleukin-1 (IL-1) independently. The response to rIL-1 was inhibited (less than 90%) by anti-GM-CSF, suggesting that the proliferative response to IL-1 was mediated by GM-CSF. This was supported by experiments which demonstrated that blast cell conditioned medium prepared in the presence of IL-1 contained GM-CSF activity which stimulated the growth of normal granulocyte-macrophage precursors (CFU-GM) and of homologous GM-CSF responsive AML blasts. As IL-1 but no GM-CSF activity was detected in BCCM prepared without exogenous IL-1 and a neutralizing antibody to IL-1 inhibited the autonomous growth of blasts in suspension culture, we conclude that the endogenous secretion of IL-1 by leukemic cells stimulated autocrine GM-CSF secretion, inducing autonomous growth of the blast cell population.

The flexural strength of repaired glass-ionomer cements

The flexural strength of three glass-ionomer-type cements was measured by means of a four-point bend test. Specimens were tested at one hour and seven days after being mixed. The maleic copolymer materials showed similar strengths at one hour and seven days, while the water-based polyacrylic acid material showed a reduction in strength over the seven-day period. For assessment of the capacity of fresh glass ionomer to bond with old material, further half-length specimens of all materials were prepared and additions made at one hour and seven days. These specimens were tested at one hour and seven days after the addition. There was a considerable reduction in the strength of all specimens where additions had been made. The degree of reduction varied with the type of material. All fractures on the addition specimens occurred at the junction between the two sections.