Human papillomavirus infection and anal dysplasia in renal transplant recipients

• Author: H. S. Patel, A. R. Silver, T. Levine, G. Williams, J. M. Northover
• Published: Aug 20, 2010
• Pages: 1716-1721
• DOI: 10.1002/bjs.7218

Abstract

Background:

Immunosuppression is a known risk factor for anal human papillomavirus (HPV) disease, including anal squamous cell carcinoma. Additional risk factors for HPV‐related disease have not been studied in the renal transplant population. The demographics of anal HPV and associated risk factors were investigated in this population.

Methods:

Anal cytology and polymerase chain reaction were used to assess anal HPV disease in a cohort of transplant recipients at the Royal London Hospital. Risk factors associated with increased immunosuppression and HPV exposure were collated to determine any association with anal disease.

Results:

Anal dysplasia was associated with anal oncogenic HPV infection (P < 0·001), duration of immunosuppression (P = 0·050), previous genital warts (P = 0·018) and receptive anal intercourse (P = 0·013).

Conclusion:

Anal dysplasia was related to immunosuppression and patient factors in this cohort. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd

Management of blunt injuries to the spleen

• Author: P. Renzulli, T. Gross, B. Schnüriger, A. M. Schoepfer, D. Inderbitzin, A. K. Exadaktylos, H. Hoppe, D. Candinas
• Published: Aug 26, 2010
• Pages: 1696-1703
• DOI: 10.1002/bjs.7203

Abstract

Background:

Non‐operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.

Methods:

All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed.

Results:

There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty‐seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71).

Conclusion:

NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

New anatomical classification of the axilla with implications for sentinel node biopsy

• Author: K. B. Clough, R. Nasr, C. Nos, M. Vieira, C. Inguenault, B. Poulet
• Published: Aug 26, 2010
• Pages: 1659-1665
• DOI: 10.1002/bjs.7217

Abstract

Background:

The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random.

Methods:

A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D).

Results:

In 98·2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86·8 per cent) or above it (zone B, 11·5 per cent). In only four patients (1·8 per cent) was the SLN located laterally in the axilla.

Conclusion:

Regardless of the site of the tumour in the breast, 98·2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial comparing surgery, endovenous laser ablation and ultrasound‐guided foam sclerotherapy for the treatment of great saphenous varicose veins

Background
Endovenous ablation techniques and ultrasound‐guided foam sclerotherapy (UGFS) have largely replaced open surgery for treatment of great saphenous varicose veins. This was a randomized trial to compare the effect of surgery, endovenous laser ablation (EVLA) (with phlebectomies) and UGFS on quality of life and the occlusion rate of the great saphenous vein (GSV) 12 months after surgery.

Methods
Patients with symptomatic, uncomplicated varicose veins (CEAP class C2–C4) were examined at baseline, 1 month and 1 year. Before discharge and at 1 week, patients reported a pain score on a visual analogue scale. Preoperative and 1‐year assessments included duplex ultrasound imaging and the Aberdeen Varicose Vein Severity Score (AVVSS).

Results
The study included 214 patients: 65 had surgery, 73 had EVLA and 76 had UGFS. At 1 year, the GSV was occluded or absent in 59 (97 per cent) of 61 patients after surgery, 71 (97 per cent) of 73 after EVLA and 37 (51 per cent) of 72 after UGFS (P < 0·001). The AVVSS improved significantly in comparison with preoperative values in all groups, with no significant differences between them. Perioperative pain was significantly reduced and sick leave shorter after UGFS (mean 1 day) than after EVLA (8 days) and surgery (12 days).

Conclusion
In comparison with open surgery and EVLA, UGFS resulted in equivalent improvement in quality of life but significantly higher residual GSV reflux at 12‐month follow‐up. 



Author: M. Venermo, J. Saarinen, E. Eskelinen, S. Vähäaho, E. Saarinen, M. Railo, I. Uurto, J. Salenius, A. Albäck,
Published: Aug 26, 2016
Pages: 1438-1444
DOI: 10.1002/bjs.10260

Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm

Objective: The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative.

Background: Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies.

Methods: A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ2, and Fisher Exact tests.

Results: Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%.

Conclusions: Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.journals.lww.com

by Shah, Sohail R.; Sinclair, Kelly A.; Theut, Stephanie B.; Johnson, Kathy M.; Holcomb, George W. III; St. Peter, Shawn D. / Today, 5:30 AM