Citations

To investigate the usefulness of a standard surgical preparation in prevention of surgical site contamination, 49 consecutive patients undergoing foot or ankle surgery were randomly assigned to standard preparation with chlorhexidine gluconate home scrubs and preoperative povidone-iodine or to standard preparation plus preoperative preparation with 70% alcohol. Results were available for all 49 patients. Cultures were positive for normal aerobic bacteria from the toes of nine of 26 patients (35%) receiving standard surgical preparation and from the toes of 13 of 23 patients (57%) receiving standard preparation plus alcohol (P=0.12). No patient had a positive culture for anaerobic organisms or clinical evidence of infection or wound problems. Standard surgical preparation did not provide a completely sterile field, and the inclusion of alcohol added no benefit.

Over the last decade, the mechanism of formation of intraneural ganglion cysts has been established through a meticulous review of clinical findings and correlation with patterns produced on magnetic resonance imaging (MRI). Pathognomonic imaging patterns distinguish these rare lesions from the more common extraneural variants in almost all cases. In this report, we present a new pattern of cyst occurrence in the subparaneurial compartment of the nerve and provide potential anatomic explanations for its pathogenesis. Using an anatomic framework of connective tissue compartments of the nerve, we reviewed 63 (56 fibular and seven tibial) intraneural ganglion cysts in the knee region evaluated at our institution and all reports with MRI in the world's literature for evidence of cyst occurrence in the subparaneurial compartment. We identified six cases (five in the common fibular nerve and one in the tibial nerve) at our institution that had MR evidence of cyst in the subparaneurial compartment with a new complex lobulated pattern. All cases had articular branch connections to the superior tibiofibular joint, which at operation were resected along with the joints. Follow‐up revealed complete recovery in all instances and no clinical or radiological signs of recurrence. Three cases out of 80 in the literature exhibited the new complex lobulated MRI pattern. We present a new pattern of intraneural ganglion cyst occurrence in a potential space that surrounds peripheral nerves‐ the subparaneurial compartment. We believe that the unifying articular theory applies to the pathogenesis and management of these rare variants. Clin. Anat. 29:530–537, 2016. © 2015 Wiley Periodicals, Inc.

Background. Reconstruction of intrapelvic defects can be a challenging problem in patients with limited regional muscle flap options and previously resected omentum. In such situations, alternative methods of mobilizing vascularized tissue may be required.Methods. A case of a patient that underwent pelvic extirpation for recurrent rectal cancer who had limited donor sites for flap reconstruction is presented. The mucosa was removed from a blind loop of colon, and a pedicled seromuscular flap based on the colonic mesentery was placed into the pelvis for vascularized soft-tissue coverage and elimination of dead space.Results. The postoperative course was only complicated by a small subcutaneous fluid collection beneath the sacrectomy skin incision, which was drained with radiological assistance. The patient recovered without any major postoperative complications.Conclusion. Seromuscular colonic flap is a useful option for soft-tissue coverage after pelvic extirpation and should be considered by plastic surgeons when other reconstruction options are not available.

Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal stem cell disorders with an inherent tendency for leukemic transformation. Diagnosis is currently based on the presence of peripheral blood cytopenias, peripheral blood and bone marrow dysplasia/blasts, and clonal cytogenetic abnormalities. With the advent of next generation sequencing, recurrent somatic mutations in genes involved in epigenetic regulation (TET2, ASXL1, EZH2, DNMT3A, IDH1/2), RNA splicing (SF3B1, SRSF2, U2AF1, ZRSR2), DNA damage response (TP53), transcriptional regulation (RUNX1, BCOR, ETV6) and signal transduction (CBL, NRAS, JAK2) have been identified in MDS. Conventional prognostication is by the revised International prognostic scoring system (IPSS‐R) with additional adverse prognosis conferred by presence of ASXL1, EZH2, or TP53 mutations. Currently Food and Drug administration (FDA)‐approved drugs for the treatment of MDS are not curative and their effect on survival is limited; they include the hypomethylating agents (HMA) azacitidine and decitabine and lenalidomide for MDS with isolated del(5q). To date, allogeneic stem cell transplant (ASCT) remains the only treatment option for possible cure. Given the current lack of drugs with convincing evidence of favorable effect on survival, we consider ASCT as the treatment of choice for most patients with symptomatic disease, and especially for those with high‐risk disease. For nontransplant candidates, participation in clinical trials is preferred over conventional therapy. There is not one right way of treatment for patients who are not candidates for either ASCT or clinical trials and palliative drugs of choice depend on the clinical problem, such as symptomatic anemia (ESAs, danazol, HMA), thrombocytopenia (HMA), or neutropenia (myeloid growth factors). Conversely, there is no controlled evidence to support the use of iron chelating agents in MDS. Going forward, we believe it is time to incorporate mutation information in clinically derived prognostic models in MDS and encourage development of novel drugs with disease‐modifying activity. Am. J. Hematol. 91:76–89, 2016. © 2015 Wiley Periodicals, Inc.

Objectives/HypothesisThe primary goals of microsurgery for vestibular schwannoma (VS) include preservation of neural function and complete tumor removal. In a subset of patients, adherent tumor remnant may be intentionally left behind in order to minimize risk of new neurologic deficits. It is not well established if residual tumor volume predicts likelihood of tumor remnant growth.MethodsPatients with sporadic VS who underwent near‐total (NTR) or subtotal (STR) VS resection between 2000 and 2014 were reviewed. Postoperative tumor remnants were volumetrically contoured using T1‐weighted gadolinium‐enhanced magnetic resonance imaging obtained within 3 months of surgery.ResultsA total of 103 patients met study criteria, and the median duration of radiographic follow‐up was 41 months (mean 56.1 months, range 12–150 months). Fifty patients underwent NTR and 53 received STR. Overall 14 (13.6%) tumors recurred at a median of 41.0 months. Patients who underwent STR were over 13 times more likely to recur compared with those treated with NTR (hazard ratio 13.31; 95% confidence interval 1.71–103.91; P = 0.014). The median time to recurrence following NTR was 124 months compared to 32 months after STR (P < 0.001).ConclusionsLong‐term follow‐up in patients undergoing incomplete resection is essential. Near‐total resection has a significantly lower rate of recurrence compared to STR. Maximal surgical resection should be the goal in VS microsurgery. The decision to pursue less than complete resection should be based on intraoperative impression, when it is felt that continued dissection of adherent disease would compromise neurologic outcome.Level of Evidence4. Laryngoscope, 126:1877–1882, 2016

Purpose Polycythemia vera (PV) is a myeloproliferative neoplasm (MPN) associated with disabling symptoms and a heightened risk of life-threatening complications. Recent studies have demonstrated the effectiveness of JAK inhibitor therapy in patients with PV patients who have a history of prior hydroxyurea (HU) use (including resistance or intolerance), phlebotomy requirements, and palpable splenomegaly. We aimed to determine how these features contribute alone and in aggregate to the PV symptom burden. Patients and Methods Through prospective evaluation of 1,334 patients with PV who had characterized symptom burden, we assessed patient demographics, laboratory data, and the presence of splenomegaly by disease feature (ie, known HU use, known phlebotomy requirements, splenomegaly). Results The presence of each feature in itself is associated with a moderately high symptom burden (MPN symptom assessment form [SAF] total symptom score [TSS] range, 27.7 to 29.2) that persists independent of PV risk category. In addition, symptoms incrementally increase in severity with the addition of other features. Patients with PV who had all three features (PV-HUPS) faced the highest total score (MPN-SAF TSS, 32.5) but had similar individual symptom scores to patients with known HU use (PV-HU), known phlebotomy (PV-P), and splenomegaly (PV-S). Conclusion The results of this study suggest that patients with PV who have any one of the features in question (known HU use, known phlebotomy, or splenomegaly) have significant PV-associated symptoms. Furthermore, it demonstrates that many PV symptoms remain severe independent of the number of features present.

In recent years, the emerging electronic cigarette (e-cigarette) marketplace has shown great development prospects all over the world. Reddit, one of the most popular forums in the world, has a very large user group and thus great influence. This study aims to gain a systematic understanding of e-cigarette flavors based on data collected from Reddit. Flavor popularity, mixing, characteristics, trends, and brands are analyzed. Fruit flavors were mentioned the most (n = 15,720) among all the posts and were among the most popular flavors (n = 2902) used in mixed blends. Strawberry and vanilla flavors were the most popular for e-juice mixing. The number of posts discussing e-cigarette flavors has increased sharply since 2014. Mt. Baker Vapor and Hangen were the most popular brands discussed among users. Information posted on Reddit about e-cigarette flavors reflected consumers’ interest in a variety of flavors. Our findings suggest that Reddit could be used for data mining and analysis of e-cigarette-related content. Understanding how e-cigarette consumers’ view and utilize flavors within their vaping experience and how producers and marketers use social media to promote flavors and sell products could provide valuable information for regulatory decision-makers.

Background Lapatinib (L) plus trastuzumab (T) improves outcomes for metastatic human epidermal growth factor 2–positive breast cancer and increases the pathologic complete response in the neoadjuvant setting, but their role as adjuvant therapy remains uncertain. Methods In the Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization trial, patients with centrally confirmed human epidermal growth factor 2–positive early breast cancer were randomly assigned to 1 year of adjuvant therapy with T, L, their sequence (T→L), or their combination (L+T). The primary end point was disease-free survival (DFS), with 850 events required for 80% power to detect a hazard ratio (HR) of 0.8 for L+T versus T. Results Between June 2007 and July 2011, 8,381 patients were enrolled. In 2011, due to futility to demonstrate noninferiority of L versus T, the L arm was closed, and patients free of disease were offered adjuvant T. A protocol modification required P ≤ .025 for the two remaining pairwise comparisons. At a protocol-specified analysis with a median follow-up of 4.5 years, a 16% reduction in the DFS hazard rate was observed with L+T compared with T (555 DFS events; HR, 0.84; 97.5% CI, 0.70 to 1.02; P = .048), and a 4% reduction was observed with T→L compared with T (HR, 0.96; 97.5% CI, 0.80 to 1.15; P = .61). L-treated patients experienced more diarrhea, cutaneous rash, and hepatic toxicity compared with T-treated patients. The incidence of cardiac toxicity was low in all treatment arms. Conclusion Adjuvant treatment that includes L did not significantly improve DFS compared with T alone and added toxicity. One year of adjuvant T remains standard of care.