Breast cancer-related lymphedema (BCRL) is a common complication of breast cancer. 1 Indocyanine green (ICG) lymphography 2 can assess lymphatic functionality. However, some patients undergoing taxane-based chemotherapy experience a period of interstitial edema during which no flow is observed on ICG lymphography, because when the dye is injected near the first web space over the dorsum of the hand, it does not flow beyond the wrist. 3 Over time, this resolves and either returns to normal or results in dermal backflow (DBF). The present study aimed to investigate the association between lymphatic functionality and the risk factors for BCRL using ICG lymphography, while particularly focusing on the no-flow pattern.This study retrospectively reviewed 422 breast cancer cases involving axillary lymph node dissection (ALND). BCRL was diagnosed based on ICG lymphography patterns or, for patients with edema unable to undergo ICG lymphography, by comparing volume differences. The patients were divided into two groups based on the presence/absence of BCRL: BCRL( + ) and BCRL( −). The following characteristics were compared between the groups: age, body mass index, laterality, type of surgery (breast-conserving or mastectomy), disease staging, regional lymph node irradiation, hormone therapy, and type of chemotherapy (taxane, nontaxane, or no chemotherapy).Patients exhibiting the no-flow pattern underwent ICG lymphography every 3 months. DBF patterns typically do not change within such a short period, but because the noflow pattern was the result of temporary interstitial edema, changes were observed from one lymphography to the next ( Figure 1 ). Patients with prolonged edema who could not be diagnosed by ICG lymphography alone were assessed by lymphoscintigraphy. 4 Of the 422 patients who underwent ALND, 100 (23.7%) were diagnosed with BCRL. Compared with the BCRL( −) group, the BCRL( + ) group had significantly higher rates of lymph node irradiation (45% vs. 32%; P = 0.020) and taxanebased chemotherapy (94% vs. 63%; P < 0.001). Postsurgical disease staging was significantly more severe in the BCRL( + )
Background Facial pressure ulcers are a rare yet significant complication. National Institute for Health and Care Excellence (NICE) guidelines recommend that patients should be risk-assessed for pressure ulcers and measures instated to prevent such complication. In this study, we report case series of perioral pressure ulcers developed following the use of two devices to secure endotracheal tubes in COVID-19 positive patients managed in the intensive care setting. Methods A retrospective analysis was conducted on sixteen patients identified to have perioral pressure ulcers by using the institutional risk management system. Data parameters included patient demographics (age, gender, comorbidities, smoking history and body mass index (BMI)). Data collection included the indication of admission to ITU, duration of intubation, types of medical devices utilised to secure the endotracheal tube, requirement of vasopressor agents and renal replacement therapy, presence of other associated ulcers, duration of proning and mortality. Results Sixteen patients developed different patterns of perioral pressure ulcers related to the use of two medical devices (Insight, AnchorFast). The mean age was 58.6 years. The average length of intubation was 18.8 days. Fourteen patients required proning, with an average duration of 5.2 days. Conclusions The two devices utilised to secure endotracheal tubes are associated with unique patterns of facial pressure ulcers. Measures should be taken to assess the skin regularly and avoid utilising devices that are associated with a high risk of facial pressure ulcers. Awareness and training should be provided to prevent such significant complication. Level of evidence: Level IV, risk/prognostic study.
Introduction Locally advanced nonmelanoma skin cancers of the head and neck are well described in the current literature. However, data about clinical and survival outcomes are lacking. We present survival data from a tertiary head and neck cancer unit in London. Methods A retrospective analysis of data collected from a single institution was conducted. All patients with locally advanced cutaneous scalp carcinomas invading the skull between 2011 and 2019 were included. Data included patient demographics, tumor, comorbidities, interventions, flap survival, and metal work exposure. Survival outcomes were examined using Kaplan-Meier analysis. Results Twenty-three patients were identified. The mean age was 72 years. Eighteen patients were male, and 5 were female. Five patients were immunosuppressed. Nineteen patients underwent outer cortex drill-down/full-thickness calvarial resection, followed by reconstruction with free tissue transfer. Six patients had titanium mesh reconstruction after segmental skull resections. Three patients underwent further surgery because of exposed metalwork. Disease-free survival at 3 years after surgery was 60%. Conclusions Locally advanced nonmelanoma skin cancers invading the bone are sporadic. There are little published data on clinical and survival outcomes in this group. Despite the nature of these skin lesions, a high degree of local control can be obtained by extensive surgical resection, outer table drill-down, and calvarial resection. We conclude that aggressive management of the bony invasion improves disease-free survival and improves local control.
A woman aged 44 underwent elective standard abdominoplasty and bilateral mastopexy (superiorly based pedicle with vertical scar) following weight loss of 8.5 stone (53.9 kg) over a 5-year period. She had type 2 diabetes and her antidiabetic medications included metformin, liraglutide and empagliflozin. Towards the end of the first postoperative day, she reported gradual onset of nausea, vomiting and abdominal pain. Her condition continued to deteriorate overnight, becoming tachycardic and tachypnoeic. Urgent investigations showed severe diabetic ketoacidosis with euglycaemia. She was managed with fluid resuscitation, insulin infusion and intravenous sodium bicarbonate in the high dependency unit. She made a complete clinical and biochemical recovery and was discharged on day 9 postoperatively. This case illustrates a diagnostic challenge of a serious life-threatening complication of diabetes in the postoperative period associated with a novel class of antidiabetic medications, sodium-glucose cotransporter 2 inhibitors.
A woman aged 67 years attended the emergency department with acute abdominal and back pain of 1-day duration with associated vomiting. The patient had multiorgan failure. Resuscitation was started with intravenous fluids and vasopressors. An abdominal CT scan was completed which confirmed the diagnosis of acute gastric volvulus. The patient was successfully resuscitated from a cardiorespiratory arrest during transfer to the operating theatre. The patient subsequently underwent a total gastrectomy with stapling of the oesophageal and duodenal stumps. The abdomen was packed and left open as a laparostomy with a planned relook 48 hours later was to be performed. Unfortunately, the patient continued to deteriorate postoperatively in the intensive care unit despite maximum organ support for multiorgan failure. A decision was made to withdraw treatment and the patient died 10 hours postoperative. This case illustrates the presentation of acute gastric volvulus at a late stage and the high mortality rate associated with it.
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