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Funder: Amgen, Funder: Roche, Funder: Universitätsspital Basel, Funder: Merck, Funder: AstraZeneca, Funder: Pfizer, AIM: Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario. METHODS: A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology. RESULTS: The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR. CONCLUSIONS: The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR.

Optimal margins for ductal carcinoma in situ (DCIS) remain controversial in breast-conserving surgery (BCS) and mastectomy. We examine the association of positive margins, reoperations, DCIS and age.A retrospective study of histopathological reports (4489 patients). Margin positivity was defined as ink on tumor for invasive carcinoma. For DCIS, we applied 2 mm anterior and side margin thresholds, and ink on tumor in the posterior margin.The incidence of positive side margins was 20% in BCS and 5% in mastectomies (p 0.001). Of these patients, 68% and 14% underwent a reoperation (p 0.001). After a positive side margin in BCS, the reoperation rates according to age groups were 74% (49), 69% (50-64), 68% (65-79), and 42% (80+) (p = 0.013). Of BCS patients with invasive carcinoma in the side margin, 73% were reoperated on. A reoperation was performed in 70% of patients with a close (≤1 mm) DCIS side margin, compared to 43% with a wider (1.1-2 mm) margin (p = 0.002). The reoperation rates were 55% in invasive carcinoma with close DCIS, 66% in close extensive intraductal component (EIC), and 83% in close pure DCIS (p 0.001).Individual assessment as opposed to rigid adherence to guidelines was used in the decision on reoperation.

The aims of the Oncoplastic Breast Consortium initiative were to identify important knowledge gaps in the field of oncoplastic breast-conserving surgery and nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction, and to recommend appropriate research strategies to address these gaps. A total of 212 surgeons and 26 patient advocates from 55 countries prioritised the 15 most important knowledge gaps from a list of 38 in two electronic Delphi rounds. An interdisciplinary panel of the Oncoplastic Breast Consortium consisting of 63 stakeholders from 20 countries obtained consensus during an in-person meeting to select seven of these 15 knowledge gaps as research priorities. Three key recommendations emerged from the meeting. First, the effect of oncoplastic breast-conserving surgery on quality of life and the optimal type and timing of reconstruction after nipple-sparing or skin-sparing mastectomy with planned radiotherapy should be addressed by prospective cohort studies at an international level. Second, the role of adjunctive mesh and the positioning of implants during implant-based breast reconstruction should ideally be investigated by randomised controlled trials of pragmatic design. Finally, the BREAST-Q questionnaire is a suitable tool to assess primary outcomes in these studies, but other metrics to measure patient-reported outcomes should be systematically evaluated and quality indicators of surgical morbidity should be further assessed.

Adverse reactions to ophthalmic patients during 9909 fluorescein angiographies during 9 years were registered. Nausea (4.6%) and vomiting (1.3%) were the most common untoward reactions. Allergic skin manifestations occurred in 48 patients, and 5 patients complained of shortness of breath. 56 patients (0.6%) felt dizzy during or immediately after the investigation. Nine patients complained of chest pain, three of whom developed myocardial infarction. Sixteen patients collapsed during the procedure. One healthy male, 42-year-old, collapsed after the injection of fluorescein during angiography, and electrocardiogram showed an asystole of 24 seconds. Otherwise, the electrocardiograms registered on 100 consecutive patients did not reveal any systematic changes in heart rate or rhythm during fluorescein angiography.

This follow-up study describes the 47 patients out of 1506 intracapsularly extracted cataracts (1505 patients) who presented with a psychotic reaction post-operatively. Matched non-psychotic cataract patients served as a control group. The mean age of both groups of patients was 78 years at time of surgery, female/male ratio was 39/8, and the mode of anaesthesia was local analgesia/general anaesthesia 16/31. The surgery had been performed in 1977–1979 and this follow-up examination in autumn 1983. Twenty-seven patients of the study group and 16 of the controls had died during the interval period. The difference between the groups was statistically significant. The patients of the study group were statistically significantly more dependent on nursing, and their mental performance, according to an orientation test, was more reduced, compared to the controls. Visual prognosis in the operated eye was unfavourable in the study group, versus the controls, mainly because of visual deprivation due to mental debilitation. Pre-operative vision did not predict future psychotic reaction.

For a female-to-male transgender person, mastectomy is the most important procedure making the social interaction easier. Along with the size of the breasts, the quantity and quality of skin will influence the selection of surgical technique. Although complications are rare, corrective surgery is performed for as many as 40% of the patients. Of male-to-female transsexual persons, 60 to 70% opt for breast enlargement. Breast enlargement can be carried out by using either silicone implants or fat transplantation. Since the surgical procedures on breasts are irreversible, their implementation requires confirmation of the diagnosis of transsexualism by a multidisciplinary team.

The requirement for high-performance reporter probes in real-time detection of polymerase chain reaction (PCR) has led to the use of time-resolved fluorometry of lanthanide chelates. The aim of this study was to investigate the applicability of the principle of lanthanide chelate complementation (LCC) in comparison with a method based on hydrolysis enhancement and quenching of intact probes. A real-time reverse transcription (RT) PCR assay for kallikrein-related peptidase 3 (KLK3, model analyte) was developed by using the LCC detection method. Both detection methods were tested with a standard series of purified PCR products, 20 prostatic tissues, 20 healthy and prostate cancer patient blood samples, and female blood samples spiked with LNCaP cells. The same limit of detection was obtained with both methods, and two cycles earlier detection with the LCC method was observed. KLK3 messenger RNA (mRNA) was detected in all tissue samples and in 1 of 20 blood samples identically with both methods. The background was 30 times lower, and the signal-to-background (S/B) ratio was 3 times higher, when compared with the reference method. Use of the new reporter method provided similar sensitivity and specificity as the reference method. The lower background, the improved S/B ratio, and the possibility of melting curve analysis and single nucleotide polymorphism (SNP) detection could be advantages for this new reporter probe. © 2013 Elsevier Inc. All rights reserved.

Dark adapted single flash and light adapted 30 Hz photopic flicker ERGs were recorded from a litter of seven Labrador Retrievers bred from parents affected with generalized progressive rod-cone dystrophy. After an initial increase of b-wave amplitudes from 5 weeks to 4 months similar to the controls, the b-wave amplitudes of the litter were significantly decreased (P less than 0.005) at 7 months. At 21 months the b-wave amplitudes were very low, although some response to 30 Hz photopic flicker was still left. The ERG changes indicated a late onset progressive rod-cone dystrophy which developed after maturation of the retina. The development of this photoreceptor dystrophy has not previously been described.

Early ultrastructural findings of a progressive photoreceptor dystrophy and corresponding ERG findings are reported in 3 Labrador Retrievers from a litter of 7 pups bred from 2 dogs clinically and electroretinographically affected with generalized progressive retinal dystrophy. The pups were euthanized at 5, 11 and 15 months post partum. The most prominent ultrastructural finding was photoreceptor dystrophy. At 5 months the outer nuclear layer (ONL) consisted of 8-10 layers and seemed reduced in thickness, pyknotic nuclei were seen in this layer. The receptor outer segments (OS) were short and swollen. Some disorientation of OS discs occurred. In the 11-months specimen 7-8 ONL layers were identified. Overall thinning of the neuro-retina had occurred and fewer receptors compared to the 5-months specimen were present. By 15 months the ONL was further reduced to about 4 layers. Enlarged internuclear spaces were present in the ONL as well as around inner segments (IS). Phagocytic cells were frequent among remains of OS. The pigment epithelium appeared normal. The dark adapted ERG b-wave amplitudes and photopic 30 Hz flicker responses were low in comparison to controls of the same breed, and decreased with age. The condition represents a progressive rod-cone dystrophy which shares similarities with primary receptor dystrophy in man such as retinitis pigmentosa.

SUMMARY In a prospective study, 50 of 1 505 (3.3%) patients undergoing cataract extraction during a three-year period developed postoperative psychiatric reactions. Old age and markedly deteriorated vision seemed to contribute to this complication, which in all cases was reversible.

The memory performance of 60 female patients, scheduled for either local or general anaesthesia and extraction of senile cataract, was investigated. Six subtests of the Wechsler Memory Scale and four items of memory tests according to Luria were performed. One week postoperatively there was a diminution in the performance of the Wechsler Memory Scale and Luria tests. Comparison of the pre- and postoperative diminutions between the local and general anaesthesia groups was statistically significant only in the Luria tests. According to this study general anaesthesia does not affect memory function more profoundly than local anaesthesia supplemented with tranquilizing and/or analgesic drugs. In this respect, the advantages of general anesthesia should be utilized, at least in patients without clearcut contraindications.

SUMMARY Pancuronium bromide has proved to be a useful non-depolarizing long-acting neuromuscular blocking agent which is nearly three times (2.42) as potent as alcuronium chloride. Pancuronium bromide blockade can be reversed fairly quickly by anticholinesterase agents, and die patient recovers to the 90% level of muscle tone in 15-20 minutes. ZUSAMMENFASSUNG Pancuroniumbromid hat sich als brauchbarer nicht-depolarisierender langwirkender neuromuskularer Blocker erwiesen, der fast dreimal so stark (2,42) ist als Alcuroniumchlorid. Die Blockade durch Pancuroniumbromid kann mittels Anticholinesterasen ziemlich rasch aufgehoben werden; der Patient erreicht innerhalb von 15 bis 20 Minuten wieder 90% seines Muskeltonus.

Ten patients (one male and nine females), aged 33.2+/-12.0 years, were given electrophysiological studies before and during general anaesthesia. A mixture of thiopentone sodium, halothane, and nitrous oxide was used for anaesthesia. Electroretinogram (ERG) and visual evoked potentials (VEP) were recorded with scalp electrodes, and an averaging technique was used to improve signal-noise ratio. The recordings were made under standard conditions 15 to 20 min after induction of the anaesthesia. The amplitudes of the a- and b-waves of the ERG were significantly diminished whereas their latencies remained unchanged. The peak-to-peak amplitudes of the early components N1 and P2 of the VEP were significantly lowered, and the latencies of N0, P1, and N1 were prolonged by anaesthesia. These modifications are suggested to reflect metabolic changes in the sensitive layers of the retina and in the optic tract.

With atracurium and vecuronium, spontaneous recovery of residual neuromuscular blockade monitored electromyographically during 0.5% isoflurane anaesthesia was studied in 60 patients undergoing plastic surgery. After thiopentone, in random order, either atracurium 0.5 mg kg-1 or vecuronium 0.1 mg kg-1 was administered and isoflurane added to N2O and O2 mixture. Following spontaneous recovery of both the single twitch amplitude (T1) to 75% of the control value and the train-of-four ratio (TOF ratio) to 75%, incremental doses of the relaxant were given to maintain the T1 at less than 10%. Before the end of surgery, the blockade was again permitted to recover spontaneously. During the initial spontaneous recovery, the mean recovery time of T1 from 25% to 75% (the recovery index) with atracurium was longer (P less than 0.001) than that with vecuronium (13.2 min and 10.1 min, respectively) but, during the second recovery, the mean recovery index was shorter (P less than 0.05) with atracurium than with vecuronium (16.1 min and 19.8 min, respectively). The recovery time from T1 75% to TOF ratio 75%, indicating the recovery rate of residual neuromuscular blockade, with atracurium was about 15 min after both the initial and the second recoveries. With vecuronium, the respective recovery times were significantly (P less than 0.001) longer (25.6 min and 38.5 min, respectively). It is concluded that with vecuronium there is slower spontaneous recovery of residual neuromuscular blockade than with atracurium.

Fourteen female patients 27.7 +/- 10.0 years of age were studied by electrophysiological means before and during general anaesthesia. A mixture of thiopentone sodium, enflurane and nitrous oxide was used for anaesthesia. Electroretinogram (ERG) and visual evoked potentials (VEP) were recorded with electrodes placed on the lower lid and scalp and an averaging technique was used. The recordings were made under standard conditions with the pupils dilated, the eyes adapted to the dark and after 15-20 min stable anaesthesia. The latency of the a-wave did not change, whereas the b-wave was delayed (P less than 0.01). The amplitude of the a-wave tended to decrease; however, an increase of amplitude was also present. Therefore the change was not significant. The b-wave was unchanged. Changes induced by anaesthesia were often noted in the shape of P130, where a change from V to W-form took place or the reverse. The latencies of the late components N180 and P220 were increased during anaesthesia (P = 0.006 and P = 0.001, respectively). No statistically significant change occurred in the N180 and P220 amplitudes. The amplitudes of N60 and P130 became smaller (P = 0.002 and P = 0.0003, respectively) during anaesthesia. The effect of enflurane on the components of the VEP seems to indicate a cortical site of action.

SUMMARY One hundred fifty elderly female patients undergoing cataract extraction were divided into three groups. Fifty patients were premedicated with droperidol, pethidine and atropine; another group of 50 patients with pethidine and atropine. They were operated on under local anesthesia. The control group consisted of 50 patients premedicated with pethidine and atropine, and they were given general anesthesia. Postoperative nausea and vomiting were registered until noon the next day. Comparison of different groups showed that droperidol decreases the occurrence of postoperative sickness.

Characteristics, and the occurrence of other diseases, and complications related to diabetes mellitus of 91 consecutive diabetic patients who underwent vitreous surgery in 1979-1985 were examined. The mean age of the patients was 40 years (median 37, range 19-74), and the mean duration of diabetes 23 years (range 5-44). All, but one, had insulin therapy. Abnormalities in the cardiovascular and/or renal function were found in 89 of the 91 patients (98%). Signs of cardiovascular disease were observed in 58 patients (64%): 42% had elevated blood pressure (greater than or equal to 150/100 mmHg), 46% were on antihypertensive therapy, 14% had a history or signs of ischaemic heart disease, 12% had been digitalized, 7% had a history of cerebral ischaemia, and 8% had had surgery for gangrene of the lower limb. Signs of nephropathy were recorded in 64 patients (70%); 6 of them were on dialysis therapy, and two had received a kidney transplant. Symptoms possibly related to autonomic neuropathy e.g. postural hypotension, urinary tract symptoms, and gastric discomfort were found in 27%. Nine patients (10%) had some kind of thyroid disease, and two of them signs of multiple autoimmune endocrinopathy. The percentage surviving decreased from 96% at one year to 80% after 5 years of follow-up.

The effect of prior administration of tubocurarine (5 mg) or alcuronium (3 mg) on changes in cardiac rate and rhythm caused by the second dose of suxamethonium (1 mg/kg) during halothane-nitrous oxide-oxygen anaesthesia was studied in 60 patients. Tubocurarine and, particularly alcuronium were found to prevent bradyarrhythmias caused by the second dose of suxamethonium. These non-depolarizing relaxants had a moderate stabilizing action on the cardiac rhythm also during intubation and the commencement of artificial ventilation. The relaxation obtained by the first dose of suxamethonium (1 mg/kg) was sufficient to permit quiet intubation in all cases. The use of a non-depolarizing muscle relaxant prior to suxamethonium during halothane-nitrous oxide-oxygen anaesthesia is recommended. ZUSAMMENFASSUNG Bei 60 Patienten wurde die Wirkung einer Voraus-injektion von Tubocurarin (5 mg) oder Alcuronium (3 mg) auf Veranderungen der Herzfrequenz und des Herzrhythmus, verursacht durch eine Zweitdosis von Suxamethonium (1 mg/kg) wahrend einer Halothan-N2O-Narkose untersucht. Es zeigte sich, das Tubocurarin und insbesondere Al-curonium Bradyarrhythmien verhinderten, die sonst nach der Zweitdosis von Suxamethonium auftreten. Diese nicht-depolarisierenden Relaxantien hatten auch wahrend der Intubation und des Beginns der kunstlichen Beatmung eine masiggradig stabilisie-rende Wirkung auf den Herzrhythmus. Die durch die erste Dosis von Suxamethonium (1 mg/kg) erzielte Erschlaffung war in allen Fallen ausreichend fur eine glatte Intubation. Die Vorausgabe eines nicht-depolarisierenden Muskelrelaxans vor Suxamethonium wahrend einer Halothan-N2O-O2-Narkose wird empfohlen.