Search

Objective: The aim of this study was to analyze the wound complication (WC) rate and to determine the risk factors for WC in patients with soft tissue sarcoma treated with preoperative radiotherapy followed by surgical resection., Methods: Using the database of Oxford University Hospital (OUH) we retrospectively studied 126 cases of soft tissue sarcomas treated with preoperative radiotherapy and surgery between 2007 and 2021. WC were defined as minor wound complication (MiWC) not requiring surgical intervention or major wound complication (MaWC) if they received a secondary surgical intervention. Univariate and multiple regression analyses were performed using frequency of WC and MaWC as a dependent variable., Results: The incidence of WC and MaWC was 43.7% (55/126) and 19% (24/126). Age (OR:1.03, 95%CI: 1.00-1.06, p = 0.016), tumor size (OR:1.11, 95%CI:1.01-1.21, p = 0.027) and tumor site namely proximal lower limb vs upper limb (OR:10.87, 95%CI 1.15-103.03, p = 0.038) were risk factors on multivariate analysis. In nested case control analysis, the incidence of MaWC was 43.6% (24/55), the mean recovery time is 143 days in patients with MaWC. Smoking increases the risk for MaWC (OR:8.32, 95%CI:1.36-49.99, p = 0.022). The time interval between surgery and wound complication reduces the risk for MaWC (OR:0.91, 95%CI:0.84-0.99, p = 0.028) in multivariate analysis., Conclusions: Age, tumor site and size are risk factors for WC requiring preoperative radiotherapy. Smoking and the time interval between surgery and wound complication are risk factors for MaWC as compared with MiWC. MaWC rate (19%) are comparable to those in postoperative radiotherapy and surgery alone., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Published by Elsevier Ltd.)

Objective: Improvements to the medical student surgical learning environment are limited by lack of granular data and recall bias on end-of-clerkship evaluations. The purpose of this study was to identify specific areas for intervention using a novel real-time mobile application., Design: An application was designed to obtain real-time feedback from medical students regarding the learning environment on their surgical clerkship. Thematic analysis of student experiences was performed at the conclusion of 4 consecutive 12-week rotation blocks., Setting: Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts., Results: Fifty-four medical students at a single institution were asked to participate during their primary clerkship experience. Students submitted 365 responses over 48 weeks. Multiple themes emerged which were dichotomized into positive and negative emotions centered on specific student priorities. Approximately half of responses were associated with positive emotions (52.9%) and half with negative emotions (47.1%). Student priorities included the desire to feel included in the surgical team (resulting in feeling engaged/ignored), to have a positive relationship with members of the team (perceiving kind/rude interactions), to witness compassionate patient care (observing empathy/disrespect for patients), to have a well-planned surgical rotation (experiencing organization/disorganization within teams), and to feel that student well-being is prioritized (reporting opportunities/disregard for student wellness)., Conclusion: A novel, user-friendly mobile application identified several areas to improve the experience and engagement of students on their surgery clerkship. Allowing clerkship directors and other educational leaders to collect longitudinal data in real time may allow for more targeted, timely improvements to the medical student surgical learning environment., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The Patient-Reported Outcome Measurement Information System (PROMIS) Preference score (PROPr) can be used to assess health state utility (HSU) and estimate quality-adjusted life-years in cost-effectiveness analyses. It is based on item response theory and promises to overcome limitations of existing HSU scores such as ceiling effects. The PROPr contains 7 PROMIS domains: cognitive abilities, depression, fatigue, pain, physical function, sleep disturbance, and ability to participate in social roles and activities. We aimed to compare the PROPr with the 5-level EQ-5D (EQ-5D-5L) in terms of psychometric properties using data from 3 countries., Methods: We collected PROMIS-29 profile and EQ-5D-5L data from 3 general population samples (United Kingdom = 1509, France = 1501, Germany = 1502). Given that cognition is not assessed by the PROMIS-29, it was predicted by the recommended linear regression model. We compared the convergent validity, known-groups construct validity, and ceiling and floor effects of the PROPr and EQ-5D-5L., Results: The mean PROPr (0.48, 0.53, 0.48; P<.01) and EQ-5D-5L scores (0.82, 0.85, 0.83; P<.01) showed significant differences of similar magnitudes (d = 0.34; d = 0.32; d = 0.35; P<.01) across all samples. The differences were invariant to sex, income, occupation, education, and most conditions but not for age. The Pearson correlation coefficients between both scores were r = 0.74, r = 0.69, and r = 0.72. PROPr's ceiling and floor effects both were minor to moderate. The EQ-5D-5L's ceiling (floor) effects were major (negligible)., Conclusions: Both the EQ-5D-5L and the PROPr assessed by the PROMIS-29 show high validity. The PROPr yields considerably lower HSU values than the EQ-5D-5L. Consequences for quality-adjusted life-year measurements should be investigated in future research., (Copyright © 2021. Published by Elsevier Inc.)

Background: Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous disorder of orthostatic intolerance with few proven treatments., Objective: The purpose of this study was to determine the efficacy of an unsupervised at-home training regimen for the treatment of POTS., Methods: We reviewed the medical records including autonomic function testing, symptom scores, and activities of daily living in individuals with POTS who were invited to participate in a 6-month outpatient cardiovascular exercise program., Results: Seventy-seven individuals were invited (invited group), 48 of 77 (62%) participated (treated group) and 43 of 77 (56%) of those completed. Twenty-nine of 77 (38%) did not participate (control group). After 6 months, 11 of 48 (23%) individuals in the treated group met heart rate criteria for POTS compared with 27 of 29 (93%) in the control group (χ 2 test, P < .0001). Supine heart rate (68 ± 8 beats/min vs 77 ± 10 beats/min; P < .001) and standing heart rate (95 ± 11 beats/min vs 115 ± 10 beats/min; P < .001) decreased in the treated group compared with the control group. The frequency of syncope decreased in the treated group (P < .001). An improvement in the EuroQol perceived quality of life scale score was detected in the treated group (61 ± 15 vs 71 ± 12 after 6 months, P < .001) compared with the control group (64 ± 9 vs 66 ± 8 after 6 months; P = .52)., Conclusion: In this study, we report a successful pragmatic clinical trial of an outpatient exercise protocol in a tertiary care referral population that significantly improved cardiovascular function and quality of life in patients with POTS., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Evaluation of disorders of the autonomic nervous system is both an art and a science, calling upon the physician's most astute clinical skills as well as knowledge of autonomic neurology and physiology. Over the last three decades, the development of noninvasive clinical tests that assess the function of autonomic nerves, the validation and standardization of these tests, and the growth of a large body of literature characterizing test results in patients with autonomic disorders have equipped clinical practice further with a valuable set of objective tools to assist diagnosis and prognosis. This review, based on current evidence, outlines an international expert consensus set of recommendations to guide clinical electrodiagnostic autonomic testing. Grading and localization of autonomic deficits incorporates scores from sympathetic cardiovascular adrenergic, parasympathetic cardiovagal, and sudomotor testing, as no single test alone is sufficient to diagnose the degree or distribution of autonomic failure. The composite autonomic severity score (CASS) is a useful score of autonomic failure that is normalized for age and gender. Valid indications for autonomic testing include generalized autonomic failure, regional or selective system syndromes of autonomic impairment, peripheral autonomic neuropathy and ganglionopathy, small fiber neuropathy, orthostatic hypotension, orthostatic intolerance, syncope, neurodegenerative disorders, autonomic hyperactivity, and anhidrosis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Delayed orthostatic hypotension is a fall in blood pressure beyond 3 min of standing or upright tilt table testing. The prevalence, clinical features and pathophysiology are reviewed. To date, there is little data to support a standardized or recommended treatment. However, the 10-year mortality rates of individuals with delayed orthostatic hypotension are approximately 50%. Despite the fact that delayed orthostatic hypotension carries the same symptoms, risks and high mortality rate as classical orthostatic hypotension, but is under-recognized. The frequency with which delayed orthostatic hypotension develops into classical orthostatic hypotension, the high associated mortality rates and risk of development of the neurodegenerative disorders classified as alpha-synucleinopathies underscores the need for further study of this condition., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Treatment induced neuropathy of diabetes (TIND) is an iatrogenic painful sensory and autonomic neuropathy. Although the prevalence is not known, it is seen in up to 10% of tertiary cases referred for evaluation of diabetic neuropathy., Evidence: TIND is associated with a decrease in the glycosylated hemoglobin A1C in individuals with longstanding hyperglycemia. TIND is more common in individuals with type 1 diabetes, but can occur in anyone with diabetes through the use of insulin, oral hypoglycemic medications or diet control. There is an acute or subacute onset of neuropathy that is linked to the change in glucose control. Although the primary clinical manifestation is neuropathic pain there is a concurrent development of autonomic dysfunction, retinopathy and nephropathy., Conclusion: TIND is more common than previously suspected. The number of cases reported over the past 10 years is much greater than historical literature predicted. Increased attention to target glucose control as a physician metric could suggest a possible explanation for the increased in TIND cases reported in recent years. At present, supportive care is the only recommended treatment. Future research is necessary to define the underlying mechanism, prevent development and to guide treatment recommendations., Competing Interests: Declaration of competing interest Christopher H. Gibbons has received research funding from Grifols, and has served as a scientific advisor for Lundbeck, Biohaven, and Cutaneous NeuroDiagnostics., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Human papillomavirus (HPV) vaccination has been anecdotally connected to development of dysautonomia, chronic fatigue, complex regional pain syndrome and postural tachycardia syndrome., Objectives: To critically evaluate a potential connection between HPV vaccination and above noted conditions., Methods: We reviewed the literature containing the biology of the virus, pathophysiology of infection, epidemiology of associated cancers, indications of HPV vaccination, safety surveillance data and published reports linking HPV vaccination to autonomic disorders., Results: At this time the American Autonomic Society finds that there are no data to support a causal relationship between HPV vaccination and CRPS, chronic fatigue, POTS or other forms of dysautonomia., Conclusions: Certain conditions are prevalent in the same patient populations that are vaccinated with the HPV vaccine (peri-pubertal males and females). This association, however, is insufficient proof of causality., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Parkinson disease (PD) is a progressive neurodegenerative disorder characterized by motor and non-motor symptoms and signs. Many reports suggest that diminished heart rate variability occurs early, even prior to the cardinal signs of PD. In a longitudinal study of PD, we evaluated whether heart rate variability (HRV) obtained using a 10-second ECG tracing, and the electrocardiographic QT-interval would be associated with PD severity and progression. Subjects were derived from a longitudinal study of 1741 individuals with early, stable PD. The severity of PD was measured using the global statistical test (GST). In a subset, the heart rate corrected QT-interval (QTcB) was calculated for each electrocardiogram (ECG). The HRV was measured for each ECG and then transformed to fit a normal distribution. The baseline analysis included 653 subjects, with 256 completing the 5-year follow up study. There was an association (P<0.05) between QTcB and PD severity in individuals that were taking QT-interval affecting drugs. A longer QT-interval at baseline was associated with more advanced PD at 5years (P<0.05), and greater disease progression over 5years (P<0.05). There was an association between diminished HRV and an orthostatic decrease in standing blood pressure at baseline in individuals with PD (P<0.05). HRV was not associated with PD severity or progression. In conclusion, we were able to detect measurable associations between the QTcB interval and PD severity, PD severity 5years later, and the change in disease over time. However, routine ECG tracings appear inadequate for the evaluation of autonomic function in PD., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Complex symptomatic ganglion cysts arising from the proximal tibio-fibular joint (PTJ) are not an uncommon presentation in specialist knee clinics and can be managed by aspiration or excision. There is, however, a high rate of recurrence and often there is progressive involvement of the common peroneal nerve (CPN) and its branches, and permanent nerve damage may result., Methods: This study is a review of the outcome of recalcitrant and recurrent cyst disease with CPN involvement treated by proximal fibulectomy. Nine patients with clinical and radiological diagnosis of a ganglion cyst involving the proximal tibio-fibular joint were treated by proximal fibulectomy. Average age was 47.2years (19 to 75). Patients were followed up clinically and radiologically. Medical notes were reviewed to assess clinical/pathological characteristics, surgical outcome, recurrence rate and the symptoms of instability and nerve function., Results: None of the patients were lost to follow-up. After an average follow-up of 83months (15 to 150), none of the patients had clinical or radiological evidence of recurrence. All patients were pain-free and had a complete resolution of nerve symptoms and no evidence of CPN injury. None of the patients complained of localised pain or knee instability and there were no wound healing problems., Conclusions: MRI now confirms TFJ-ganglion cysts to be more common than previously recognised. Where there is refractory disease with progressive nerve symptoms and evidence of nerve sheath involvement, joint excision by proximal fibulectomy gives a satisfactory functional result in controlling disease and preventing further nerve damage., Level of Evidence: IV., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Syncope is a common presenting complaint in both the inpatient and outpatient settings. The main goals in the clinical evaluation of syncope are to identify an underlying etiology, to stratify risk and to guide plans for therapeutic intervention. Testing begins with an initial electrocardiogram to screen for any cardiac rhythm abnormalities. Heart rate variability to paced breathing provides a standard measure of cardiac parasympathetic function and offers clues towards an autonomic cause of syncope. A Valsalva maneuver is used to evaluate for parasympathetic dysfunction through the Valsalva ratio. In addition, sympathetic adrenergic function is assessed through evaluation of blood pressure response during the Valsalva maneuver. Abnormalities to the Valsalva maneuver can suggest clues towards an autonomic cause of syncope. Head-up tilt table testing is an important part of the autonomic evaluation of patients with syncope, and can be diagnostic for many disorders that result in syncope including orthostatic hypotension, neurally mediated syncope, postural tachycardia syndrome or delayed orthostatic hypotension. Autonomic function testing provides a safe and controlled environment for evaluation of patients, and plays a pivotal role in the diagnosis of syncope, particularly in challenging cases. While the initial clinical evaluation of syncope involves a detailed history and physical examination; in situations where the diagnosis is unknown, the addition of autonomic testing is complementary and can lead to identification of autonomic causes of syncope., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Small fiber neuropathy is common in a number of systemic diseases and is often challenging to diagnose. Laser Doppler imaging (LDI) is a test of small fiber neurovascular function that can quantify the integrity of the vasomotor C-fiber mediated axon-reflex, but no standardized method of analysis exists. We developed a novel LDI analysis technique and tested it in a human model of small fiber neuropathy. Eighteen healthy subjects (age 24 ± 3 years) underwent LDI testing to assess the axon-mediated flare area in response to 10% acetylcholine iontophoresis. LDI measurements were taken before and longitudinally after a 48-hour application of 0.1% capsaicin (to cause a transient small fiber neuropathy) on the skin of the thigh; placebo cream was placed on the contralateral thigh as a control. We compared our new LDI image analysis technique to two previously published methods. The new LDI analysis technique was the only method to show a consistent difference in axon-reflex area between capsaicin treated and placebo treated skin on all testing days (p<0.05) with maximum attenuation of the flare area immediately post-application (438 ± 298 mm(2) vs. 824 ± 375 mm(2), p<0.05). In conclusion, this study demonstrates that our novel flare area method for LDI analysis can detect neurovascular dysfunction in a model of small fiber neuropathy, is an improvement over existing methods, and may supplement clinical assessment of small fiber neuropathy., (© 2013.)

Purpose: Liposarcoma is one of the most common soft tissue sarcomas in adults. It is often low-grade and can occasionally involve neurovascular structures. We present the functional and oncological outcome resulting from planned marginal excision of a series of forearm low-grade liposarcomas with nerve involvement., Methods: The Oxford tumor registry was used to identify cases of histologically proven, well-differentiated liposarcoma of the forearm, with nerve involvement, treated surgically between 1997 and 2006. Nerve involvement was identified clinically with symptoms or signs of nerve compression, or by images showing direct contact of the tumor with a nerve on magnetic resonance imaging. This was then further defined at the time of surgery as tumor abutting (capsular involvement) or encasing a peripheral nerve. Demographic and clinical data were collected and oncological outcome was assessed by noting local and distant recurrence during follow-up. Postoperative functional outcome was assessed using the Toronto Extremity Salvage Scores., Results: Eight cases were identified, 6 with preoperative neurological symptoms. The total group comprised 6 men and 2 women with a mean age of 61 (range, 30-71) years. At surgery, all had their tumors successfully excised, with preservation of the involved nerves. In those with preoperative neurological symptoms, complete recovery occurred by 18 months after surgery. The average follow-up was 5 years (range, 3-9 y). There were no cases of either local or distant recurrence of disease, with a mean Toronto Extremity Salvage Score of 99%., Conclusions: Planned marginal excision of a well-differentiated liposarcoma, arising in the forearm and involving nerve, can result in excellent functional and oncological outcome., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate treatment options for patients with chronic mesenteric ischemia in the United Kingdom., Methods: Early and late outcomes of patients with chronic mesenteric ischemia who underwent bypass or percutaneous angioplasty (PTA) in 12 centers were compared on an intention-to-treat basis., Results: A total of 76 patients underwent 101 procedures (PTA 49; bypass 52). Of these, 36 had a PTA first, and 40 had a bypass first. Among those who underwent a primary PTA, nine required a subsequent bypass. Three patients who underwent a primary bypass also required a graft PTA, and three patients required further surgery. Patients who underwent a primary PTA were found to be significantly older and tended to have greater comorbidities. As compared with PTA, primary bypasses were more frequently undertaken in an urgent manner or as an emergency (43% vs. 8%). Perioperative morbidity for bypass was significantly greater than that for PTA (32% vs. 6%). Overall, 30-day mortality for bypass tended to be greater than that for PTA (13% vs. 4%; n.s.), but was similar for patients treated electively in the two groups (4% vs. 3%). Cumulative 1- and 5-year survival (bypass: 85%, 63%; PTA: 67%, 31%) and primary patency (bypass: 81%, 69%; PTA: 54%, 32%) rates were found to be significantly better after primary bypass., Conclusions: Treatment preferences were center-dependent. Symptomatic recurrence was found to be less frequent and patency rates were better after a primary bypass. PTA may be a viable alternative in patients with significant comorbidities., (Copyright © 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Autoimmune autonomic ganglionopathy is a disorder of isolated autonomic failure associated with antibodies to the nicotinic acetylcholine receptor of the autonomic ganglia resulting in severe orthostatic intolerance, syncope, constipation, gastroparesis, urinary retention, dry mouth, dry eyes, blurred vision and anhidrosis. We report the autonomic test results, antibody titers and clinical findings in 8 patients with antibodies to the nicotinic acetylcholine receptor of the autonomic ganglia. There was a sigmoidal relation between the antibody titers and the fall in systolic blood pressure (r(2)=0.84). The threshold occurred with antibody titers of approximately 1 nmol/l. Over the linear portion of the sigmoid curve, with antibody titers in the 1-3 nmol/l range, increasing antibody titers resulted in more severe orthostatic hypotension (r=0.94, P<0.001). The saturation point of the sigmoidal relation occurred at approximately 3 nmol/l with drops in systolic blood pressure of approximately 100 mmHg during upright tilt. The antibody titers correlated inversely with the Valsalva ratio (r=-0.87, P<0.001), the 30:15 ratio (r=-0.84, P<0.001) and the expiratory to inspiratory ratio (r=-0.67, P<0.01). Patients with orthostatic intolerance, anhidrosis, constipation, urinary dysfunction, sicca syndrome and pupillary dysfunction had higher antibody titers than subjects that did not (P<0.01 in all cases). Autoimmune autonomic ganglionopathy is a clinically heterogeneous disease with variable presentation, particularly in subjects with lower antibody titers. Our data suggest that patients with higher antibody titers have wide spread dysautonomia while those with lower antibody levels may present with, or evolve into, more focal or restricted presentations.