A qualitative study of the development of a multidisciplinary case conference review methodology to reduce involved margins in pelvic exenteration surgery for recurrent rectal cancer

Aim Pelvic exenteration surgery remains the only curative option for recurrent rectal cancer. Microscopically involved surgical margins (R1) are associated with a higher risk of local recurrence and decreased survival. Our study aimed to develop a post hoc multidisciplinary case conference review and investigate its potential for identifying areas for improvement. Method Results Patients who underwent pelvic exenteration surgery for recurrent rectal cancer with R1 resections at a tertiary referral centre between April 2014 and January 2016 were retrospectively reviewed from a prospectively maintained database. Patients with non-rectal cancers or who underwent palliative surgery were excluded. Cases, imaging and histopathology were evaluated by a dedicated panel including colorectal surgeons, an abdominal radiologist and a gastrointestinal pathologist. R1 resections were reported in 32 of 110 pelvic exenterations. Patients with other tumours were excluded and one patient had a palliative resection. Nine male patients with 11 exenterations were included with a median age of 56 years. All patients had positive soft tissue margins, and one patient also had an involved bony margin. Failures were due to (interdisciplinary) communication problems, specific management of tumour biology (multifocality, spiculated tumours), which can lead to radiological undercalling, and inadequate surgical technical planning. In hindsight, surgery would have been withheld from one patient. Conclusion A retrospective multidisciplinary case evaluation of pelvic exenteration patients with involved surgical margins led to a list of recommendations which included the need to plan for wider surgical soft tissue resections and improvement in interdisciplinary communication. Lessons learned may increase clear margin rates in future resections

Breaking bony bridges by physeal distraction

Physeal distraction for breaking bony bridges and the late treatment of long bone deformities in children near maturity, has been used in our Department since June, 1983. In all cases (4 bones in 3 patients) a deformity was present at the extremity of a long bone due to a bony bridge caused by a previous injury to the growth cartilage. The results were excellent and in our opinion there are advantages over other methods. The operation itself is not extensive and very little damage is done. There is no need for internal fixation or bone grafts. It is possible to obtain lengthening and to adjust the angular correction during treatment. We conclude that it is possible to correct angular deformities and bone shortening due to bony bridges by physeal distraction without the need for resection of the bony bridge. At present we recommend this method in children near skeletal maturity, especially in those cases with bone shortening

Heterotopic bone formation in abdominal scars

Heterotopic bone formation in abdominal scars has not often been described. Two cases are presented and the literature is discussed.S. Afr. Med. J., 48, 329 (1974)

Facial developmental vascular anomalies

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72907/1/j.1754-4505.1995.tb00491.x.pd

Osteochondroma of the proximal humerus with frictional bursitis and secondary synovial osteochondromatosis

We report a case of multiple hereditary exostosis in a 33-year old patient with clinical symptoms of pain and impression of a growing mass of the left shoulder alerting potential risk of malignant transformation of an osteochondroma. Imaging studies illustrated perilesional bursitis surrounding an osteochondroma of the proximal humerus. Malignant transformation was excluded with MRI. Fragments of the osteochondroma were dislocated in the inflammatory synovial bursa illustrating a case of secondary synovial osteochondromatosis

Detailed Simulation of the Cochlea: Recent Progress Using Large Shared Memory Parallel Computers

We have developed and are refining a detailed three-dimensional computational model of the human cochlea. The model uses the immersed boundary method to calculate the fluid-structure interactions produced in response to incoming sound waves. An accurate cochlear geometry obtained from physical measurements is incorporated. The model includes a detailed and realistic description of the various elastic structures present. Initially, a macro-mechanical computational model was developed for execution on a CRAY T90 at the San Diego Supercomputing Center. This code was ported to the latest generation of shared memory high performance servers from Hewlett Packard. Using compiler generated threads and OpenMP directives, we have achieved a high degree of parallelism in the executable, which has made possible to run several large scale numerical simulation experiments to study the interesting features of the cochlear system. In this paper, we outline the methods, algorithms and software tools that were used to implement and fine tune the code, and discuss some of the simulation results

Histologic Evaluation of the Efficacy of rhBMP-2 Compared With Autograft Bone in Sheep Spinal Anterior Interbody Fusion

Study Design. The sheep anterior lumbar spinal fusion model was used to study the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2)–collagen composite in comparison with autograft to enhance spinal interbody fusion. Comparisons were drawn from temporal radiographic and end-point biomechanical and histologic data. Objective. To analyze histologically the ability of rhBMP-2 to achieve complete arthrodesis between vertebral bodies. Summary of Background Data. Studies using rhBMP for enhancement of anterior interbody fusion have used numerous endpoints. However, systematic histologic evaluation of the fusion has not been conducted. Methods. Twelve sheep underwent single-level anterior lumbar interbody fusion performed with a cylindrical fenestrated titanium interbody fusion device (INTER FIX, Medtronic Sofamor Danek, Inc., Memphis, TN). The device was filled either with rhBMP-2–collagen (n = 6) or autogenous iliac crest bone graft (n = 6). Radiologic evaluation was carried out at 2-month intervals, and all sheep were killed 6 months after surgery. Nondestructive biomechanical testing for stiffness to flexion, extension, and lateral bending moments, un-decalcified histology, and qualitative and quantitative histologic evaluation were performed. Results. Radiographs revealed a bony bridge anterior to the cage in five of six rhBMP-2-treated animals, whereas it was present only in one of five in the autogenous bone graft group. Segments treated with rhBMP-2 were 20% stiffer in flexion than autograft-treated segments at 6 months. Six of six in the rhBMP-2 group and two of six in the autograft group showed complete fusion. There was a significantly higher rate of bony continuity observed at the fenestrations of the rhBMP-2 group. Three times more number of cage fenestrations in the rhBMP-2 group demonstrated “all-bone” when compared with the autograft group (P \u3c 0.001). Further, the scar tissue in and around the autograft-treated cages was 16-fold more (P \u3c 0.01) than that seen for rhBMP-2-treated cages. Conclusions. The study demonstrates that rhBMP-2 can lead to earlier radiologic fusion and a more consistent increased stiffness of the segments when compared with autograft in sheep anterior lumbar interbody fusion. Furthermore, a three times higher histologic fusion rate is attainable with significantly reduced fibrous tissue around the implant when rhBMP-2 is used

Empirical equations for estimating maximum length from length at first maturity

10.1111/j.1439-0426.2009.01215.

When the back office moved to the front burner: settlement fails in the treasury market after 9/11

Settlement fails, which occur when securities are not delivered and paid for on the date scheduled by the buyer and seller, can expose market participants to the risk of loss due to counterparty insolvency. This article examines the institutional and economic setting of the fails problem that affected the Treasury market following September 11 and describes how the Federal Reserve and the U.S. Treasury responded. The authors explain that fails rose initially because of the physical destruction of trade records and communication facilities. Fails remained high because a relatively low federal funds rate and investor reluctance to lend securities kept the cost of borrowing securities to avert or remedy a fail comparable to the cost of continuing to fail. The fails problem was ultimately resolved when the Treasury increased the outstanding supply of the on-the-run ten-year note through an unprecedented "snap" reopening. The article also suggests other ways to alleviate chronic fails, such as the introduction of a securities lending facility run by the Treasury and the institution of a penalty fee for fails.Treasury bills ; Government securities ; War - Economic aspects