Functional recovery after bilateral extended autologous latissimus dorsi breast reconstruction : a prospective observational study

Background: The impact of unilateral extended autologous latissimus dorsi (EALD) flap harvest and axillary surgery on shoulder function has been well described, but the impact of bilateral EALD flap harvest has not been clearly defined nor is it clear whether reconstructions should be synchronous or staged. Methods: In this prospective observational study, patients undergoing bilateral EALD breast reconstruction (February 2003–December 2009) completed the disability, arm, shoulder and hand (DASH) questionnaire preoperatively and at five post-operative timepoints. Intensive shoulder physiotherapy was offered to those whose DASH score was >30 at 6 weeks or >20 at 12 weeks post-operatively. Results: Sixty patients underwent bilateral EALD flap breast reconstruction (51 synchronous, 9 metachronous). Patients with pre-existing shoulder pathology (n = 1) and those who failed to return any post-operative DASH questionnaire (n = 10) were excluded from initial DASH analysis. However, these eleven patients were included in a separate analysis as an intention-to-treat analysis. Statistical analysis was performed using non-parametric, Friedman test and multiple comparison model. Forty-nine patients’ DASH scores were analysed. DASH score initially increased after surgery and then returned to functionally normal within 3–6 months (median DASH: preoperative = 1 vs 6 weeks post-operation = 26, p = <0.001; vs 3 months = 19, p = <0.001; vs 6 months = 13, p = <0.001); thereafter, the scores remained less than 12 (p = <0.001). Median DASH score after synchronous reconstruction was not higher than that after metachronous reconstructions, although the metachronous sample size was small. Conclusion: With appropriate patient selection and intensive physiotherapy, bilateral EALD breast reconstruction does not appear to cause significant long-term impairment of shoulder function, and patients can now be counselled about the likely timecourse of shoulder recovery. There seems no reason to stage bilateral reconstruction to reduce shoulder morbidity

Academic Lives

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/43551/1/11133_2004_Article_417286.pd

Complexity and Community Context: Learning from the Evaluation Design of a National Community Empowerment Programme

Community empowerment interventions, which aim to build greater individual and community control over health, are shaped by the community systems in which they are implemented. Drawing on complex systems thinking in public health research, this paper discusses the evaluation approach used for a UK community empowerment programme focused on disadvantaged neighbourhoods. It explores design choices and the tension between the overall enquiry questions, which were based on a programme theory of change, and the varied dynamic socio-cultural contexts in intervention communities. The paper concludes that the complexity of community systems needs to be accounted for through in-depth case studies that incorporate community perspectives

Unusual psychiatric syndromes part 1

This is a series of 49 unusual psychiatric syndromes produced by students at Liverpool and Lancaster schools of medicine, coordinated and helped by Dr Jane Wilcock a community clinical tutor for Liverpool and Mr Nick Mullin as CPN and medical educator at Lancaste

Communication issues in requirements elicitation: A content analysis of stakeholder experiences

The gathering of stakeholder requirements comprises an early, but continuous and highly critical stage in system development. This phase in development is subject to a large degree of error, influenced by key factors rooted in communication problems. This pilot study builds upon an existing theory-based categorisation of these problems through presentation of a four-dimensional framework on communication. Its structure is validated through a content analysis of interview data, from which themes emerge, that can be assigned to the dimensional categories, highlighting any problematic areas. The paper concludes with a discussion on the utilisation of the framework for requirements elicitation exercises

The Iowa Homemaker vol.17, no.6

Genuinely “Big” Business by Grace McIlrath Ellis, page 1 Every Gram of Jam by Ruth Kunerth, page 2 Confessions of Shoe Salesman and Florist by Paul Montgomery and Paul Buehler, page 3 What Would You Do If by Harriet Beyer, page 4 Food Shots Are Not So Candid by Ruth Dahlberg, page 5 Yumph Invades the Formal Field by Lois Swenson, page 6 Just Skin Deep by Donna Button, page 7 On Your Own Toes by Jane Helser, page 8 Resolve to Charm by Frances Dickerson, page 9 What’s New in Home Economics edited by Marjorie Pettinger, page 10 No Peacock Tongues by Daisy Mary Kimberley, page 12 She Knows Her Turkeys by Mary Ellen Lynch, page 13 On the Airwaves by Grace Strohmeier, page 13 Science in the Kitchen, page 14 Radiation Ratings by Kay Dodds, page 15 The Gavel Strikes by Donna Button, page 16 What Goal Posts? By Jean Metcalf and Rachel Roewe, page 17 Alums Make News by Faithe Danielson, page 18 Up With the Dawn by the editor, page 2

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2):a multicentre observational cohort study

Background: Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. Methods: Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. Findings: Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0–20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1–5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27–10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29–0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53–0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60–0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07–0·43, p=0·0065; and 0·33, 0·14–0·51, p=0·00059, respectively). Interpretation: In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. Funding: The Stroke Association and the British Heart Foundation