Methicillin-resistant Staphylococcus aureus (MRSA) infection in lower extremity amputations – a gigantic health-care problem or a false alarm?

Objectives:  Methicillin-resistant Staphylococcus aureus (MRSA) poses not only an increasingly serious health-care problem but also a notoriously gigantic public issue.  We aimed to evaluate whether MRSA infection is a significant negative predictive factor for amputation healing and morbidity, in comparison to non-MRSA infections.Materials and Methods:  A cross-sectional comparative study of all the lower extremity amputations during the 25-month study period to examine the influence of MRSA and non-MRSA infection on clinical outcome.  Results were compared between MRSA- and non-MRSA-infected patients using Fisher’s exact test.Results:  During the two-year period, 171 patients underwent lower limb amputations for acute or chronic limb ischemia.  Sixteen (9.3%) had documented wound infection; including 10 MRSA (62.5%), 2 methicillin-sensitive Staphylococcus aureus (12.5%), 2 Pseudomonas aeruginosa (12.5%), 1 coagulase-negative staphylococci (6.2%) and 1 enterococcus (6.2%).  Patients with MRSA and non-MRSA infections were well matched in demographics, indication & level of amputation, duration of operation, American Society of Anesthetists (ASA) grades, and wound classification (p<0.05).   There was no death or morbidity observed within 30 day post-operative period in all groups within the study.  Over a 28 months median follow-up (range 16-50 months), an overall survival of 93% was observed.  Twelve patients (7%) died including one in MRSA group and 11 in no infection group. Conclusion:  MRSA infection does not adversely affect the clinical outcome in patients undergoing lower extremity amputations.  Regardless of presence of MRSA bacteria; common infection control measures, thorough wound debridement, careful wound surveillance and judicial administration of antibiotics should be routinely applied to all patients

Follicular Lymphoma of Breast: a Case Report from Pakistan

Introduction: Breast Lymphoma (BL) is a rare breast tumor and accounts for less than 1% of all breast malignancies. It is further categorized into primary breast lymphoma and secondary breast lymphoma. This manuscript presents a case report of a patient diagnosed with secondary breast lymphoma. Case description: A 51-year-old female presented in the one-stop breast clinic with six months history of having a static, painless left breast lump. Mass was firm, non-tender, and 2 cm in size. It was not adherent to skin or muscle, and it was present in the upper outer quadrant of the left breast. Mammo-sonography revealed a circumscribed mass of 17 mm in the outer quadrant of the left breast. There were enlarged ipsilateral lymph nodes. Core biopsy suggested atypical lymphoid infiltrates. She underwent wide local excision of breast and axillary nodal mass. The definitive histological diagnosis revealed a follicular lymphoma (FL) grade 2/3, non-Hodgkin's lymphoma. Staging computed tomography scan features were suggestive of cervical lymphadenopathy. Hence, staging workup proved this to be a case of secondary breast lymphoma. Practical implication: The early diagnosis of breast lymphoma is highly relevant. Its diagnosis is challenging due to non-specific clinical presentation and imaging features. Commonly FL is diagnosed on excisional biopsy or after wide local breast mass excision. Primary and secondary lymphomas, though rare, should be considered in the differential diagnosis of breast malignancies

THE ROLE OF INTRAOPERATIVE FROZEN SECTION OF SENTINEL LYMPH NODES IN UPFRONT BREAST CONSERVATION CANCER SURGERY

Objective: Sentinel lymph node biopsy is the standard of care in clinically negative axilla in breast cancer patients for which frozen section (FS) is routinely performed intraoperatively. The objective of this study was to justify the use of FS in terms of number of tests performed and their impact on decision-making and cost saving. Materials and Methods: We retrospectively reviewed our prospectively maintained data from January 2014 to January 2018 for intraoperative FS in upfront breast conservation surgery patients. Results: A total of 357 patients were studied. All were female. Median age was 50 years (24–84). Mean tumour size was 29.11 mm. Numbers of sentinel lymph nodes identified were 1 in 50 (14.2%) patients, 2 in 121 (33.89%) patients and ≥3 in 186 (52%) patients. Number of positive sentinel lymph nodes was 0 in 264 (73.9%) patients, 1 in 62 (17.4%) patients, 2 in 20 (5.6%) patients and ≥3 in 11 (3.08%) patients. Axillary lymph node dissection (ALND) was offered to 30 (8.4%) patients as per the American College of Surgeons Oncology Group Z0011. The results for ALND showed that only 8 (2.3%) out of 30 patients had positive nodes identified in the additional axillary nodes dissected. Sensitivity of FS was 97% and specificity was 98.86%. False-negative rate was 3.22%. Conclusion: Intraoperative FS can be safely omitted in early breast cancer patients undergoing upfront breast conservation cancer surgery due to high sensitivity and specificity leading to low false-negative rates. ALND can be performed as a second operation as warranted only in a minority of patients. Key words: American College of Surgeons Oncology Group Z0011 trial, axillary lymph node dissection, intraoperative frozen section, sentinel lymph node biops

Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017

A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8–38.5) million) in 2000 to 6.0% (55.5 (44.8–67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic

A PICTORIAL REVIEW OF ONCOPLASTIC & RECONSTRUCTIVE BREAST SURGERY

Oncoplastic surgery (OPS) of the breast has revolutionised the surgical practice in the past few years worldwide and has become an integral part of the breast cancer surgical treatment. OPS blends the principals of good local oncological control with plastic surgery techniques for immediate breast reshaping to provide best cosmetic results as well as oncological safety. It helps in extending the boundaries of breast-conservation treatment to include a group of patients who would otherwise require mastectomy to achieve complete excision of the tumour. OPS is a broad concept that can be used for several different combinations of oncological breast-conserving surgery and reconstructive surgery in the form of breast re-shaping/re-modelling. Careful patient selection and pre-operative planning are key components for the success of any OPS operation for breast cancer. Thorough surgical planning is mandatory including clinical assessment and breast measurements with reference to tumour/breast volume ratios. Mastectomy and total breast reconstruction are an option for patients that cannot have breast conservation. In this article, we provide a pictorial review of various oncoplastic and reconstructive breast operations, explaining the indications, essential principles, concepts and techniques of various surgical procedures.Key words: Breast cancer, oncoplastic surgery, breast reconstructio

Breast conservation surgery (BCS) for breast cancer in a resource limited country- Are we upto the challenge!

Objective: To analyse outcomes of breast conservation surgery and to identify the factors that could have affected the outcomes. Method: The retrospectively study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of breast conservation surgery cases done between January 2011 and October 2014 in order to cover up for the 5-year follow-up of the last enrolled patient. Data, obtained through the institutional information and database system, included disease-recurrence, 5-year disease-free survival and overall survival. Data was statistically analysed using SPSS 20. Results: Of the 553 cases, 417(75%) had no loco-regional recurrence or distant metastasis, while 136(25%) had some form of loco-regional, distant or contralateral metastasis at 5-year follow-up. In patients who had recurrence or metastasis, only progesterone receptor status, nodal status and mode of treatment showed significant association (p<0.05). Mortality at 5-year follow-up was 77(14%). Amongst the patients who died, only progesterone receptor status and nodal status had significant association (p<0.05). Five-year overall survival for the cohort was 476(86%), whereas 5-year disease-free survival was 409(74%). Conclusion: Breast conservation surgery was found to have favourable outcomes, while progesterone status, nodal involvement and mode of treatment significantly affected the outcome. Key Words:  Breast cancer, Breast conserving surgery, 5-year disease free survival, 5-year overall survival Continuous..

Clinicopathological Features and Treatment Outcomes of Male Breast Cancer in Pakistani Population: A 10-Year Retrospective Cross-Sectional Study

Background: Male breast cancer (MBC) accounts for 1% of global breast cancer cases. On account of its rarity, very few prospective clinical trials have been carried out on MBC. Pakistan has the highest incidence of breast cancer in Asia, but very limited data are available on MBC. Objectives: The objective is to determine the clinicopathological characteristics and treatment patterns of MBC in Pakistani population. Design: This is a retrospective cross-sectional study. Methods: A retrospective cross-sectional study carried out using the cancer database of Shaukat Khanum Memorial Cancer Hospital & Research Center. Men with a histologically proven breast cancer, stage 0 to III disease and requiring surgical intervention were included. The Kaplan-Meier curve and log-rank test were used for survival analysis. Results: Sixty-eight patients with MBC were included with a median age at diagnosis of 55 years. Most patients were stage II (47.1%). Invasive ductal carcinoma (IDC) was the commonest type (89.7%). Estrogen receptor (ER), progesterone receptor (PR), and Her-2 receptor positivity were 92.6%, 86.8%, and 32.4%, respectively. Mastectomy was performed in 95.6% of the cases. Neoadjuvant and adjuvant chemotherapy was administered in 25 (36.8%) and 26 (38.2%) patients, respectively. Fifty-five (80.9%) patients received adjuvant radiotherapy. Most of the patients (89.7%) received tamoxifen. The 5-year overall and disease-free survival was 88.2% and 80.9%, respectively. Patients receiving neoadjuvant chemotherapy had a better overall and disease-free survival ( P = .025). Conclusions: Male breast cancer occurs at a relatively earlier age in Pakistani population as compared with Western men. Mastectomy is the preferred surgical option for MBC on account of the advanced disease and delayed presentation. Neoadjuvant chemotherapy has a statistically significant effect on overall and disease-free survival, but in spite of these benefits, it remains underutilized

Impact of SSO-ASTRO margin guidelines on re-excision rate in breast-conserving surgery: A single-center experience

Introduction: Breast-conserving surgery (BCS) has been historically linked with a high rate of re-excision. To address this issue, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) developed consensus guidelines in 2014 to standardise practices and improve clinical outcomes for BCS patients. In our tertiary cancer care hospital, we assessed the impact of these guidelines on the re-excision rate following BCS. Materials and Methods: We conducted a retrospective study on breast cancer patients who underwent BCS at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan. The study compared the re-excision rate before the implementation of the SSO-ASTRO consensus guidelines (November 2015 to July 2017) and after the implementation (January 2018 to August 2019). Margins were considered positive if "ink on tumour" was present and negative if "no ink on tumour" was present. Fisher's exact test or chi-square test was used to compare the re-excision rates between the pre- and post-guideline periods. Results: A total of 919 patients were identified, with 533 from the pre-guideline period and 386 from the post-guideline period. Of the 919 patients, 31 with ductal carcinoma in situ (DCIS) were excluded from the re-excision analysis because the guidelines were not implemented on the DCIS. Furthermore, the overall rate of re-excision in our data was 4.3%. The re-excision rate decreased from 71.1% to 28.9% (P ≤0.05) following the adoption of the guidelines. We observed a statistically significant decrease in the re-excision rate after implementing the SSO-ASTRO guidelines. Conclusion: Implementation of the SSO-ASTRO margin guidelines led to a notable decrease in the overall re-excision rate in our data set. These findings suggest that continued adherence to the guidelines may lead to a further reduction in the re-excision rate in the future

Are global influences of cascade dams affecting river water temperature and fish ecology?

Abstract Global warming is affecting animal populations worldwide, through chronic temperature increases and an increase in the frequency of extreme heatwave events. Reservoirs are essential for water security. All watersheds with reservoirs are impacted by their construction. These artificial ecosystems controlled by humans change considerably the natural terrestrial and aquatic ecosystem and systems and their biodiversity. The rapid increase in population growth, urbanization, and industrialization are accompanied by an increase in river discharges, which increases the total amount of pollutants. HMs contamination in aquatic environments, as well as the subsequent absorption of HMs into the food chain by aquatic creatures and people, endangers public health. Multiple uses of reservoirs promote benefits in terms of economic development, income, and employment. HMs in water can be ingested directly by aquatic species like fish and can also be ingested indirectly through the food chain; thus, it is much more important and required to conduct frequent monitoring of the aquatic environment. As a result, this review summarizes knowledge about the effects of cascade dams on river water temperature and increases on the stress physiology of fishes, and adaptation to climate change is also needed to produce more fish without global warming