Kenneth M. Joyce

An Assessment of Histological Margins and Recurrence of Melanoma In Situ

Background: Melanoma in situ (MIS) accounts for up to 27% of all melanomas. MIS has no metastatic potential and the aim should be to excise the lesion completely with a clear histological margin, although margin clearance remains undefined. We aimed to assess the relation of histological excision margins of MIS to recurrence and progression to invasive disease. Methods: We analyzed all patients with MIS excised by wide local excision or staged excision in our institution over a 5-year period from December 2008 to January 2014 using a prospectively maintained database. Clinicopathologic details included patient demographics, anatomical site of lesion, melanoma subtype, histological excision margin, and recurrence. Results: A total of 410 patients had MIS excised during this time, the majority of which were lentigo maligna subtype (79%). The average histological excision margin was 3.7 mm. The rate of recurrence was 2.2% (9/410), with a median follow-up of 23 months. Lentigo maligna had a similar rate of recurrence to non-lentigo MIS (2.3% vs 1.2%) (P = 0.69). The mean excision margin of those that recurred was 1.9 mm compared with an average of 3.8 mm in those that did not. The rate of recurrence of MIS with histological excision margin ⩽3.00 mm was 3.8% compared with 0.5% in those with a histological margin >3.00 mm (P = 0.03). One case of MIS recurred as invasive disease. Conclusion: At institutions using wide local excision or staged excision for MIS, a histological margin of >3.0 mm is required to achieve a low recurrence rate.

An Evaluation of the Use of Deliberate Practice and Simulation to Train Interns in Requesting Blood Products

Introduction Technical or practical skills deficits upon graduation from medical school are prevalent and contribute to increasing medical error. The current study sought to evaluate the efficacy of a simulation- and deliberate practice-based learning program for requesting blood products, delivered to newly graduated interns. Methods The requesting of blood products by a group of 27 “trained” interns was prospectively compared with that of a group of 30 “untrained” interns throughout the first 13 weeks of internship at an Irish teaching hospital. Results Our analysis showed that the training intervention reduced the risk of a rejected sample by 65% as compared with interns who did not receive the training. Moreover, the risk of a rejected sample for trained interns was 45% lower than for much more experienced doctors. The untrained interns required more than 2 months of clinical experience to reach an error rate that was not significantly different from that of the trained interns. Conclusions These findings indicate that skills acquired through deliberate practice generalized to the clinical setting led to a significant reduction in blood product prescribing errors.

Levels of Evidence in the Plastic Surgery Literature: A Citation Analysis of the Top 50 'Classic' Papers

Background The plastic surgery literature is vast, consisting of a plethora of diverse articles written by a myriad of illustrious authors. Despite this considerable archive of published material, it remains nebulous as to which precise papers have had the greatest impact on our specialty. The aim of this study was to identify the most cited papers in the plastic surgery literature and perform a citation analysis paying particular attention to the evidence levels of the clinical studies. Methods We identified the 50 most cited papers published in the 20 highest impact plastic surgery journals through the Web of Science. The articles were ranked in order of number of citations acquired and level of evidence assessed. Results The top 50 cited papers were published in six different journals between the years 1957 and 2007. Forty-two of the papers in the top 50 were considered as level IV or V evidence. No level I or II evidence was present in the top 50 list. The average level of evidence of the top 50 papers was 4.28. Conclusions In the plastic surgery literature, no positive correlation exists between a high number of citations and a high level of evidence. Anatomical reconstructive challenges tend to be the main focus of plastic surgery rather than pathologic diseases and consequently, papers with lower levels of evidence are relatively more valuable in plastic surgery than many other specialties.

Plastic surgery and the breast: a citation analysis of the literature.

Background: A large proportion of the plastic surgery literature is dedicated to the breast. It is one of the most common topics in our specialty, yet it is unclear which articles have been the most influential. The purpose of this study was to identify the top 100 most-cited articles on breast in the plastic surgery literature and examine the characteristics of each individual article. Methods: Using an electronic database through the Web of Science, we were able to determine the 6 journals that contributed to the 100 most-cited articles on breast in the plastic surgery literature. Results: Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. Plastic and Reconstructive Surgery contributed the most articles to the top 100 with 81 articles including the most-cited article which has been referenced 673 times to date. The United States produced 73% of the top 100 articles, and the most prolific institution was the University of Texas M. D. Anderson Cancer Center with 15 articles. Conclusions: This study has identified the most influential articles on breast in the plastic surgery literature over the past 68 years and highlighted many important scientific breakthroughs and landmarks that have occurred during this time.

Use of a barbed suture tie-over technique for skin graft dressings: a case series.

Background A tie-over dressing is the accepted method to secure skin grafts in order to prevent haematoma or seroma formation. We describe the novel application of a barbed suture tie-over for skin graft dressing. The barbs act as anchors in the skin so constant tensioning of the suture is not required. Methods From January 2014 to August 2014 we used the technique in 30 patients with skin defects requiring split-thickness or full-thickness grafts. Patient demographics, clinicopathological details and graft outcome were collected prospectively. Results The majority of cases were carried out for split-thickness skin grafts (n=19) used on the lower limb (n=20). The results of this novel technique were excellent with complete (100%) graft take in all patients. Conclusions Our results demonstrate the clinical application of a barbed device for securing skin grafts with excellent results. We find the technique quick to perform and the barbed device easy to handle, which can be applied without the need for an assistant.

100 citation classics in the melanoma literature: a bibliometric analysis.

BACKGROUND Modern immunologic therapies targeting genetic mutations have created a renewed interest in melanoma research, and this is reflected in the increasing number of published works. OBJECTIVE The purpose of this study was to identify the top 100 most cited articles in melanoma and to examine the characteristics of each individual article. METHODS Using an electronic database through the Web of Science, we were able to determine the 22 journals that contributed to the 100 most cited articles in melanoma. RESULTS Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. The New England Journal of Medicine contributed the most articles to the top 100 with 20 articles, whereas the most cited article originated from the Archives of Surgery and has been cited 2,384 times. The United States produced 74% of the top 100 articles, and the most prolific institution was the National Cancer Institute in Maryland with 18 articles. CONCLUSION This study has identified the most significant contributions to melanoma research over the past 63 years and identifies many important scientific breakthroughs and landmarks that have occurred during this time.

Fat Grafting: A Citation Analysis of the Seminal Articles

Background: There has been substantial rise in the volume of published works on fat transfer in the medical literature in the past 25 years, and this is indicative of its growing popularity. However, many unanswered questions remain, and there is no consensus as to the optimum technique. Consequently, the scientific and clinical research on fat grafting continues to increase rapidly. The purpose of our study was to perform a bibliometric analysis of the most-cited articles in fat transfer. Methods: Through the Web of Science, all articles relating to fat grafting were identified in the plastic and reconstructive literature. The 100 most-cited articles were identified and analyzed individually. Results: Total citations ranged from 35 to 363 and the most-cited paper by Sidney Coleman was published in Plastic and Reconstructive Surgery. The United States produced 46% of the most-cited papers, and the University of California was the most prolific institution. Twenty-one articles focused on lipofilling to the face while 14 articles looked at fat grafting to the breast. Conclusions: The scientific relevance of a published work is reflected in the number of citations from peers that it receives. Therefore, the 100 most-cited papers in fat grafting have been the most influential articles on this field, and they are likely to be the ones that are remembered most.

Early post-operative removal of urethral catheter in patients undergoing colorectal surgery with epidural analgesia – A prospective pilot clinical study

BACKGROUND Urethral catheter (UC) removal is often delayed following colorectal resection due to the perceived increased risk of post-operative urinary retention (POUR) in patients with post-operative epidural analgesia (POEA). We aimed to determine if UC removal at 48 h, irrespective of ongoing POEA use, altered the risk of POUR and other morbidities associated with urethral catheterisation and immobility. METHODS We performed a prospective randomised controlled pilot clinical study. Eligible patients were randomised to an experimental arm, SG1 (UC removal 48 h post-operatively), or a control arm, SG2 (UC removed following cessation of POEA). Rates of POUR, urinary tract infection (UTI), pulmonary complications and surgical site infection (SSI) were recorded. Forty-four patients were recruited (SG1: n = 22; SG2: n = 22). RESULTS No females developed POUR, while it occurred in three males (20%) in SG1 and 2 males (22.2%) in SG2. All patients who developed POUR had undergone rectal resection. Males in SG1 were not at significantly increased risk of POUR compared to those in SG2 (R.R 0.875, p = 1). No patient developed UTI post-operatively. The rate of pulmonary complications (SG1: n = 2; SG2: n = 3, p = 0.229) and SSI (SG1: n = 5; SG2: n = 2, p = 0.146) were similar between both study arms. DISCUSSION Males undergoing rectal surgery appear to be at increased risk of developing POUR in the presence of epidural analgesia, independent of the timing of UC removal. CONCLUSIONS All female patients undergoing colorectal resection and male patients undergoing colonic resection may have their urethral catheter removed at 48 h irrespective of use of POEA. CLINICAL TRIALS REGISTRATION NUMBER NCT01508767 (http://www.clinicaltrials.gov).

Proximal Interphalangeal Joint Dislocations and Treatment: An Evolutionary Process

Background Proximal interphalangeal joint (PIPJ) dislocations represent a significant proportion of hand clinic visits and typically require frequent follow-ups for clinical assessment, orthotic adjustments, and physiotherapy. There are a large number of treatment options available for PIPJ dislocations, yet no prospective or controlled studies have been carried out, largely due to the diversity of the various types of injuries. Methods We retrospectively reviewed all the PIPJ dislocations in our institution over a five-year period and directly compared the different splinting techniques that we have used over this time frame. Results There were a total of 77 dislocations of the PIPJ (57 men and 20 women) that were included in our study. We found that our management has shifted gradually from complete immobilisation to controlled early mobilisation with figure-of-eight splints. Following treatment, the range of motion of the PIPJ in the figure-of-eight group was significantly greater than that in the other three methods (P<0.05) used. There were significantly fewer hospital visits in the figure-of-eight splint group than in the other treatment groups. Conclusions The treatment of PIPJ dislocations has undergone a significant evolution in our experience. Early controlled mobilisation has become increasingly important, and therefore, splints have had to be adapted to allow for this. The figure-of-eight splint has yielded excellent results in our experience. It should be considered for all PIPJ dislocations, but careful patient selection is required to achieve optimum results.

Symptomatic Breast Cancer Diagnosis and Multimodal Management in Women Aged 40 to 50 Years; Consequences of Current Mammographic Screening Programs

INTRODUCTION Consensus exists that screening mammography is appropriate for women aged 50 to 69 years. However, the effectiveness of such screening for women aged 40 to 50 years is still questioned. The aim of our study was to analyze breast cancer management in the 40- to 50-year age group. We also wished to determine the proportion of patients with a significant family history and whether this was associated with more advanced disease. PATIENTS AND METHODS All female patients with primary breast cancer diagnosed between 40 and 50 years of age were included over a 4-year period. The database of the National Breast Cancer Research Institute was interrogated, and a chart and radiology review carried out to obtain relevant details of clinical presentation, family history, radiological findings, and treatments undertaken. RESULTS Three hundred thirty-four patients were diagnosed in this cohort during the study period. Twenty-two percent of those diagnosed had a family history of breast cancer with 1.8% having a genetically confirmed predisposition to breast cancer. A significant proportion of patients presented with advanced disease, with 50% of patients having nodal involvement and 3% who presented with distant metastases. The overall rate of mastectomy was 47%, with minimal variation between the surgeons who performed the surgeries. More than half of the patients in our analysis underwent axillary clearance (51%). CONCLUSION Our results indicate that a large proportion of patients in the 40- to 50-year age group presented with advanced disease and required aggressive surgical and adjuvant treatment. The presence of a family history did not identify a subgroup with more advanced disease at presentation.