Follow-up Regime Research Articles

Metabolomic Profiling of Lipids and Fatty Acids: 3 Years Postoperative Laparoscopic Sleeve Gastrectomy.

Simple SummaryLaparoscopic Sleeve Gastrectomy (LSG) is one of the most effective type of bariatric surgery for weight loss that enables reduction in the size of stomach and associated comorbidities arises from obesity. LSG is well-accepted and safe surgical procedure, but it may lead to malabsorption of nutrients. However, long-term impact of LSG on other risk factors, including blood lipid and fatty acid (FA) profiles, largely remains unknown. The present study aimed to investigate the lipid and plasma FA profiles in patients who underwent LSG in reference to control group with obesity. We determine the markers of inflammation and metabolic risk in these groups by measuring different saturated, monounsaturated, polyunsaturated, and medium-chain FAs. We also estimated the activity of enzymes involved in synthesis of endogenous FA using the product precursor ratios of individual FAs as markers of global metabolic risk. Our study findings showed that patient’s 3-yrs post LSG developed a favorable lipid profile than control with similar metabolic profile in both groups, as determined by the blood FA profile and FA ratios. Our findings showed that LSG offers extended positive effect on the lipid profile in obese population. Though, lifestyle interventions following strict regular follow-up to maintain general health and well-being.Visceral obesity is common in the United Arab Emirates and worldwide. Although laparoscopic sleeve gastrectomy (LSG) leads to effective and sustainable weight loss, its long-term beneficial impact on other risk factors, including blood lipid and fatty acid (FA) profiles, remains unknown. These two profiles were assessed in patients 3 years after undergoing LSG and in LSG candidates (controls). Lipid profiles were measured using the Cobas e411 modular analyzer, and 35 FAs were identified. The age and body mass index were 36.55 ± 8.65 years and 31.49 ± 6.43 kg/m2 in the LSG group and 35.44 ± 9.51 years and 32.29 ± 5.38 kg/m2 in the control group, respectively. The overall lipid profile was more favorable in the LSG group than in the control group. Total saturated, monounsaturated, and polyunsaturated FAs were similar between the groups, but total medium-chain FAs were more abundant in the LSG group. In endogenous FA synthesis, the estimated activity of C16Δ9 desaturase and Δ5 desaturase decreased, whereas that of elongase increased in the LSG group compared with that in the control group. The benefits of LSG on blood lipid and FA profiles in patients with 3-year LSG may be limited. Hence, lifestyle interventions combined with a long-term and strict regular follow-up regime may be warranted for patients undergoing LSG.

Optimizing Multivitamin Supplementation for Sleeve Gastrectomy Patients

PurposeMicronutrient deficiencies are frequently reported after sleeve gastrectomy (SG), and therefore lifelong daily multivitamin supplementation is highly recommended. Based on literature and the results of a previous randomized controlled trial, a specialized multivitamin supplement for SG patients was further optimized (WLS Optimum 2.0, FitForMe). The present study reports on its short-term effectiveness.Materials and MethodsAn open-label study was performed in which 76 patients were included to receive WLS Optimum 2.0 for 12 months (Opt 2.0 group). This group was compared with a group of 75 patients that had received WLS Optimum 1.0 for 12 months during a previous study (Opt 1.0 group).ResultsIntention-to-treat analysis (Opt 1.0, n = 69; Opt 2.0, n = 75) showed higher serum levels of vitamin B12, vitamin B6, and zinc, and a lower prevalence of deficiencies for vitamin B12 and phosphate in the Opt 2.0 group. MCV and serum folic acid levels were higher in the Opt 1.0 group. Over the 12-month study period, mean increase in serum levels of phosphate, vitamin B6, and zinc was higher in the Opt 2.0 group, and MCV and serum vitamin D levels increased more in the Opt 1.0 group.ConclusionThe present study showed that the use of a specialized multivitamin supplement for SG patients is effective at preventing deficiencies for most vitamins and minerals, specifically in compliant patients. However, a strict follow-up regime remains necessary to monitor nutritional status and to improve patient compliance.

Laparoscopic Treatment of Incisional and Ventral Hernia.

Background and Objectives:Although several large studies regarding patients undergoing minimally invasive repair of incisional hernia are currently available, the results are not particularly reliable as they are based on heterogeneous groups, different surgical techniques, different mesh types, or with a too short follow period.Methods:We conducted a retrospective observational trial, collecting data from patients who underwent laparoscopic repair of a primary abdominal wall or an incisional hernia using the laparoscopic Intraperitoneal Onlay Mesh technique and a single mesh type, i.e., a composite polyester mesh with a hydrophilic film (Parietex CompositeTM mesh – Medtronic, Minneapolis, MN - USA). All patients signed an informed consent.Results:One thousand seven hundred seventy-seven patients were enrolled. The median surgery time was 50 minutes and the median length of hospital stay was 2 days. Intraoperative complications occurred in 12 patients (0.7%), while early postoperative surgical complications occurred in 115 (6.5%); during follow-up, bulging mesh was diagnosed in 4.5% of cases and hernia recurred in 4.3% of patients. An overlap equal or greater than 4 cm resulted as a significant protective factor, while the use of absorbable fixing devices was a risk factor for recurrence (odds ration: 9.06, p < 0.001, 95% confidence interval: 4.19 – 19.57).Conclusions:Minimally invasive treatment of primary and postincisional abdominal wall hernias is a safe, effective, and reproducible procedure. An overlap equal or greater than 4 cm, the use of nonabsorbable fixing devices and a postoperative care and follow-up regime are crucial in order to obtain good results and low recurrence rates.

Challenges of the Public Accounts Committee of Ghana’s Parliament in ensuring an efficient public financial management

ABSTRACT The Public Accounts Committee (PAC) has been established by Standing Order 151 (2) to exercise an oversight function over the Executive on public expenditure on behalf of Ghana’s Parliament. The Committee is to review the Auditor General’s report and make recommendations to prevent future occurrences. With the consistent and increasing mismanagement of public finances, the PAC has been criticised as not being effective in its role in ensuring efficient public financial management in Ghana. The study sought to understand the work of the PAC with a focus on the challenges hindering the PAC to perform its functions in ensuring efficient public financial management. Employing a qualitative research approach, the study found that the challenges of the PAC were the late submission of Audit reports, a dysfunctional follow-up regime, extreme partisanship of the members of the committee, and inadequate technical support to analyse audit reports.

Modern treatment of perineuriomas: a case-series and systematic review

BackgroundPerineuriomas are rare benign peripheral nerve sheath tumours of perineurial cell origin and can be classified into intraneural and extraneural perineuriomas. They most commonly present a mononeuropathy of gradual onset and slow progression, resulting in progressive neurological deficits like hypoesthesia or motor weakness. Therapy is still variable. Aim of the study was to compare our surgical treatment and our follow-up regime including high-resolution nerve sonography with the current literature to evaluate best treatment of perineuriomas.MethodsRetrospective analysis of our dataset “peripheral nerve lesion” to identify patients suffering from perineuriomas between 01.01.2012 until 31.12.2018. Surgical treatment and the follow-up examination of three patients were described. Additionally, a systematic review including PubMed, the Cochrane Collaboration Library, Scopus and Google Scholar was performed for literature published between January 1, 1990 and October 31, 2019 independently by 2 authors.ResultsIn the first case, the left ulnar nerve was affected. In the second case, the left peroneal nerve and in the third case the right median nerve was affected. High-resolution nerve sonography was performed in each case. All patients underwent interfascicular neurolysis combined with a targeted fascicular biopsy under electrophysiological monitoring. Neurological deficits improved subsidized by rehabilitation. Surgical therapy and the neurological outcome were compared with literature. Systematic review revealed 22 articles, which met the inclusion criteria. Therefore, demographics, surgical treatment and neurological outcome of 77 patients were analysed.ConclusionsPerineuriomas are rare benign nerve sheath tumours with a slow progression, sometimes difficult to diagnose. Decompression and neurolysis may improve neurological deficits. High resolution nerve sonography might serve as a helpful additional diagnostic tool in this process.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK).

Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

Nutritional status following One Anastomosis Gastric Bypass

One Anastomosis Gastric Bypass (OAGB) has been accepted as an effective treatment for morbid obesity. However, data are scarce regarding nutritional implications of this procedure. Thus, our aim was to describe the health and nutritional status 12-20 months following OAGB surgery. A prospective cohort study on patients who underwent OAGB surgery from January 2016 to May 2017 in a large, multi-disciplinary, bariatric clinic. Pre-surgery data including demographic details, anthropometrics, co-morbidities, blood tests and lifestyle habits were obtained from the patients' medical records. Follow-up evaluations were performed 12-20 months post-surgery and data collected included anthropometrics, blood tests, eating and lifestyle parameters, adherence to follow-up regime and gastrointestinal (GI) related side effects. In addition, patients were asked to rate their overall state of health (OSH) from 0 to 100 using a visual analogue scale (VAS). Eighty-six OAGB patients (72.1% women) were tested 14.7±2.0 months post-operatively. Their mean age and BMI preoperatively were 46.1±11.4 years and 42.0±4.9kg/m2, respectively. The mean % excess weight loss at 12-20 months postoperatively was 88.4±19.3%. Lipid and glucose profiles were significantly improved at 12-20 months postoperatively compared to baseline (P<0.001 for all). Relatively high proportions of nutritional deficiencies were found pre-operatively and postoperatively for iron (33.9% vs. 23.7%, P=0.238), folate (30.9% vs. 11.8%, P=0.004), vitamin D (56.6% vs. 17.0%, P<0.001) and hemoglobin (16.7% vs. 42.9%, P<0.001). Postoperatively, most participants reported taking multivitamin, calcium, vitamin D and vitamin B12 supplementation (≥62.8%), having participated in at least 6 meetings with a dietitian (51.8%) and presently doing physical activity (69.4%). The mean postoperative OSH VAS score was 88.2±12.3, but most participants reported on flatulence (67.4%) and some reported on diarrhea (25.6%) as GI side effects of the surgery. Substantial improvements in health and anthropometric parameters are found in the short-term follow-up after OAGB, with a satisfactory reported quality of life and adherence to recommendations. However, a high prevalence of some GI side effects, nutritional deficiencies and specially anemia is a matter of concern.

The transition of pediatric Marfan patients to adult care: a challenge and its risks.

Care for patients with Marfan syndrome (MFS) has improved substantially in recent decades. Increasing clinical knowledge and genetic analysis allow early diagnosis of the disease in childhood. Because of the earlier initiation to preventive and medical treatment, patients' life expectancy has risen. To ensure optimal care, pediatric patients require a safe follow-up regime, multidisciplinary care, and a safe transition to adult care. We collected a sample of 149 pediatric Marfan patients, of whom 34 patients had already been transferred to adult care or who were currently transitioning. First, we evaluated clinical aspects of patients that manifest in childhood and are present in the transition process. Second, we analyzed the transition process itself. We found age-dependent manifestation of organ pathologies. Dilatation of the sinus of Valsalva showed a particularly high prevalence during the transition process and 62% of patients required medical treatment. Mean onset of aortic root dilatation was 9.9±5.8 years. Concerning systemic manifestation in MFS skin striae, wrist and thumb sign, and reduced elbow extension occurred significantly more often in patients who were transitioning than in younger children with MFS. All other clinical Marfan features showed an increased prevalence in patients who were transitioning compared with younger patients. In our cohort, transition was successful in 20 patients (58.9%), 12 patients (35.3%) are still in the transition process and 2 patients (5.9%) were lost to follow up. Marfan patients in the transition process are already under a chronic disease condition with a high onset of especially cardiovascular pathologies. Although early medical treatment in childhood is effective, the pathologies of the connective tissue require lifelong attention and influence life in many ways. The big challenge during transition is the double change of responsibility from the parents and pediatric doctor to the patient and adult doctor. Consequently, patients in transition process require special attention and close contact with the doctor and the family. A reevaluation by the supervising pediatric Marfan specialist of the successful transition to adult care is indispensable before the pediatric care of Marfan patients is completed.

Infiltrative lamina propria invasion pattern as an independent predictor for cancer-specific and overall survival of instillation treatment-naïve stageT1 high-grade urothelial bladder cancer.

To investigate established prognostic factors and relatively new histopathological tumor characteristics including metric substage and lamina propria invasion patterns in a large series of T1 high-grade non-muscle-invasive bladder cancer. Between 1989 and 2012, 322 patients with initial stageT1 high-grade bladder cancer underwent transurethral resection, followed by re-transurethral resection and a conservative approach with follow-up regime alone or instillation treatment. Transurethral resection specimens were reassessed by two experienced urological pathologists for tumor grade according to the World Health Organization 1973 classification, metric T1 substage, lamina propria invasion pattern and associated carcinoma insitu. The median follow-up period was 42months (interquartile range 25-72months). In addition to Kaplan-Meier analyses, uni- and multivariable Cox regression analyses were used to compare progression-free survival, cancer-specific survival and overall survival for the studied parameters comparing two subcohorts. While in patients after instillation treatment no examined feature was shown as an independent predictor for prognosis, there were predictive histopathological features in multivariable Cox regression analyses in instillation treatment-naïve patients: associated carcinoma insitu (hazard ratio 2.278, 95% confidence interval 1.119-4.634, P=0.023) and World Health Organization 1973 grade3 (hazard ratio 2.950, 95% confidence interval 1.021-8.536, P=0.046) for worse progression-free survival, infiltrative lamina propria tumor pattern for worse cancer-specific survival (hazard ratio 2.369, 95% confidence interval 1.034-5.429, P=0.042) and overall survival (hazard ratio 1.049, 95% confidence interval 1.024-1.075, P=0.001). The results of the present T1 high-grade bladder cancer series suggest that lamina propria invasion pattern is a promising parameter to predict the prognosis of T1 high-grade bladder cancer in an instillation treatment-naïve subcohort. Prospective multicenter evaluations are warranted. The need for instillation treatment in T1 high-grade bladder cancer is clearly demanded.

The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

IntroductionSegmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. Materials and methodsA convenience questionnaire survey of attending surgeons was conducted during the United Kingdom’s Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). ResultsBased on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. ConclusionWe concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.

Increased Proliferation as Independent Predictor of Disease Recurrence in Initial Stage pTa Urothelial Bladder Cancer.

Objectives:To investigate the predictive impact of the proliferation biomarker Ki-67 on the clinical course of patients with initial stage pTa urothelial carcinoma of the bladder (UCB).Methods:We retrospectively analyzed all patients treated by transurethral resection of bladder tumors (TUR-B) for UCB between 1992–2004 in a single-center. Disease recurrence (≥pTa UCB) and absent tumor in histopathology, assessed by TUR-B with a non-malignant result for endoscopic suspect bladder lesion displayed endpoints. Immunohistochemical (IHC) analysis of formalin-fixed and paraffin-embedded tissue blocks was performed with an immunostainer using a primary antibody for Ki-67. Semiquantitative evaluation of Ki-67 was performed by three reviewers. Increased proliferation was defined with a cut-off value of ≥50%. Uni- and multivariable binary regression analyses were applied to address prediction of disease recurrence.Results:215 patients (84% male, median age 69 years at first diagnosis) were evaluable and included to the study. 89 patients stayed disease-free (41%), 126 patients showed recurrence (59%). Recurrence rates of patients with Ki-67 expression <10%, 10–24%, 25–49% and ≥50% were 14.8% vs. 30.8% vs. 63.9% and 80.7%, respectively (p < 0.001). In Kaplan-Meier analysis patients with increased proliferation ≥50% showed a statistically significant worse 10-year recurrence-free survival (19% vs. 57%, p < 0.001). Multivariable regression analysis revealed instillation treatment (p = 0.001) and high proliferation of Ki-67 (p < 0.001) to be independent predictors of recurrence in stage pTa UCB.Conclusions:High proliferation with Ki-67 expression ≥50% was strongly associated with worse recurrence-free survival in patients with initial stage pTa UCB. Stage pTa UCB patients with increased Ki-67 expression should undergo a strictly follow-up regime comparable to stage pT1 bladder carcinoma, while at least patients with Ki-67 expression <10% might be feasible for more liberate follow-up regime after evaluation of our data in randomized, prospective and multicenter studies.

Next generation post EVAR follow-up regime.

Durability of endovascular aneurysm repair is critical, since a significant proportion of patients suffer from procedure-related complications and secondary interventions after repair of abdominal aortic aneurysms. Therefore, regular follow up including imaging is recommended. The rationale behind current surveillance programs is to allow early detection and elective treatment of complications. However, current recommendations are laborious and resource consuming, may be deleterious to many patients and are largely inefficient. Furthermore, they do not account for novel imaging modalities or for the use of new endovascular devices. The authors review the current recommendations from international societies, and of the evidence for new imaging modalities that could be as alternatives, namely contrast enhanced ultrasound, three-dimensional contrast-enhanced ultrasound and digital tomosynthesis. The evidence on surveillance after repair with new devices, specifically with sealing technology, and its imaging specificities is also discussed. Lastly, the authors review the evidence for risk stratification of surveillance. Stratified follow up regimes may be based on preoperative anatomical characteristics or on postoperative imaging results, at different time points. Effective sealing, absence of endoleaks and sac dynamics are the most commonly used factors for stratification. In conclusion, there is still no consensus on surveillance after endovascular aneurysm repair, with regard to both modality and timing. Novel devices, and especially those using sealing technology, require more intensive surveillance as the expected results at mid- and long-term remain undetermined. Risk stratification of follow-up seems possible but still requires prospective validation before generalization.

Risk factors for recurrence of facial basal cell carcinoma after surgical excision: A follow-up analysis

Several tumour features and surgical factors have been implicated in an increased risk of BCC recurrence after excision; however, there are limited data on facial lesions specifically. This study sought to evaluate risk factors of facial BCC, which may influence future treatment and follow-up regimes. Facial BCCs excised from a single surgeon practice over a 2-year period were included in the study. Data pertaining to patient demographics, lesion depth of invasion, surface area, excision margins, perineural infiltration, location, previous history of recurrence, histological subtype and ulceration were extracted. A search of recurrence was conducted over the following 70-80 months. In total, 331 cases of facial BCC were included, and 10 lesions recurrences (3%) were identified within the observation period. Infiltrative (p=0.02) and micronodular (p=0.04) subtypes as well as incomplete or close (within 1mm) peripheral (p=0.01) and deep excision margins (p=0.04) were significantly associated with tumour recurrence. Five of the 10 recurrent lesions had been re-excised for a recurrence previously, placing them at much greater risk of future recurrence (p=0.00). Incomplete and close excision margins, infiltrative and micronodular subtypes and previous excision are strong risk factors for facial BCC recurrence. Although depth of invasion, perineural infiltration, ulceration and surface area may indicate the aggressive nature of a lesion, the results suggest that with adequate excision margins, these factors may not influence the recurrence rate. The strongest risk factor was a lesion having already recurred after previous excision, and it suggested that these lesions be treated with particular caution and a closer follow-up regime be employed.

Primary care follow-up of radical prostatectomy patients: A regional New Zealand experience.

BackgroundContemporary recommendations regarding the duration of follow-up after radical prostatectomy (RP) are highly heterogeneous. Protocol-based follow-up schemes have been implemented to facilitate the expeditious identification of patients with recurrence. The aim of this study is to assess the reliability and comfort of general practitioners (GPs) in follow-up of RP.MethodsFollowing institutional ethical approval, we performed a retrospective review in patients undergoing follow-up after RP between January 2004 and December 2010. Patient factors, disease variables, and follow-up prostate specific antigen (PSA) compliance was collected. “Noncompliant” follow-up care was defined as: patients that had not received a PSA for a 14 month period within 5 years of prostatectomy. Patient and disease-based risk factors for noncompliant follow-up were assessed. GPs were also surveyed in their follow-up practice of RP patients, to assess their familiarity in caring for these patients.ResultsIn total, 65 cases were identified that met the inclusion criteria. At 60 months of follow-up, 66% (43/65) of patients had a compliant follow-up regime. For patients with noncompliant follow-up at 60 months, median time of compliance did not differ significantly when assessing preoperative PSA, Gleason sum, extraprostatic extension, or surgical margin status. Of the GPs surveyed, 68% of GPs felt comfortable in follow-up of RP patients. Some 62% of GPs would expect the PSA to be < 0.1 and 25% of GPs would measure the PSA annually.ConclusionOur study identified that follow-up by GPs after RP is insufficient. Accordingly, there is a requirement for formal educational programs if primary care is to take a greater role in follow-up of these patients.

Radiation exposure in patients treated with endovascular aneurysm repair: what is the risk of cancer, and can we justify treating younger patients?

Background Endovascular aneurysm repair (EVAR) is becoming the mainstay treatment of abdominal aortic aneurisms (AAA). The postoperative follow-up regime includes a lifelong series of CT angiograms (CTAs) at different intervals in addition to EVAR, which will confer significant cumulative radiation exposure over time. Purpose To examine the impact of age and follow-up regime over time on cumulative radiation exposure and attributable cancer risk after EVAR. Material and Methods We calculated a mean effective dose (ED) for the EVAR procedure, CTA, and plain abdominal X-rays (PAX). Cumulative ED was calculated for standard, complex, and simplified surveillance over 5, 10, and 15 years for different age groups. Results For EVAR, the mean ED was 34 mSv (range, 12-75 mSv) per procedure. For PAX, the ED was 1.1 mSv (range, 0.3-4.4 mSv), and for CTA it was 8.0 mSv (range, 2-20 mSv). For a 55-year-old man, an attributable cancer risk (ACR) in standard surveillance at 5 and 15 years of follow-up was 0.35% and 0.65%, respectively. The corresponding values were 0.22% and 0.37% for a 75-year-old man. When using a simplified follow-up, the ACRs for a 55-year-old at 5 and 15 years were 0.30% and 0.37%, respectively. These values were 0.18% and 0.21% for a 75-year-old man. A complex follow-up with half-yearly CTA over similar age and time span doubled the ACR. Conclusion Treating younger patients with EVAR poses a low ACR of 0.65% (15-year standard surveillance) compared to a lifetime cancer risk of 44%. A simplified surveillance should be used if treating younger patients, which will halve the ACR over 15 years.

Antibradycardia therapy : Indication and implementation

Pacemaker therapy (PMT) in grown-up congenital heart disease (GUCH) must meet the demands of ayoung, dynamic and heterogeneous group of patients. The duration of the therapy has to be planned for several decades and should be accompanied by an invasive procedure at the very least. Most of the patients enter adulthood with their pacemaker (PM) already implanted; for others the indications can be derived from the published guidelines for GUCH and PMT, but need to be adjusted to the individual situation of the patient. Depending on the underlying heart disease the decision on the use of either an epimyocardial or a transvenous PM system has to be made. Both electrodes and PM should correspond to the latest technical developments to optimally adapt to the patients' multiple requirements. In the case of PM system revisions abandoned leads should be removed and vascular stenosis or occlusions cleared to be prepared for later revisions. During any cardiac surgery epimyocardial PM systems should be checked against the patient's needs and expanded or revised accordingly. Epimyocardial resynchronization systems in particular offer more opportunities for compensating for cardiac dysfunction with greater reliability using asecond ventricular lead. The PMT is an essential part of the medical treatment for many patients with GUCH and contributes significantly to the well-being and quality of life. Against this background, acompetent and consequent follow-up regime requires experienced physicians. An integrated telemetric monitoring system for the PM has proven valuable and supports the early recognition of cardiac arrhythmia.

Dental implant management and maintenance: How to improve long-term implant success?

Although dental implants are proven to be a predictable longterm treatment for patients, it is important to realize that not all implants that survive are necessarily successful. Successful implants are those that remain fully functional and healthy within the oral cavity. Peri-implantitis is a disease that is associated with implant failure, and is becoming rather prevalent. Assessing risk factors and stabilizing existing oral disease prior to the placement of implants will aid in preventing implant disease and failure. After implant placement, a strict follow-up regime with a dental professional should be implemented in order to monitor the implant and surrounding teeth for disease. The dental professional should continually encourage the patient to adhere to consistent homecare to prevent peri-implantitis from occurring, and in turn increase the success of their implants. Early diagnosis and elimination of inflammatory processes around the implants will improve the longterm prognosis as well.

Outcomes of Biofeedback Therapy for Fecal Incontinence in a UK-Based District General Hospital: How Intense Should the Follow-up Regime Be? Presidential Poster

Outcomes of Biofeedback Therapy for Fecal Incontinence in a UK-Based District General Hospital: How Intense Should the Follow-up Regime Be? Presidential Poster

Mid-term follow-up of patients with permanent sequel due to spinal cord ischemia after advanced endovascular therapy for extensive aortic disease.

Observational study. Thoraco-abdominal endovascular aortic aneurysm repair (TAEVAR) can be used to treat patients with extensive and complex aortic disease, however, at the risk of spinal cord ischemia (SCI). The aim of this follow-up study was to evaluate the life satisfaction in patients with SCI after TAEVAR. Among 83 patients undergoing TAEVAR between 2009 and 2012 at the Vascular Centre, Malmö, Sweden, 29 developed SCI in-hospital and at follow-up (median 26 months), eight had died and three had no complaints. Patients diagnosed with permanent (n=10) and transient (n=8) SCI were interviewed at home. The Life Satisfaction Questionnaire (LiSat-11) and the Satisfaction With Life Scale (SWLS) were compared with reference samples. Mid-term mortality in patients with permanent SCI (7/17) was higher than those with transient SCI (1/12) (P=0.035). Ten patients had permanent T1-S5 SCI, two were classified as ASIA Impairment Scale (AIS) A, one as AIS B and seven as AIS D at hospital discharge. Patients diagnosed with transient SCI had residual neurological deficits in the legs (n=8), urge incontinence (n=3) and fecal leakage (n=2) at follow-up. Patients with SCI had lower self-rated life satisfaction in terms of 'life as a whole', 'sexual life', 'somatic health' and 'psychological health' but better in the 'economy' domain. Assessment of life satisfaction at mid-term follow-up suggests that all patients with SCI in-hospital, whether permanent or transient, should have a multi-disciplinary follow-up regime. Most patients diagnosed with transient neurological deficits had an overlooked permanent, less severe, SCI.

Paradoxes of follow-up – health professionals’ views on follow-up after surgical treatment in gynecological cancer

Objective. Evidence now reveals that attending a follow-up program may not improve survival for low-stage gynecological cancer patients. The aim of this study was to explore health professionals’ experiences with the follow-up programs and their views on follow-up in the future.Methods. A qualitative approach was undertaken with semi-structured focus group interviews. Three focus group interviews were conducted at neutral ground. One group with onco-gynecologists, one group with specialist nurses, and one mixed group. The main themes of the interviewguide were: Existing follow-up program, life after cancer and future follow-up. The interviews were transcribed verbatim. Patterns and themes were uncovered from the data inspired by interpretive description.Results. The doctors described most advantages, such as: Quality control of their own work, detection of sequelae after surgery, and credit and appraisal from the patients. A disadvantage was the inadequate use of the nurses’ main competencies. Some dilemmas were described by the nurses as well as doctors: First, both groups were aware of the existing evidence that attendance of follow-up programs may not improve survival and yet, health professionals still performed the follow-ups and most often did not address this paradox for the patients. Second, the existing follow-up program seemed to bring the patients comfort and security on one hand, but on the other hand it seemed to induce insecurity and anxiety. The health professionals agreed that future follow-up should be individualized with focus on the single patients’ needs and psychological wellbeing. The health professionals identified a great challenge in communicating the evidence and the forthcoming changes in the follow-up programs to the patients.Conclusions. This study revealed that the existing follow-up regime contains several dilemmas. According to the health professionals, future follow-up must be more individualized, and a shift in focus is needed from relapse to quality of life after cancer.