bluuebunny/crossref_metadata_2025 huggingface dataset:
795 Predictors and Timing of Recurrence After Surgical Resection of Pancreatic Adenocarcinoma
Authors: Ang A , Michaelides A , Tissue Bank Barts Pancreas , Kocher H
Published: August 2023

Aim

To investigate the predictors and timing of recurrence after curative resection for pancreatic adenocarcinoma (PDAC).

Method

Consecutive patients who underwent curative resection for PDAC (2011-21) and consented to data and tissue collection, were followed up prospectively in a single institution. Clinico-pathological variables were analysed using the Cox proportional hazards model.

Results

91 patients (median age 71 years (range 43 – 86)) had a median follow-up of 51 (95% CI 40–61) months. 66 (72.5%) patients experienced recurrence (12 locoregional, 11 liver, 5 lung, 3 peritoneal, 29 simultaneous locoregional and distant and 6 multi-focal distant). Median time to recurrence was 8.5 (95% CI 6.6-10.5) months and median survival after recurrence was 5.8 (95% CI 4.2-7.3) months.

Stratification by recurrence location revealed no significant differences in time to recurrence (p = 0.24). Significant predictors for any recurrence were lymph node ratio ≥0.33 (p = 0.005, HR 2.8, 95% CI 1.4 – 5.8), adjuvant chemotherapy (p = 0.002, HR 0.4, 95% CI 0.2 – 0.7) and systemic inflammation score ≥500 (p = 0.01, HR 4.5, 95% CI 1.4 – 14.3).

Conclusions

Lymph node ratio, adjuvant chemotherapy and systemic inflammation score were significant predictors for recurrence after curative resection for PDAC: this needs validation in large national cohorts.
1273 Ethical Considerations in Paediatric Bariatric Surgery: A Systematic Review
Authors: Shah A , Kumar N
Published: August 2023

Aim

With childhood obesity prevalence increasing rapidly, bariatric surgery is being given greater consideration in the paediatric population. Paucity of long-term evidence, physical and emotional risks, and reliance on parental decision-making are factors constituting this subject’s moral complexity, forming debate around the eligibility and timing of offering the procedure. Consequently, a systematic review was conducted to evaluate ethical considerations.

Method

All relevant synonyms of “Paediatric”, “Bariatric Surgery” and “Ethics” were used to identify papers for inclusion in the systematic review and reference lists were also scanned. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to.

Results

10 papers were included. A key ethical dilemma frequently explored was the issue of consent, and ensuring the child is at the forefront of the decision. Paediatric bariatric surgery causes controversy as children are exposed to surgical risk early in life, and thus prolonged preventative measures are encouraged with the aim to mitigate obesity by adulthood causing unnecessary harm. Children without a strong support network have additional obesity risk, whereby withholding surgery may be viewed as inequitable and non-beneficent. There is also conflict between delaying surgery until the child is Fraser-competent versus increased complication risk.

Conclusions

Further evidence to guide assessment criteria are needed to facilitate informed consent. Post-operative support should be audited, with inclusive care and sustained health outcomes monitored. Although preventative methods are important in the paediatric population, clinicians must not discriminate against those for whom it proves ineffective, with bariatric surgery being a last resort for high-risk obese patients.
208 Evaluating the Usefulness of Crash Courses in Anatomical Education
Authors: Abelleyra Lastoria D , Rodriguez J , Miller P
Published: August 2023

Aim

To evaluate the usefulness of Crash Courses for learning Anatomy, and to explore their role in anatomical education.

Method

51 students attended an Anatomy crash course ahead of their university assessments. This consisted of 6 one-hour sessions, delivered by three 4th year medical students, taking place on a single day. A survey was presented to and responded by all participants. Parameters including, but not limited to, perceived usefulness of crash courses, and confidence in anatomical knowledge before and after the event, were enquired about. These were measured using a 5-point Likert scale. Consent was obtained from all participants for the evaluation and inclusion of their survey responses in any presentation or publication following the event.

Results

51 students (100%) reported their confidence about their upcoming exam increased after the course. On a 5-point Likert scale (1 = not confident at all, 5-very confident) confidence rating increased from 2.04 ±0.11 to 3.73 ±0.11. The Crash course’s usefulness was rated at 4.51 ±0.01 (1 = not useful at all, 5 = very useful). Top reasons for attending included learning concepts before the exam, and practising exam questions. All students reported Crash courses have a place in anatomical education. In addition, 48 (94.1%) preferred sessions to be led by students rather than lecturers. Reasons included familiarity with examinations, and relatability to the tutors.

Conclusions

Crash courses can be an effective way to enhance student learning, with high satisfaction reported. Anatomy departments and student-led anatomical societies should incorporate them into teaching schedules given their potential to enhance student learning.
1302 Should All Excised Suspected Epidermoid and Pilar Cysts Undergo Histological Analysis?
Authors: Rashid S , Pizanias M , Sekhon Inderjit Singh H K , Howlader M
Published: August 2023

Aim

Within our department, there is variation as to whether excised suspected epidermoid and pilar cysts (both often referred to as sebaceous cysts) are sent for histology. This study aimed to assess the clinical risk of not routinely sending these lesions for histological examination.

Method

A retrospective review was undertaken of consecutive patients undergoing excision biopsy of suspected epidermoid/pilar cysts between September 2016 and August 2021. Data recorded included pre-operative suspected diagnosis, operative diagnosis, histology results and whether these results had been reviewed by the surgical team.

Results

202 patients underwent excision of suspected cysts from a single District General Hospital. 112 were pre-operatively diagnosed by Registrars and 85 by consultants. In 177 cases a sample was sent for histology (88%). In 113 of these cases, the result was reviewed by the surgical team (64%).

The concordance between pre-operative diagnosis and histology was 73.8%. Concordance in pre-operative diagnosis with histology results was similar between Registrars and Consultants (80% vs 73.8%, p = 0.007).

The concordance between the operative diagnosis and histology was 82.1%. Of the 36 cases misdiagnosed at operation, histology revealed malignancy in one case (basal cell carcinoma) and pre-malignancy in another (keratoacanthoma).

Conclusions

In our study, there is a high concordance between operative diagnosis and histology (82.1%) with a relatively low risk of missing malignant or premalignant lesions (2/177, 1.1%). Given the potential economic savings, it may be possible for the surgeon to safely select which cysts need histological review rather than routinely sending all specimens.
702 Hindfoot Stability Test - Introduction and Validation of a Diagnostic Test of Subtalar Instability in Deltoid Ligament Injury Associated with Ankle Fractures
Authors: Mason L , Philpott M , Aamir J , Caldwell R , Bond A
Published: August 2023

Aim

Deltoid ligament complex (DLC) injury repair in the presence of an ankle fracture remains a topic of controversy in the current literature. No work in the current literature has commented on hindfoot and subtalar instability in the presence DLC injury associated with ankle fracture fixation. Our aim was to introduce and validate a new method for assessment of hindfoot instability, when fixing an ankle fracture with associated DLC injury.

Method

DLC injury, specifically superficial DLC, controls not only the ankle but the subtalar joint and medial longitudinal arch. Valgus stressing can unmask subtalar instability. It was noted by referencing the hindfoot position to a line parallel with the lateral aspect of the fibula, the lateral fibula line, subtalar instability was probable. We used six morphologically normal cadaveric specimens to validate the test.

Results

Six cadaveric specimens were used for validation of the hindfoot stability test. Pre-injury, no specimen illustrated bisection of the calcaneal tuberosity by the lateral fibular line on hindfoot stability test under fluoroscopy. Post-injury, all specimens showed bisection of the calcaneal tuberosity by the lateral fibular line on hindfoot stability test.

Conclusions

The hindfoot stability test assesses hindfoot stability on valgus stressing of the hindfoot using the calcaneal tuberosity bisection of a line drawn from the lateral border of the fibula as a reference point for instability. This was validated using morphologically normal cadavers.
294 Evaluation of the Clinical Utility of ANCHOR (An Artificial Neural Network for Chronic Subdural Hematoma Referral Outcome Prediction): An External Validation Study of 1713 Patient Referrals
Authors: Biswas Sayan , MacArthur Joshua , Pandit Anand , Sarkar Ved , Joshi George K
Published: August 2023

Aim

Chronic subdural hematoma (CSDH) incidence and referral rates to neurosurgery are rapidly increasing. We have previously shown that ANCHOR, a locally developed deep learning machine learning (ML) model can accurately predict CSDH referral outcome with a high degree of precision. Our objective for this study was to externally validate the accuracy of the ANCHOR model at predicting CSDH referral outcomes in an external tertiary neurosurgical centre.

Method

Patients referred to the external validation neurosurgical centre for CSDH were retrospectively analysed for 7 patient features previously identified over the same 5-year period (2015-2020). The optimal ML model identified in the previous study, the Artificial Neural network for Chronic subdural HematOma Referral outcome prediction (ANCHOR), https://medmlanalytics.com/neural-analysis-model/, was then evaluated on 6 performance metrics using the new cohort.

Results

1713 referrals were identified, of which only 29.5% (505) were accepted referrals. The ANCHOR model demonstrated good discrimination and calibration, with an accuracy of 92.294% [95%CI: 90.952 – 93.520], sensitivity of 82.970 [95%CI: 79.644 – 86.180], specificity of 96.190% [95%CI: 94.951 – 97.202], PPV of 90.108% [95%CI: 87.197 – 92.688], an AUROC of 0.896 [95%CI: 0.878 – 0.912], and a brier score loss of 0.077 [95%CI: 0.065 – 0.091]. Decision curve analysis further demonstrated superior clinical net benefit across all patient risk threshold probabilities.

Conclusions

This study successfully validated the clinical utility of the ANCHOR ML model in predicting CSDH referral outcome at an external centre. ANCHOR was able to accurately predict referral outcomes and can potentially be used in clinical practice to support CSDH referral decision making.
96 Looped Prospective Audit of Compliance to the British Orthopaedics Association Standards for Trauma and Orthopaedics (BOAST): Safe Use of Intraoperative Tourniquets in Upper Limb Surgery
Authors: Wen J , Lin Z , Bommireddy L
Published: August 2023

Background

New BOAST standards were published in October 2021, advocating the need for all tourniquet pressure to be inflated 50-100mmHg above the adult patient’s systolic blood pressure when undergoing upper limb surgeries. The aim was to assess whether conformity was present towards this standard.

Method

A closed-loop prospective audit was implemented in a specialist hand unit from October to December 2021. Readings, including blood pressure before tourniquet inflation, final inflation pressure, tourniquet time, and level of performing surgeon, were collected from documentation and analysed.

Results

A total of 100 patients were assessed. The initial audit and re-audit demonstrated low compliance levels of 36% (18/50) and 38% (19/42), respectively, despite specific educational interventions regarding the newly published standard. When comparing junior and specialist hand consultants, non-compliance was more significant at the more senior level (63.4%). All non-compliance was a result of the overinflation of the tourniquet. The average overinflation was 20.6mmHg, and the average tourniquet time was 40.9 minutes. No tourniquet complications were documented in any case.

Conclusions

The primary rationale resulting in the non-compliance from the experienced hand surgical team was that the increased risk of obscuring the operative field from bleeding, thus leading to structural damages, outweighs the complications of overinflating the tourniquet. Furthermore, systolic blood pressure cannot always be maintained within a restricted window from the anaesthetic perspective. Therefore, we propose that the guideline be opened for further discussion and more up-to-date research implemented in this field.
216 Sentinel Lymph Node Biopsies for Malignant Melanoma – a Single Centre, Closed-Loop Audit
Authors: Campos M , Mendis K , Ibrahim A , Esmaeili A
Published: August 2023

Aim

Sentinel Lymph Node Biopsy (SLNB) has been used as staging tool for Malignant Melanoma (MM) for over 15 years. This audit sought to ensure that standards of care are being met in melanoma patients undergoing SLNB at the Royal Free Hospital (RFH).

Method

A retrospective audit examined electronic notes for patients undergoing SLNB for MM at RFH March-September 2021 (Loop 1, n = 139) and September 2021-March 2022 (Loop 2, n = 100). The standard used to determine eligibility for SLNB originated from a UK consensus statement recommending SLNB in primary cutaneous melanoma ≥pT2a or pT1b and either lymphovascular invasion or a mitotic rate ≥2/mm2.

Results

In Loop 1 of the audit, 6.5% of patients undergoing SLNB (n = 9) did not meet the criteria. A further 4.3% (n = 6) did not have documented lymphovascular invasion or mitotic index and, therefore, potentially also did not meet criteria. Between loops 1 and 2, standard referral letters were disseminated to referring sites, who were also instructed to include full histology reports with referrals. In Loop 2 of the audit, 3% of patients undergoing SLNB (n = 3) did not meet the criteria. A further 11% (n = 11) did not have a documented lymphovascular invasion or mitotic index in the referral and, therefore, potentially also did not meet criteria.

Conclusions

SLNB carried out on non-eligible patients carries risks of increased morbidity and mortality. Interventions implemented between loops 1 and 2 in our single-centre audit did not lead to sustained change and highlight the need for further research and improvements.
568 Audit of Laceration Management and Documentation
Authors: Kremneva A
Published: August 2023

Aim

Evaluate adherence of emergency department (ED) staff to NICE guidelines on laceration management. Evaluate quality of laceration management documentation in ED. Re-evaluate the above following the introduction of a laceration template for ED clerking.

Method

ED documentations of 53 adult patients presented with laceration in November 2022 were analysed and evaluated based on the presence of the following components: wound size, infection risk, tetanus vaccination status & appropriateness of booster administration, wound cleaning, appropriateness of wound closure method, type of dressing, appropriateness of antibiotic prescribing, and wound care instructions (e.g., suture/ dressing removal time).

Results

49% of documentations mentioned the laceration size. Only 9% commented on the wound infection risk, making it impossible to comment on appropriateness of antibiotic prescribing in most cases; 6% of the cases were prescribed antibiotics despite the wound being closed, against guidelines. Most cases had wound cleaning (72%) and appropriate closure method (77%) documented. Dressing type was only documented in 19% of cases. Just over the half of the patients had tetanus history clarified and booster administered appropriately (59%). Only 36% of the patients received detailed wound care instructions.

Conclusions

The first audit cycle highlighted concerning gaps in ED clerking. This may lead to the NICE guidelines being incorrectly applied, which in turn presents a significant risk to patients. A laceration clerking template will be introduced in 2023 with compulsory elements that will encourage more rounded history taking. Therefore, a re-audit will be performed in February to assess efficacy of changes.
581 Documentation of Peripheral Sensory Function Assessment in Hand Trauma at a Regional Referral Unit
Authors: Dawidziuk A , Tickunas T
Published: August 2023

Aim

This audit aimed to assess the quality of documentation of sensory function assessment in hand trauma patients treated at a regional referral unit. The audit was based on The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) “Peripheral Nerve Injury” national guideline, last updated in December 2021.

Method

The scope included all hand trauma referrals received between the 1st and 10th of March 2022. Initial case screening excluded missed appointments, telephone consultations, missing hand assessment sheets and reviews of old injuries. Following that, patients with diagnoses of pulp injury, amputation, closed central slip injury, mallet injury, phalanx infection, old injuries, and removal of metalwork, which were not relevant to the audited guideline, were excluded. All remaining records were analysed for any description of sensory assessment and description of the sensation level using a 1-10 scale. Additionally, cases of volar lacerations were checked for documentation of two-point discrimination (2PD).

Results

The search yielded 97 patient records. Following the initial screening, 10 cases were excluded. 56 out of 87 remaining cases had diagnoses relevant to the audit. 24 cases were classified as volar injuries. 73% of hand assessment sheets contained any description of peripheral sensory assessment (41/56). 1-10 assessment was documented on 23% of records (13/56). 17% of volar injury records contained 2PD examination documentation (4/24).

Conclusions

Documentation of sensory assessment in hand trauma, especially two-point discrimination in volar lacerations, requires improvement. One possibility to improve the adoption of 2PD evaluation would be an introduction of a cheap and widely available assessment device.
664 Rapid-Access Head and Neck Lump Imaging Clinics Improve Compliance to the NHS Faster Diagnosis Standard, With Reduction of Head and Neck Cancer Diagnosis Times
Authors: Dar T , Maitra S , Michaels J , Bhatt N , Iyngkaran T , Sood T , Tornari C
Published: August 2023

Aim

The NHS “Faster Diagnosis Standard” (FDS) recommends patients referred for suspected cancer to be diagnosed or have cancer ruled out within 28 days. Reducing time to diagnosis and treatment in head and neck cancer is associated with improved patient outcomes. Our aim was to improve compliance to the 28-day standard in a large tertiary head and neck department, by introducing a rapid-access clinic for head and neck lumps including same day ultrasound-scanning with biopsy.

Method

Data was collected in two rounds: 3 months before and after introduction of the rapid-access clinic in September-2022. Data collected included referral reason, time from referral to specialist review, to ultrasound, and to diagnosis. Patients not fitting agreed criteria for the clinic were excluded.

Results

In the first round 39 patients had a diagnosis at time of analysis; as had 13 in the second round: Initial compliance to the 28-day FDS was 33%, this increased to 85% in the second round. Median time to diagnosis was 36 days, decreasing to 12 in the second round (p-value <0.001). Median time to ultrasound was 28.5 days in the first round, decreasing to 9 in the second round (p-value <0.001).

Conclusions

Preliminary data shows a 53% improvement in compliance to the 28-day FDS, after introduction of the rapid-access clinic. This suggests the model could significantly improve compliance to national standards for diagnosing head and neck cancer presenting via neck lumps. This should encourage other tertiary head and neck services that creating rapid-access clinics can reduce delays in cancer diagnosis and treatment.
730 An Audit of Antibiotic Prescription in Acute Pancreatitis
Authors: Othman A , Ben Abdalla M , Baston T , McComb K , Barghash M , Sadic J
Published: August 2023

Aim

To assess the prescription of antibiotics in the management of acute pancreatitis in North Manchester General Hospital and to determine adherence to NICE Guidelines (NG104).

Method

Retrospective analysis of patients admitted to North Manchester General Hospital, with a diagnosis of acute pancreatitis, between 1st January 2021 and 31st December 2021. Analysis performed by assessing case notes, electronic Prescribing and Medicines Administration (ePMA) system, radiological imaging, and blood test results. The Atlanta Classification was used to define the inclusion criteria for acute pancreatitis.

Results

A total of 98 patients were diagnosed with acute pancreatitis. Subsequently, 11 patients were excluded due to insufficient evidence to support their diagnosis. 65.5% of patients were prescribed antibiotics on admission. 12.1% of patients were prescribed antibiotics for necrosis, 12.14% for concurrent cholecystitis and 33.4% were prescribed antibiotics without indication.

Conclusions

Poor compliance with national guidelines on the recommended management of acute pancreatitis. Audit results and the recommended NICE Guidelines were disseminated to all members of the General Surgery team with further consolidation at the local governance meeting to improve knowledge and streamline practice.
792 Assessing the Frequency of Daily Patient Reviews in a Local Orthopaedic Department
Authors: Dorji T , Al Aaraj M
Published: August 2023

Aim

To investigate the frequency at which patients admitted under a local orthopaedic department are having daily reviews by various teams, and to assess the level of clinical seniority that saw these patients.

Method

Patients primarily under the care of the orthopaedic department were assessed over a 10-day period in two different time frames across November 2022. These included all male and female inpatients presenting with any condition. Data was collected manually by going through the patient notes and the most senior orthopaedic doctor who saw the patient on that day was recorded as the main reviewer.

Results

73 patients with an average age of 76.0 years were included. Overall, patients were seen by orthopaedics on 58.4% of the days they were in hospital. 21.2% of these were done with a consultant present, 10.4% by a registrar, 17.6% by a senior house officer, and a foundation doctor in 9.2% of occasions. Outcomes were worse over the weekends, where 56.8% of inpatients did not get reviewed at all. There were also considerable differences between the various teams, reviewing their patients from 32.9% to 69.1% of the time.

Conclusions

Patients should ideally be reviewed daily as not only does it affect patient flow but also ensures vulnerable individuals are getting the timely care that they need. This pilot study showed a considerable lack in the number of daily reviews, with some patients not being seen for several days. Therefore, better organisation and accountability of the workforce is required to reach higher standards of care.
861 Getting the Surgical Handover Right: A Closed-Loop Audit
Authors: Eva C , Slim N , Ghatge A , Bruno P , Blackaby J , Cutting J , Fowler G E
Published: August 2023

Aim

The European Working Time Directive has led to a reduction in hours worked by junior doctors and subsequently increased the number of handovers between colleagues. Ineffective handovers introduce the opportunity for clinical error and adversely affect patient safety. We sought to improve the quality of patient handovers in a busy surgical department, by assessing compliance with a twelve-point guideline from the Royal College of Surgeons (RCS) as the gold standard.

Method

An audit was performed across a seven-day period. For each patient discussed during the morning or evening handover, compliance was measured according to twelve domains pertaining to a patient’s admission as per RCS recommendations (e.g., diagnosis, location, relevant investigation results). Following intervention with a ‘safe handover’ checklist, we repeated the audit across a subsequent seven-day period. Secondary outcomes, such as environmental and human factors, were also assessed by a junior team member.

Results

A total of 28 handovers, incorporating 337 patients, were included. Following implementation of the checklist, compliance improved across most domains—particularly with highlighting the necessity for an additional review (33.3% vs. 91.0%) and the handover of outstanding tasks (31.5% vs. 84.3%). Compliance with discussion of resuscitation status remained low (7.0% vs 9.2%). Improvements were noted with environmental and human factors, including performance of team introductions and the opportunity to raise concerns.

Conclusions

We have demonstrated an improvement in the quality of patient handovers as per RCS guidance following the implementation of a handover checklist. Further interventions are warranted to improve handover of resuscitation status.
946 A Complete Cycle Audit of the Appropriate Management of Stable Patients Presenting Acutely with a Lower GI Bleed Using the Oakland Score Risk Stratification Tool in Order to Avoid Unnecessary Admissions
Authors: Sharma V , Smith E , Satar I , Birch D
Published: August 2023

Aim

The use of risk stratification tools such as the Oakland Score (OS) to identify patients with low risk of adverse outcomes (scale 0-35, safe discharge threshold ≤8) who present acutely with a Lower Gastrointestinal Bleed (LGIB) in order to avoid unnecessary admissions, in accordance with British Society of Gastroenterology (BSG) guidance.

Method

At a District General Hospital, data was collected retrospectively over six months. Patients who acutely presented with a LGIB were identified using patient handover lists and e-documentation was reviewed for a documented Oakland Score (OS). A departmental survey was conducted to ascertain knowledge of OS and LGIB assessment. Tailored teaching was subsequently delivered, including a summary sheet with a link to an e-calculator. A re-audit was conducted over three months to measure change of practice.

Results

Prior to intervention, 6/63 (10%) had a documented Oakland score (OS). Three patients had an OS <8 and were inappropriately admitted. A survey was completed by 11 members of the General Surgical team. Prior to intervention, 27% (3/11) were aware of OS and only 9% (1/11) reported using it practice. Following intervention, 16/38 (42%) had a documented OS. All patients (8/8) with an OS ≤8 were appropriately discharged.

Conclusions

The use of numerical risk stratification tools such as the Oakland Score, in compliance with BSG guidance, improved patient management and avoidance of inappropriate admissions. Targeted educative measures should be delivered to the department on a regular basis, to account for continual rotating of doctors and ensuring updated knowledge to further improve outcomes.
1181 Surgical Sample Collection and Non-Touch Technique for Tibial Fractures Treated with Fine Wire Frames: First Cycle Audit
Authors: Zhang J , Zhu J , Krkovic M
Published: August 2023

Aim

Tibial osteomyelitis can be an incredibly complex condition to treat, and often causes great pain and reduced quality of life for the patient throughout the treatment and rehabilitation phase. Often, fine wire fixators (FWF) are used for the most severe cases, with infection and concordant bone loss/deformity correction required. A robust diagnostic protocol is required to ensure the correct antibiotics are used for treatment.

Method

The microbiology sampling and diagnostic process for patients with tibial osteomyelitis treated with FWF were audited at a major trauma centre according to British Orthopaedic Association (BOA) guidelines. Fifty-one patients met inclusion criteria.

Results

Poor compliance was defined as <70% guidelines followed. Empirical antibiotics free period prior to diagnostic sampling was achieved in 46/51 cases (90.2%), five separate documented samples for microbiology sampling was achieved in 26/51 cases (51.0%), and documentation of sterile, non-touch, separate instrument technique for microbiology samples was documented in 5/51 cases (9.8%)

We recommend a pre-written template for clinicians on admission of patients with suspected osteomyelitis detailing empirical antibiotic status prior to diagnostic sampling, a template for the surgical team to detail site and technique used for microbiology sampling, and increased communication between surgeons and microbiologists to confirm and document number of samples taken.

Conclusions

Tibial osteomyelitis can be very difficult to manage, with the initial culture-specific antibiotic(s) being employed crucial in the treatment process. Achieving a robust and error-free diagnostic process is vital in combating this debilitating condition, and a key goal for the trauma and orthopaedics department.
1190 Optimising Trauma-Meeting Outcome Documentation
Authors: Akmal K , Murray V
Published: August 2023

Aim

Standardised documentation of consultant-led multidisciplinary team (MDT) discussions for orthopaedic referrals are vital in optimising patient care and safety. There was no formal record of trauma-meeting outcomes within our trust, which could impede the continuity of care and patient safety. We aimed to implement a more robust model for documenting trauma-meeting outcomes.

Method

This closed-loop audit consisted of two 2-week cycles. Cycle 1 audited retrospective data on the proportion of patients with documented outcomes and their referral type. A 2-week intervention was carried out between the cycles. A proforma was developed and teaching was delivered to ensure accurate documentation. Reminders were given prior to each meeting to ensure clear outcomes were voiced. A survey was used to collate feedback for improvements from the team.

Results

Data was collected from 235 patients over cycle one (n = 127) and cycle two (n = 108). Cycle one showed 70% (n = 85) had documented outcomes, in comparison to 91% (n = 98) in cycle two. Analysis by referral type showed patients without documented outcomes were largely referred from the Emergency Department to fracture clinic follow-up. Only 2.13% had documentation in cycle 1 compared to 70% in cycle 2. The survey identified that 100% (n = 11) of participants found the intervention enhanced team communication and particularly improved follow-up care within fracture clinic.

Conclusions

The audit demonstrated positive change and has been implemented as a permanent protocol within the department, which could be incorporated into other surgical MDT meetings to enhance communication and patient care.
1237 Audit Project on Golden Patient Policy Adherence and Its Improvement to Theatre Efficiency
Authors: Chen C , Pandit R , Psaltis E , Khan K
Published: August 2023

Aim

The Golden Patient (GP) is the first patient listed for theatre next day identified and reviewed the day before, with the aim to improve theatre start times and overall efficiency. We aimed to compare the data before implementation of the GP against post-implementation at University Hospital North Durham (UHND) to assess if improvement in efficiency was achieved. We also aimed to analyse the appropriateness of patients listed as GP.

Method

We analysed data of 45 listed GPs between April and August 2022 as well as 50 patients listed first in theatre prior to GP implementation and compared the documented operation start times. We then compared the data of the listed GPs against local trust criteria for identifying the GP which includes ASA grade/ anaesthetic type, case duration, surgical team availability.

Results

When comparing pre- and post-implementation of the Golden Patient guidelines, surgical start times improved on average by 30 minutes. In the GPs, 62.9% met all criteria. Compliance was mostly affected by the number of patients not sent for before 0830 AM (only 68.6% of cases met this criterion.) Otherwise, 97.1% of cases met ASA/anaesthetic criteria, and 94.3% met case duration criteria.

Conclusions

We saw a significant improvement in the average starting times of theatres with implementation of the GP. We also found that we were good at identifying potential GPs however there was much room for improvement with logistics and actually getting patients to theatre quickly.
259 Avoiding Face-to-Face Appointments Following Benign Breast Biopsies: Improving The Patient Experience Without Compromising Safety
Authors: Mistry D , Shaker H , Abbas A , Absar M S , Williams K , Wright C , Nasir N
Published: August 2023

Aim

Minimising face to face (F2F) contact can reduce the costs of outpatient clinics and increase patient satisfaction. Patients undergoing biopsy for suspected benign disease need discussing at an MDT meeting as per national guidelines, however, the majority of these do not need further treatment. We aimed to assess the utility and safety of managing patients without a further F2F appointment following benign MDT discussion.

Method

A retrospective case-note review was performed on 100 patients discussed at the benign biopsy MDT between June and August 2020. Clinicopathological data was collected on presenting symptoms, histopathology, management, and subsequent requirement for F2F appointment.

Results

Median age was 43 years (range 25-88). Eighty-one patients (81%) presented with a lump or nipple discharge. The final diagnosis was normal in 22(22%) patients, a diagnosis of fibroadenoma in 35(35%), a B3 lesion in 8 (8%) patients and another benign diagnosis in the remaining 35(35%) patients. Sixteen (16%) patients required surgery or vacuum-assisted-Biopsy, 18(18%) required further clinical or radiology follow up and 66(66%) were reassured and discharged. Forty-three (43%) patients were informed of the MDT plan by letter and 42(42%) by telephone. There were no malignancies identified in any patients. Fourteen (14%) patients required a F2F appointment most commonly because of further clinical review, patient request or interpreter requirements.

Conclusions

The vast majority of patients undergoing benign biopsy can avoid a further F2F appointment, even if further biopsies or intervention is needed. This can reduce the burden on outpatient clinics whilst improving patient convenience.
99 Computed Tomography Scanning for Sternal Wound Infections: A Systematic Review
Authors: Shirke M M , Dominic C , Debnath P , Sunny J T , Haq M , Nawaz H , Harky A
Published: August 2023

Aim

Sternal wound infection (SWI) has always been a significant risk in patients who undergo sternotomies as part of their cardiac surgical procedures. Computed tomography (CT) imaging is often used to diagnose and assess sternal wound infections. Its purpose includes identifying and locating infection and any sternal dehiscence.

Method

A systematic literature review across PubMed, Embase and Ovid was performed according to PRISMA guidelines to identify relevant articles that discussed the utility of CT scanning for SWI, common features identified, patient outcomes and sensitivity/specificity (Figure 1).

Results

25 papers were included. 100% (n = 25) of the papers were published in peer-reviewed journals. CT scans in SWIs can be seen as a beneficial aid in diagnosing as well as determining the components of infection. Commonalities were identified such as fluid collection in the mediastinum, free gas, pleural effusions, and sternal dehiscence which point towards sternal wound infection.

Conclusions

CT scanning is a novel and emerging methodology for imaging in SWI and post-sternotomy complications; hence, increased research is required to expand the literature on this area and create guidelines and cut-offs or signs for radiology professionals to identify and determine the extent of infection.
198 Clinical and Radiological Features of Cardiac Hydatid Cysts: A Case Series
Authors: Zebirate L , Bouchenafa S , Boukli Hacene A Z , Draou N E , Atbi M
Published: August 2023

Aim

Hydatid cyst disease is a pathology caused by tapeworm Echinococcus. The cardiac involvement is rare, so the aim of this study is to highlight its clinical polymorphism and different radiological features.

Method

This is a retrospective study of 7 patients diagnosed with cardiac hydatid cysts who were admitted to our department in a 5-year duration.

Results

We see that most affected individuals were women (4 out of 7), the revealing symptoms were mostly chest pain and dyspnea, only one case presented AV block with faintness. Concerning the localizations: 2 patients had pericardial cysts, 2 had intramyocardial cysts, 2 others had both pericardial and intramyocardial cysts and the last one presented an interventricular septum cyst. Six patients were diagnosed through transthoracic echocardiography (TTE) and one patient with CT of the chest. In all cases, TTE described a cystic mass except one case that presented multivesicular aspect. The diameter of the cysts ranged between 20 and 88 mm. Two patients had associated liver hydatid cyst and one had pulmonary hydatid cyst. All these patients underwent open-heart surgery for conservative treatment under cardiopulmonary bypass. Only one patient presented recurrence which was treated with albendazole with good results. No patient benefited from pre-operative medication with anthelmintic.

Conclusions

Cardiac hydatic cysts are rare and usually discovered after dyspnea or chest pain. TTE is the most efficient method of diagnosis. Due to life-threatening complications that these cysts can cause, surgery is the main modality of treatment.
95 Case Report: A Rare Case of Juvenile Hyaline Fibromatosis Presenting with Bilateral Acro-Osteolysis
Authors: Wen J , Heras-Palou C
Published: August 2023

Aim

We report a rare case of juvenile hyaline fibromatosis (JHF) leading to acro-osteolysis of bilateral hands in a 54-year-old male patient.

Method

JHF is an autosomal recessive condition resulting from a mutation of the ANTXR2/ CMG2 gene. It results in an accumulation of hyaline amorphous deposits in the skin and other organs. Other cardinal manifestations include gingival hyperplasia, flexion contracture of large joints and lytic lesions of the long bones.

This right-handed window cleaner was referred to a specialist hand unit due to the debilitating accumulation of nodular skin lesions on his bilateral hands. X-ray demonstrated apparent osteolysis to multiple distal phalanges of his bilateral hands.

The patient was experiencing difficulties with gripping, leading to barriers to completing his activities of daily living and performing competently within his occupation.

Results

Currently, there is no cure for this condition. Our patient underwent a total of nine operations over 10 years. Key indications for surgery included ulcerations of the hand lesions or optimising functional and aesthetic outcomes. Radiotherapy and chemotherapy were also attempted with limited beneficial results.

Conclusions

Our case has highlighted that JHF is an important differential to be considered by hand surgeons when presented with acro-osteolysis of the hand. This is a chronic disease that requires a multidisciplinary team approach to addressing both the social and physical manifestations of the disease. The likelihood of multiple operations is high. Therefore, careful stratification of surgical intervention coupled with shared decision-making with the patient throughout this process is fundamental.
278 Ewing's Sarcoma of the Duodenum: A Rare Case Presentation and Review of Literature
Authors: Saiyed S , Mownah O , Bowles M , Kanwar A
Published: August 2023

Introduction

Ewing's sarcoma (ES) is a rare tumour with a tendency to metastasise early and recur. It commonly affects paediatric patients. The most common subdivision comprising 70% of all ES is Ewing's sarcoma of the bone. A review of the literature identified only 5 cases worldwide of primary ES arising from the duodenum.

Case presentation

We present a case of a 42-year-old man with no prior medical history who presented with right-sided abdominal pain. A computed tomography scan of the abdomen demonstrated a 7.7cm heterogeneous mass arising from the second part of the duodenum. Oesophagogastroduodenoscopy confirmed a malignant appearing duodenal lesion with biopsy showing features consistent with small cell carcinoma. The patient underwent three cycles of neoadjuvant chemotherapy followed by elective Kausch-Whipple pancreaticoduodenectomy. A combination of immunohistochemistry and molecular studies confirmed the diagnosis of a rare Ewing sarcoma tumour originating from the duodenum with invasion into the duodenal lumen. The patient recovered well from surgery and remains disease-free 18 months following resection.

Discussion

Literature search revealed this to be an extremely rare case. The optimal treatment strategy for patients with intestinal ES is unclear, with the results of the literature search demonstrating poor outcomes following surgical resection. The long-term prognosis of intestinal ES is unknown due to its rarity. Determinants of poor outcome include tumour size >5cm, tumours involving the pelvic site, old age, non-response to chemotherapy and presence of metastases. In the case we report, the combination of neoadjuvant chemotherapy and surgery led to a good short-term post-operative outcome.
310 Rare Elusive Cause of Significant Haematuria – Case Series and Review of Literature
Authors: Waqar M , Mathias S J , Murali V , Thursby H , Luscombe C , James R , Mak D , Chakravarti A , Day C P , Dyer J
Published: August 2023

Arterioureteral fistula (AUF) is a direct communication between the ureter and an artery and is a rare cause of catastrophic, life-threatening haematuria. Fistulation may occur between the ureter and the abdominal aorta, common iliac, external and internal iliac and inferior mesenteric arteries and is typically observed in patients with a prior history of pelvic radiotherapy, oncological pelvic surgeries, aortoiliac vascular procedures and pelvic exenteration. As AUF is so rarely encountered in clinical practice, the urologist may fail to appreciate its presence until late in the patient’s presentation. We are presenting case series as well as review of literature.

Patient number 1 presented with repeated episodic large volume haematuria in whom the cause of symptoms remained persistently elusive despite repeated imaging. An eventual diagnosis of a secondary right internal iliac - ureteral fistula was ascertained on a subsequent Digital Subtraction Angiography of the renal tract. The fistula was embolised using an endovascular approach. The patient remained stable post emobilisation and was successfully discharged.

Patient number 2 presented with haematuria from her ileal conduit. Initially the cause of symptoms was thought to be due to ureteric stents. During change in her stents, brisk bleeding led to further investigation including iliac angiogram confirming bleeding from left common iliac artery. She had covered common iliac artery stent which successfully controlled her bleeding.

These cases emphasise the diagnostic difficulty of AUF, outlines the management principles of this rare disease and aims to increase awareness of this rare yet potentially lethal phenomenon amongst practitioners of urology and interventional radiology.
365 Subdural Haematoma Associated with a Dandy-Walker Malformation in an Adolescent Karate Athlete - a Case Report
Authors: Wellington J , Estrada L Valéry C
Published: August 2023

Introduction

The Dandy-Walker Malformation (DWM), retrospectively named after Walter Dandy and Arthur Walker as failure to perforate the Luschka and Magendie Foramina, is believed to be the absence of an aperture of the posterior membranous area. Said incidence is reported between 1:25000-1:35000 live births. We describe an unusual case of an adolescent who suffered a moderate traumatic brain injury (TBI) while practising karate presenting with an acute subdural haematoma (ASH) associated with a DWM.

Case Report

A fifteen-year-old Mexican adolescent with depression and anxiety presented to the emergency department 30 minutes post-direct head trauma during a karate competition. At first evaluation, the patient exhibited GCS 14 with bifrontal headache, disorientation, and six episodes of projectile vomiting. CT head revealed a right ASH with 10mm thickness and a 5.7mm midline shift. Posterior fossa malformation characterised by vermis hypoplasia and 4th ventricle cystic dilatation was also observed. An emergency craniotomy was performed, finding an ASH associated with Labbe Vein rupture near its transverse sinus drainage. Post-intervention, the patient was transferred to ICU and made an excellent recovery, discharged 2 weeks post-TBI without neurological sequelae.

Discussion

DWM is the most prevalent cerebellar malformation in humans, linked to psychiatric conditions comprising refractory schizophrenia, poor impulse control, and depression. Approximately 90% develop hydrocephalus with associated anomalies such as corpus callosum agenesis and posterior cerebellar vermis. In karate, the most frequent injuries are haematomas and tooth avulsion/subluxation. To our knowledge, this is the first case of ASH with an associated DWM in a karate athlete.
571 Squamous Cell Carcinoma After Adjustable Gastric Banding - a Case Report
Authors: Abbud N , Ackroyd R
Published: August 2023

Laparoscopic adjustable gastric banding (LAGB) is a widely accepted and effective bariatric procedure. Gastric cancer following bariatric surgery is uncommon, with only a few occurrences reported. There are nine incidences of gastric adenocarcinoma after gastric banding recorded in the literature. Squamous cell carcinoma (SCC) by comparison, is encountered far less in overall stomach malignancies. We describe the case of a 69-year-old woman who, seven years after having a gastric band placed, developed squamous cell cancer at the site of the band.

The patient initially presented with epigastric pain, and on endoscopy there was evidence of an ulcer at the gastric cardia. Extensive adhesions were also visualised around the gastroesophageal junction as a result of the band. Biopsies and staging laparoscopy confirmed a T3 N0, M0 R0 SCC of the stomach.

This is the first case report to document this rare sequela of events. We postulate that the squamous cell cancer developed secondary to chronic irritation at the site of the gastric band. Whilst rare, and symptoms vague, there is an argument to maintain a high index for suspicion of gastric cancer even following bariatric procedures.