bluuebunny/crossref_metadata_2025 huggingface dataset:
530 Repatriation of Care for Ambulatory Orthopaedic Trauma Patients Audit
Authors: Barter R , Morgan C , Wilkes I , Matthews E , Sinha I
Published: August 2024

Aim

The safe repatriation of care for non-local ambulatory orthopaedic trauma patients to their local trust is vital. Poor documentation and communication between trusts leads to delayed treatment and poor outcomes. Thorough documentation is required to prove that a satisfactory referral has been made. This audit, with two-closed loop cycles, aimed to improve the repatriation process.

Method

At a London MTC, electronic patient records were reviewed over a one-month period, examining 6 areas to assess referral quality to local trusts (initial data collection, n=17). Interventions were implemented, followed by a re-audit over a further one-month period (n=25), which was then repeated (n=18) after secondary interventions.

Initial interventions consisted of the development of new departmental guidelines (referral pathway, electronic repatriation letter template, patient information e-leaflet). Secondary interventions consisted of educational posters and a doctor tutorial. Audit standards: BOAST Fracture Clinic Services and trust recommendations.

Results

Documentation of: Named local trust in clerking, 65% to 96% to 89%; Evidence of phone referral, 94% to 96% to 100%; SHO/registrar’s name taking referral, 24% to 88% to 94%; Local trust Consultant on-call’s name, 6% to 48% to 83%; Repatriation letter sent to local trust, 0%* to 92% to 94%. Uploading of the repatriation letter to electronic record, 0%* to 40% to 89% (*letter only introduced during initial interventions).

Conclusions

Improvements have been made in all areas, increasing the quality and accountability in referrals to local trusts. We recommend the introduction of formal referral pathways for non-local ambulatory orthopaedic trauma patients to prevent miscommunication and treatment delays.
730 Current Management of Acute Lower Gastrointestinal Bleeding: Experience from a District General Hospital
Authors: Shahdoost-Rad A , Scout E , Foster J
Published: August 2024

Aim

To evaluate current practice at a District General Hospital for the management of patients with lower gastrointestinal bleed (LGIB) in the context of the 2019 British Society of Gastroenterology (BSG) guidelines.

Method

Consecutive patients presenting with acute LGIB over an 8-month period in 2022 were identified from a prospectively-maintained repository. Exclusion criteria included upper gastrointestinal bleeds, ambulatory patients and LGIB whilst already inpatients. A retrospective case note review was conducted using hospital IT systems and patient notes. Patients were categorised as “major” or “minor” bleeds, as per the BSG treatment algorithm. Data was extracted on demographics, investigation, and management of LGIB and compared with the guideline recommendations.

Results

48 patients were included in this study: 25 males and 23 females. Median age was 75 years (range 34-98). 42 patients had a major bleed, of which 17 underwent flexible sigmoidoscopy (40%), three performed as an inpatient. Eight patients underwent colonoscopy (19%), with one performed as an inpatient. Of seven patients who received blood products, five were in line with recommended blood transfusion triggers (71%). Of 14 patients admitted on either warfarin or a direct oral anticoagulant, 12 were appropriately suspended on admission (85%).

Conclusions

We demonstrate adherence to a number of the recommendations of the BSG guidelines for LGIB. At our unit there was a preference for outpatient sigmoidoscopy for stable patients rather than inpatient colonoscopy as recommended in the guideline. This may reflect a weak level of evidence in support of this recommendation.
777 Local Audit Based on MAGIC Study to Improve Abscess Management at Royal Devon University Healthcare Trust
Authors: Shams O , Alexiadis A , Khirfan H , Ragatha R
Published: August 2024

Aim

To assess efficacy of current management approaches of subcutaneous abscess at the Royal Devon University Healthcare Trust (RD&E).

Method

Our audit is based on the MAGIC (Management of Acute surGIcal absCesses) national audit which involved anonymous retrospective analysis of patient records at the RD&E during September – December 2022. We collected data on patient demographics, clinical characteristics, and their management. Furthermore, we conducted a literature review to compare our results to the recommended practice.

Results

31 patients records were analysed whereby 22 underwent surgical intervention (general anesthetic 17, local anesthetic 5) whereby the most common incision type was transverse (n=7). Nine patients were diabetic, two were immunosuppressed, 29 had hidradenitis suppurativa, while 19 had a past medical history of abscesses (n=31). The most common abscess type was pilonidal sinus (n=10). Eighteen patients received antibiotics prior to hospital admission, 12 of whom underwent surgery. Furthermore, 19 patients received antibiotics upon admission to hospital (n=31). Of the surgically treated cohort, 19 underwent packing and six were discharged with antibiotics.

Conclusions

Most subcutaneous abscess are approached surgically. However, postoperative care varies widely, with prolonged packing and frequent use of antibiotic postoperatively. Literature reviews have suggested no benefit of postoperative packing and specified certain circumstances of antibiotic use. Furthermore, clear communication with primary care providers detailing clear postoperative instructions is vital for patient safety and cost effectiveness.
1056 Audit of Compliance with Local Guidelines on Opioid and Laxative Co-Prescribing in General Surgery Patients at the Queen Elizabeth Hospital Birmingham
Authors: Zhan R , Dobrzycka M , Loyala J V , Elserafy A , Tan B
Published: August 2024

Aim

Constipation is a well-known side-effect of opioids, which are often prescribed in post-operative patients already at risk of ileus. Opioid associated constipation can further affect postoperative recovery and delay discharge. University Hospitals Birmingham guidelines suggest patients prescribed regular or as-required opioids for >1 day should be co-prescribed both stimulant and softener laxatives. This audit aims to assess compliance with these guidelines in the General Surgery department at the Queen Elizabeth Hospital Birmingham.

Method

Inpatients under the upper gastrointestinal, sarcoma, and colorectal teams on a single date were identified and included. Retrospective review of drug charts was undertaken to identify patients prescribed opioids for >1 day and those co-prescribed laxatives. Stool charts were reviewed to assess bowel opening and Bristol stool charting.

Results

87% (n=35) out of 40 patients were prescribed opioids. 34% (n=12) of these patients were co-prescribed laxatives; only 17% (n=6) were co-prescribed laxatives with both stimulant and softener action. Bowel motions were charted for 74% (n=26) of patients prescribed opioids.

Conclusions

Compliance with local guidelines on co-prescribing of laxatives with opioids is below expected. Accurate documentation of bowel motions and Bristol stool charting is important in guiding on laxative indication and prescription to prevent opioid associated constipation. Results of this audit will be shared with the department and education provided. Nursing staff will be encouraged to complete bowel charting in patients prescribed opioids. A re-audit will be undertaken after these measures are implemented.
1083 Assessment of Antibiotic Prescribing Compliance: Are We Adhering to NICE Guidelines for Recording Stop/Review Dates in Surgical Wards- A Closed Loop Audit
Authors: Noor M , Szentpali A , Anyanechi E M , Ghosh A , Richardson J
Published: August 2024

Aim

We've noticed instances where general surgical patients received antibiotics without a recorded stop/ review date in electronic prescribing system, potentially exceeding the recommended duration resulting in neutropenic sepsis in one instance . We aim to ensure compliance with NICE antibiotic prescribing guidelines by reviewing our practices and making necessary improvements for better patient care.

Method

Initial retrospective data analysis involved 50 inpatients receiving antibiotics in the surgical ward. For the subsequent re-audit, we implemented interventions and performed a prospective analysis on data from 40 patients over a two-week period in the same ward.

Results

Initial Audit Findings: Only 56% of patients had a recorded stop/review date for antibiotics. Discussions with junior doctors highlighted several reasons:

Lack of Awareness of the NICE guideline of antibiotics stewardship.

Patient Transfers: Patients moving between teams resulted in existing prescriptions without updated reviews.

Paper Documentation: Decisions about antibiotics were documented in paper notes, not reflected on electronic prescribing system.

Based on these findings, we implemented the following interventions: informal discussions and an email to junior doctors highlighting the findings and relevant NICE guidelines, along with placing physical posters in doctors' stations for easy reference. In the re-audit, 61.1% of patients had recorded stop/review dates, indicating more than 10% improvement.

Conclusions

Following discussions with prescribers post re-audit, our plan involves engaging with the electronic prescribing system. We propose adding an option to input review dates and making it mandatory to include stop/ review date when prescribing antibiotics to ensure sustained adherence to NICE guideline.
590 VTE Prophylaxis Post-Thoracic Cancer Surgery: An Audit
Authors: Ahmed A , Jesuyajolu D , Fontaine E
Published: August 2024

Aim

The administration of extended VTE prophylaxis for 28 days has been recommended by NICE for patients following major cancer surgery in the abdomen or pelvis. Manchester Foundation Trust (MFT) has expanded upon this guideline to include patients having thoracic cancer surgery. However, the policy is occasionally not adhered to, owing to prescription errors and more. Our aim was to investigate policy compliance and identify areas for improvement to help optimise patient safety.

Method

For the first cycle, electronic records were scrutinised for patients who had thoracic surgery between 1st August 2023 to 14th August 2023 to ascertain if the above policy was followed. This included calculating the number of days for which Dalteparin was administered whilst the patient was in hospital, or, if the patient was discharged, (as in most cases), how many doses they were discharged with. Following this, a poster was created describing the MFT protocol and distributed across the thoracic ward, with an electronic version being sent on a secure messaging application to junior members of the team. For the second cycle the same method was adopted over a two-week period starting on 23rd October 2023.

Results

The first cycle demonstrated compliance as 82%. Following the intervention, compliance had increased to 90%.

Conclusions

The distribution of the poster highlighting the protocol had increased the number of patients receiving the correct VTE prophylaxis. However, with VTE being a serious post-operative complication, it is essential to aim for 100% compliance. Perhaps this can be achieved through further intervention such as departmental teaching.
999 A Review of Left Atrial Appendage Occlusion for Peri-Operative Thromboembolic Risk Reduction at a Single Institution
Authors: Singh C , Hamid U , Chacko J , Nicou N , Boulemden A , Szafranek A , Qureshi S
Published: August 2024

Aim

Left Atrial Appendage Occlusion for thromboembolic risk reduction in patients with AF undergoing cardiac surgery is evidence-supported. We explored our practice to understand the scale of AF burden and challenges in undertaking adequate Left Atrial Appendage occlusion therapy in cardiac surgical patients.

Method

This was a retrospective analysis of surgical database, hospital records, and post-op re-admission spells with AF or with acute neurological events.

Results

Between Jan 2019 and Jan 2023 there were n=108 (5%) re-admissions due to AF and 39 (1.8%) secondary to AF-related Stroke/TIA. Fifty-seven (n=57, 38%) of these underwent DC cardioversion. Median time to re-admission was 2 months (range: <1 month-2 years) with AF, and 4 months (range: 1 month-5 years) with neuro-thromboembolism.

In a cohort of n=144 patients undergoing cardiac surgery with pre-existing AF(Paroxysmal/established), 70 patients (48.6%) underwent concomitant Left Atrial Appendage clip application (size 35mm-45mm). In non-recipients (n=74, 51%); emergency/urgent status, redo surgery, and small LAA were the commonest reasons for non-application. Post-op anticoagulation was instituted in all with few exceptions. Four patients (2.7%) in the non-recipient group had a previous history of stroke. Two patients (1.3%) in the non-recipients had new post-op stroke whereas no patient in the recipient group had post-op stroke. Overall mortality in non-recipients was n=17, 23%, and in recipients was n=4, 5%.

Conclusions

Contemporary evidence supports significant thromboembolic risk reduction with Left Atrial Appendage Clip application. Our experience underpins benefits in a disease spectrum that is associated with significant morbidity and resource utilisation.
312 Giant Hepatic Cyst Misdiagnosed as Pancreatic-Pseudocyst: A Case Report
Authors: AlHassan N , Olaniyi O
Published: August 2024

Background

A hepatic cyst is a benign hepatic tumor that is usually asymptomatic with normal liver function tests. The diagnosis of hepatic cyst is sometimes incidental on exploratory laparotomy as misdiagnosis may occur upon radiological investigations. Different modalities of treatment of symptomatic cysts include percutaneous aspiration, injection of sclerosing agents, laparoscopic or open fenestration, and surgical cystectomy.

Aim

To highlight clinical and radiological challenges in the diagnosis of hepatic cysts and different management modalities.

Case

We present a case of a 3-year-old boy with an 8-month history of progressive abdominal distension. There was no history of jaundice or abdominal pain. No history of leg swelling or decreased urine output and no preceding abdominal trauma. A radiological assessment of pancreatic pseudocyst was made. Exploratory laparotomy revealed a giant hepatic cyst on the right and left lobe more on the anterior surface. The gallbladder was separate from the cyst. The cyst was completely excised and weighed 9kg. The histology report was in keeping with mesenchymal harmatoma.

Conclusions

A hepatic cyst is a benign tumor of the liver ranging from small to huge size causing compression of the adjacent structure. It is usually asymptomatic with rare malignant potential. A giant hepatic cyst poses a diagnostic radiological challenge leading to misdiagnosis which affects patient management. It is recommended that a giant hepatic cyst should be considered as a differential diagnosis of intra-abdominal masses.
683 An Aberrant Retropharyngeal Internal Carotid Artery (ICA) Associated with Airway Obstruction: A Case Report
Authors: Holland J
Published: August 2024

Background

The ICA ascends towards the skull base in the carotid sheath, posterolateral to the posterior pharyngeal wall. Various patterns of congenital and acquired ICA anomalies in relation to the pharynx have been described in the literature. Very few studies have associated these anatomical variations with clinical symptoms of airway obstruction.

Case report

An 85-year-old female patient presented to Accident & Emergency (A&E) with a recent history of several discrete episodes of positional airway obstruction on leaning forward. The description of symptoms from patient and first responders was consistent with stridor. No other relevant medical history was identified. Flexible nasal endoscopic examination (FNE) revealed a smooth pulsatile lesion in the posterior pharyngeal wall. No other abnormality was detected. CT head and neck characterized an anatomically aberrant and tortuous internal carotid artery in the retropharynx, partially obstructing the oropharynx/supraglottis. The patient was monitored for 48 hours without incident. No further treatment was recommended due to her frailty, and she was discharged with a telephone follow up.

Conclusions

Although causality cannot be proven, the partial obstruction of her airway by a large aberrant ICA vessel provides a likely explanation for her symptoms. No other cause for her symptoms was identified. This interesting case presents an unusual differential diagnosis for positional airway obstruction. It also highlights a rare but important anatomical variation in the path of the ICA which ought to be considered during oropharyngeal or laryngeal surgery to avoid catastrophic arterial injury.
974 Unexpected Finding of Fish Bone Perforation of Pylorus in a Patient with Epigastric Pain and Fevers
Authors: Tong C W , Alhayo S , Chu F
Published: August 2024

Objective

This case report describes an uncommon presentation of epigastric pain from pyloric perforation secondary to ingestion of a fish bone. The objective is to emphasize the need for increased awareness of foreign body ingestion as a differential for acute abdominal pain. Prompt diagnosis and endoscopic intervention is required in cases of gastrointestinal perforation due to foreign bodies.

Case

We describe a 43-year-old man G with a background of Crohn’s disease presenting with 2 days of epigastric and right upper quadrant abdominal pain, associated with fevers and loose stools. He had signs of epigastric tenderness with localised peritonitis and raised inflammatory markers. G was initially thought to have cholecystitis or Crohn’s flare up hence a computed tomography (CT) was requested, which surprisingly identified a fish bone lodged in the pyloric wall with evidence of localised fat stranding. Urgent gastroscopy performed confirmed a 3cm fish bone lodged in pylorus, which was successfully removed. G recovered well without complications and was discharged on postoperative day three.

Discussion

Accidental ingestion of fish bones is not uncommon, however, only 1% of cases cause gastrointestinal perforation. We explored the complexities of diagnosing gastrointestinal perforations, the role of CT in localisation and endoscopy as a first line intervention whenever feasible.

Conclusions

This case report highlights the importance of recognising foreign body perforation as a differential diagnosis in patients with acute abdominal pain and fevers. Endoscopic intervention is valuable in facilitating the extraction of foreign objects with minimal complications.
1060 A Rare Case of Upper Gastrointestinal Bleeding - Case Report
Authors: Rudwan A A , Al Badi N , Forde N , Al Bakhour A B , Haidaran A I D
Published: August 2024

The most common causes of upper gastrointestinal bleeds (UGIB) are peptic and posterior duodenal ulcers, usually resulting from a gastroduodenal artery (GDA) bleed. We present a case of a patient who suffered from an UGIB after the commencement of Apixiban to treat newly diagnosed Atrial Fibrillation. Despite endoscopic intervention, clear computed tomography angiography (CTA) and GDA embolisation, bleeding persisted leading to a hypovolemic shock. (Interventional Radiology images)

This is a rare occurrence which led the team to request a second CTA, revealing extravasation of contrast in the duodenum. This indicated persistence of bleeding which consequently led to an emergent surgery. The patient underwent an exploratory laparotomy and an ulcer was discovered during intraoperative endoscopy.

Because of the position of the ulcer in the posterior-lateral duodenal wall, and its persistence in bleeding despite GDA embolisation it is suspected that the bleeder was most likely to be the inferior pancreaticoduodenal artery (IPDA) or an aberrant blood vessel.

Our teaching points focus on the importance of considering the pancreaticoduodenal anastomosis and other anatomical variants as sources of bleeding when managing an UGIB.
1064 Cystic Parathyroid Adenoma: A Rare Occurrence in Setting of Stage IV Chronic Kidney Disease with Tertiary Hyperparathyroidism
Authors: McKnight K , Griffin K , Al Kendi B , Kerin M , Abd Elwahab S
Published: August 2024

Background

Cystic parathyroid adenomas represent a rare subtype of parathyroid adenomas characterised by cystic degeneration for which surgical intervention is the only curative treatment. Conservative medical management is a suitable option for patients with multiple comorbidities or mild symptoms. To our knowledge this is the first case of a bilobed cystic parathyroid adenoma in a patient with tertiary hyperparathyroidism secondary to long standing chronic kidney disease.

Case presentation: A 65-year-old lady with stage IV CKD was referred to the endocrine surgical department having presented with hip pain. Investigations revealed hypercalcaemia, high parathyroid hormone in the setting of bilateral small echogenic kidneys. Imaging identified a bilobed parathyroid mass. 99m-technetium sestamibi scan confirmed a parathyroid adenoma. Having failed conservative management a minimally invasive parathyroidectomy was performed with histological analysis reporting a cystic parathyroid adenoma.

Conclusions

Cystic parathyroid adenomas are a rare cause of tertiary hyperparathyroidism and usually present with signs and symptoms of high calcium and high parathyroid hormone. Accurate diagnosis requires a combination of laboratory investigations and imaging. Management commonly involves surgical resection especially following failure of conservative treatments.
1254 Radiofrequency Ablation for Treatment of Hemorrhoid Disease, Minimally Invasive Novel Treatment
Authors: Maharjan A , Ngo V , Win M , Rajaganeshan R
Published: August 2024

Aim

To describe our radiofrequency ablation(RFA) result, assessing patient symptoms and quality of life (QoL) before and after the intervention. We aim to evaluate the outcomes of this alternative procedure for managing grade 2-3 haemorrhoids at a single centre. Haemorrhoids are the most common surgical presentations, affecting up to 1 in 3 people. An alternative procedure is the use of radiofrequency ablation (RFA) to shrink and treat the haemorrhoids under local anaesthetic. The management is dependent on the severity of symptoms and the grade of haemorrhoids.

Method

A single centre retrospective study between March 2022 and July 2023 of patients who had RAFAELO under local anaesthetic without sedation for the treatment of grade 2-3 haemorrhoids. Primary outcomes were assessed by haemorrhoid severity score (HSS) and EQ-5D-5L VAS score before and after the procedure at 2-4 months and 12 months.

Results

53 patients were included for analysis. The mean age of patients was 55 years old (SD+/-14) with a 2:3 ratio of female to male. 14% of patients had grade 2 haemorrhoids and 86% had grade 3 Hemorrhoids. The mean HSS score pre-op was 13.78 which improved to mean post-op score of 5.6. The mean EQ-5D-5L VAS pre-op score was 64.75 which decreased to mean post-op of 28.49.

Conclusions

This study supports that RAFAELO is a safe and effective procedure and can be performed in the outpatient setting. However, further studies with larger samples, longer follow-up and comparison with other procedures are still required.
1035 Digitally Enabled Pathways: A New Era for Otology and Rhinology Services
Authors: Spinos D , Lee J , Beech T , Coulson C , Muzaffar J
Published: August 2024

Introduction

Hearing and ear problems, alongside nasal symptoms, are common concerns in both primary and secondary healthcare worldwide. The advent of telemedicine has yielded promising results, reducing the waiting lists for specialist ENT review, and offering access to care to deprived and isolated communities. Although the benefits of remote ENT services have been highlighted throughout the literature, there is a significant lack of homogeneity in both the outcome measures of the different authors, but also the modality of technology employed. We undertook a scoping review to map all these interventions, identify their potential benefits and also highlight any potentially unexplored areas.

Method

We undertook a scoping review, following the principles of PRISMA-ScR guidelines. We reviewed four different databases- MEDLINE, EMBASE, Google Scholar and Cochrane Library.

Results

Initially 208 articles were identified for title and review. Reviews were excluded but used for snowball sampling. Full text review was performed for 88 articles, reporting a wide spectrum of applications being reported, including screening, diagnosis and intervention utilising both synchronous and asynchronous methods. An even wider range of interventions were mapped, including boothless audiometry, otoscopy, nasal endoscopy, and photographic assessment of nasal deviation. Different authors used qualitative, quantitative or mixed methods to assess the effect of their intervention, reporting patient and stakeholder satisfaction, economic benefit, face to face conversion rates and diagnostic accuracy.

Conclusions

Remote ENT is a new service delivery method with growing evidence across its different aspects highlighting its safety and efficiency, supporting its further expansion.
481 Management of Perianal Abscess at Basildon and Thurrock University Hospital
Authors: Lesi O , Islam T , Ahmad S , McDowell K
Published: August 2024

Aim

Perianal abscess is a common surgical presentation seen in the emergency secondary care setting; our aim is to evaluate the current surgical management at Basildon Hospital.

Method

A questionnaire was distributed amongst 24 surgical colleagues varying from consultants, registrars/SAS and core trainees to review their current management of perianal abscess. In conjunction, for comparison an audit was conducted of surgical operation notes for 35 perianal abscesses drained between April and September 2023.

Results

Following 17 responses to the questionnaire, the most common incision made was cruciate (41.20%), with radial being the least (11.80%). In addition, 47.10% reported documenting to continue packing post-operatively, with an equal proportion not doing so. Microbiology culture was routinely sent by 88.20% of respondents. In comparison, the audit concurred a cruciate incision was most commonly performed (25.71%), with radial, transverse and elliptical incisions equally the least performed (5.71%). Furthermore, 97.14% of cases had a post-operative plan instruction to continue regular packing, with this being dis-concordant with results of the questionnaire. In 91.42% of cases a microbiology culture was sent intra-operatively.

Conclusions

Amongst surgeons at Basildon variation exists in the incision utilised to drain perianal abscesses, however a circumanal incision is currently recommended by ACPGBI guidelines to avoid damage to external sphincters. Packing is persistently part of post-operative management plans despite studies demonstrating that this increases pain for patients as well as cost. The role of routine microbiology sampling must be reviewed in the department as it is of limited value in the management of patients with perianal abscess.
707 How Do Consultant Surgeons Identify Malnutrition in the Emergency Setting, What Are the Barriers and What Is the Impact for Patients? a Qualitative Study
Authors: Ashmore D , Baker D , Wilson T , Halliday V , Lee M
Published: August 2024

Background

Patients undergoing an emergency laparotomy are often malnourished. Identifying malnourished patients is a prerequisite to offering targeted nutritional support. This study explores how consultants identify malnourished patients, why they use that approach and the barriers experienced.

Method

General surgical consultants involved in emergency surgery were invited. We used purposive sampling to ensure a broad representation of consultant experience across different practice settings. Following ethical approval (University of Sheffield 050436), semi-structured interviews were conducted online, audio-visually recorded, and transcribed verbatim. Interviews were coded and analysed in NVivo. A framework was developed and reviewed by an independent researcher and supervising team. Interviews continued until saturation.

Results

Eighteen interviews were conducted (14 male, consultant experience ranging 6 months-23 years) across three hospital settings (4 district general, 10 teaching, 4 intestinal failure unit). Identifying malnutrition consisted of three themes: ‘surgeon’ (knowledge, experience, planning ahead); ‘patient’ (selection, composition, clinical progress, operative considerations); and ‘institution’ (collaboration, extended surgical team). Three themes also encompassed the barriers experienced: ‘surgeon’ (understanding, culture, ownership, time constraints); ‘institution’ (provision, staffing, conflict, hospital setting); and ‘wider context’ (research, external factors). These influenced clinical decision making, which had two themes; ‘to join or not to join’ (risk taking, site of anastomosis) and ‘nutritional support’ (timing, delivery).

Conclusions

This study highlights a range of barriers that consultants experience when assessing patients for malnutrition, which affects operative and clinical decision making. It provides a framework upon which issues can be addressed by surgeons and policy makers in order to improve outcomes for malnourished patients.
1014 Vermi-Bourne Appendicitis - More Common Than You Might Think
Authors: Seehra J , Boam T , Gemmill E
Published: August 2024

Aim

Enterobius vermicularis is a common parasitic infection, however its direct association with acute appendicitis remains highly debated. Systematic reviews in the African and American continents have identified prevalence of E.vermicularis-associated appendicitis ranging from 33% in Nigeria to <1% in Venezuela with an average global prevalence of 4%. UK rates are poorly documented. We aim to investigate prevalence and histological effects of E.vermicularis associated with acute paediatric appendicitis at a district general hospital.

Method

A retrospective case series of paediatric patients with aged between 5 and 16 who underwent operative intervention for presumed appendicitis between 01/08/2021 to 31/10/2023 was undertaken.

Results

Of 132 included patients, 13 patients had histologically proven E.vermicularis (9.8%) and 102 had acute appendicitis (77.3%). 11 of 13 E.vermicularis cases had associated acute appendicitis (84.6%). Majority were male patients (55.3%) with a mean age of 11.8 years. Histology identified serositis in 69.23% and lymphoid hyperplasia in 53.85% of E.vermicularis cases. None presented with acute perforation and majority cases were clinically diagnosed (92.31%) with a 7.69% readmission rate.

Conclusions

E.vermicularis should be considered as a differential causative agent for appendicitis. A tailored and specific history should be taken keeping a high level of suspicion in the paediatric population. Post-operative advice should include over-the-counter oral mebendazole for the patient and all household family members.
169 De-Mystifying the Characteristics of Gall-Bladder Malignancies in an Underdeveloped Country
Authors: Madhusudanan Pillai G , Girijavallbhan Nair P
Published: August 2024

Aim

To consolidate existing research on the epidemiology, risk factors, pathogenesis, clinical presentation, diagnostic approaches, treatment modalities, and prognostic factors associated with gallbladder malignancies.

Method

A systematic review was conducted across major databases to identify studies, case reports, and clinical trials related to gallbladder malignancies. Articles published within the last few decades were studied, and the findings were analysed and compared against a brief case review of 8 patients, who presented to a single centre in India.

Results

In our case series, 3 out of 8 patients with GBC were diagnosed post operatively on histopathology and were subjected to radical resections as a second procedure. 4 out of 8 were diagnosed at an advanced stage and treated with palliative intent and 1 was found to have metastatic disease intra operatively. The literature review covers the global prevalence, and disparities in incidence of gallbladder malignancies. It evaluates the role of imaging modalities, biomarkers, and advancements in surgical, chemotherapeutic, and targeted therapeutic interventions. Challenges in early detection and the need for effective screening programs are highlighted.

Conclusions

The synthesis of this review stresses on the need for further research and improved clinical approaches to improve the understanding, early detection, and management of gallbladder malignancies, ultimately aiming to improve patient outcomes and challenge the existing data on the epidemiology of GB malignancies in under-developed countries, thus prompting further exploration of this topic in larger prospective trials.
295 Exploring Gemcitabine and Zoledronic Acid Effects on Tumour Cell Markers: Implications for Immune Response Enhancement
Authors: Atapaka S , Bodman-Smith M
Published: August 2024

Aim

This study aims to investigate the influence of Gemcitabine (GEM) and Zoledronic Acid (ZA) on critical tumour cell markers—ULBP-1, ULBP-2, ULBP-3, MICA/B, and HLA-1—in order to enhance susceptibility to gamma-delta T cells. The research focuses on understanding how these drugs affect marker expression using Raji, Daudi, and Thp-1 cell lines.

Method

GEM and ZA were administered at varying concentrations to the cell lines, employing flow cytometry for detailed marker expression analysis. The experiment aimed to observe alterations in the expression levels of ULBP-1, ULBP-2, ULBP-3, MICA/B, and HLA-1 markers following drug exposure.

Results

ULBP-1 consistently exhibited increased expression across all cell lines, suggesting potential vulnerability of tumour cells to gamma-delta T cell attacks. However, ULBP-2 responses were inconsistent, and ULBP-3 displayed variable patterns based on the specific cell line and treatment regimen. MICA/B expression showed an increase with higher ZA concentrations, though this observation was limited. HLA-1 markers remained relatively stable across cell lines, indicating a consistent population of live cells.

Conclusions

The findings suggest that GEM and ZA may alter specific tumour cell markers, potentially enhancing vulnerability to immune responses. However, drawing definitive conclusions requires extensive experimentation and statistical analysis due to limitations such as low repetitions. Future research should involve increased repetitions and rigorous statistical tests to determine the significance of these observed marker expression changes. Ultimately, this study sets the groundwork for exploring GEM and ZA as adjuncts to conventional cancer treatments, potentially unlocking their therapeutic potential in enhancing immune responses against tumours.
307 The Impact of Bone Quality on Surgical Decision-Making in Elective Primary Total Hip Arthroplasty: A Qualitative Analysis
Authors: Abouharb A , Karia M , Sabharwal S
Published: August 2024

Aim

This inductive/deductive qualitative hybrid study aims to explore the impact of bone quality on decision-making amongst surgeons performing elective primary Total Hip Arthroplasty (THA).  

Method

Purposive and snowball sampling were used to recruit Consultant Orthopaedic Surgeons specialised in elective lower limb arthroplasty. Semi-structured interviews were conducted virtually and on Hospital premises, and audio was transcribed. An iterative inductive/deductive strategy was used to code interview transcripts, and thematic analysis was undertaken using NVivo software (Version 14.23.0), in accordance with Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Results

There were 10 surgeons from eight centres in the United Kingdom interviewed. Thematic saturation was achieved after eight interviews. Five main themes, and 13 sub-themes were identified. Bone quality impacted decisions around preoperative planning, surgical procedure, implant choice, iatrogenic injury prevention, and hip biomechanics. Many surgeons (7/10) described changing surgical procedure based on their intraoperative assessment of bone quality. There was consensus on the superiority of cemented femoral fixation in osteoporosis, and the importance of assessing X-rays preoperatively, though attitudes differed on acetabular fixation method, the utility of radiographs to measure bone quality, and current surgical guidelines.

Conclusions

Bone quality has a significant impact on the decision-making of experienced arthroplasty surgeons, though there are significant limitations in current methods of assessing it. The divergence identified amongst surgeons on the utility of X-rays to assess bone quality, and towards surgical guidelines merit further investigation.
436 Infra-Inguinal Angiogplasty Outcomes Audit Through the Lens of GRIFT and Sustainable Delivery
Authors: Saw Y C , Small E , Lumsden M
Published: August 2024

Aim

To evaluate the clinical outcomes in patients with Critical Limb Ischaemia (CLI) six months after lower limb arterial angioplasty. To quantify the risk of index limb loss within our cohort and develop a dataset for further audit and quality improvement. Assess surgical resource usage and reconcile with national Getting It Right First Time (GIRFT) strategy and sustainable service delivery. Post-pandemic challenges including increased waiting lists have elevated the risk of angioplasty failure since the 2018 GIRFT Vascular Surgery Report.

Method

A Health Intelligence dataset was obtained for all lower limb angiograms for a thirteen-month period beginning in January 2022 for a single tertiary centre. Morbidity and mortality data were collected.

Results

The cohort included 129 patients with a mean age of 71.9 years (range: 39-96 years). Limb salvage was successful in 53% of patients (n=69) with 15% of patients requiring a subsequent amputation (n=19). Of patients who underwent BKA, 50% would receive the BKA within 60 days (n=9). However, the rate of debridement excluding amputation at 6 months post-angioplasty was 18% (n=23). Mortality at 6 months was 25% (n=32).

Conclusions

Lower limb angioplasty remains crucial for limb salvage and symptom control. Utilisation of pre-angioplasty prognostic scores aid in assessing procedure risk and supporting collaborative decision-making. Review of the CLI patients who required early amputation will allow for development of a stratification/scoring system to predict successful angioplasty, aligning with principles of GIRFT and promoting sustainable medical practice.
674 Patient Services Not Fit for Purpose: Analysis of Skin Cancer Pathway
Authors: Lau J , Marla A , Borra P , Parthiban S , Butler P , Ponniah A
Published: August 2024

Background

NHS public satisfaction fell to 29% in 2022; a record low in NatCen’s British Social Attitudes report since its debut in 1983. Exacerbated by COVID-19, services have redesigned to having an almost 3-fold increase in percentage of telehealth appointments. Now >40% of initial skin cancer appointments in our service are delivered remotely, an approach prioritising efficiency over patient-centred care. This study attempts to gain a comprehensive understanding of patient perceptions and attitudes in our skin cancer pathway.

Method

A snapshot survey of 103 consecutive patients, aged 22-96, 58% female, was conducted over one year at the Royal Free Hospital's skin cancer service. Data was analysed using thematic analysis, allowing for identification of recurring themes and patterns, following the American Association for Public Opinion Research’s guidelines for population analysis. Statistical analysis of frequency data was also applied.

Results

Key findings include a clear preference towards face-to-face as opposed to tele-dermatology in 62% of patients. Tele-dermatology’s primary drawback is only allowing for the assessment of one lesion in a clinic appointment, leaving 54% of patients with multiple unassessed lesions. Patients expressed satisfaction (72%) with waiting times for their initial appointment, however, 68% of patients were dissatisfied with the waiting time for their biopsy results.

Conclusions

The present configuration of services is not fit for patient needs. This study identifies key themes addressing appointment scheduling, telehealth limitations and communication preferences, offering guidance to healthcare providers to improve the quality of care for skin cancer patients, enhancing patient satisfaction and overall healthcare quality.
955 Is Non-Operative Management Equal to or Superior to Operative Management of Distal Radius Fractures for Patients Over 60?
Authors: Kim E , Walmsley P
Published: August 2024

Aim

Distal radius fractures are managed operatively with the implantation of a fixation device or conservatively with casting. However, most studies on distal radius fracture management focus on younger populations, and there is inconclusive evidence regarding the optimal management of elderly populations. This study evaluates current evidence to determine whether operative or non-operative management is superior for elderly distal radius fractures.

Method

A literature search was performed on Medline and EMBASE for papers from the year 2000 onwards. Level I-III studies that compared operative to non-operative management of distal radius fractures in patients aged 60 and above were included in this study. Data was analyzed using the Cochrane ROBINS-I and RoB 2 risk of bias tools and then formulated into forest plots and a double bar graph.

Results

13 heterogeneous studies involving 1,371 elderly patients with distal radius fractures were included. Significant bias was present in these studies, mainly with the non-comparability of treatment groups. At one year follow-up, operative management demonstrated significantly superior results in grip strength, radiographic outcome, and patient-reported outcome measures. Non-operative management demonstrated significantly lower complication rates and costs. Pain and time to union demonstrated a negligible difference between managements.

Conclusions

There is some evidence suggesting operative management provides better functional outcomes to elderly patients with distal radius fractures. Therefore, treatment should be guided by whether the patient’s functional needs outweigh the risk of complications with surgery. Additionally, intra-articular fractures were associated with osteoarthritis and high redisplacement when managed nonoperatively, potentially making operative management preferred with these patients.
966 Managing Infection Risk in Flexible Cystoscopy: An Audit and Service evaluation
Authors: Hicks O
Published: August 2024

Aim

The aim of this audit and service evaluation was to investigate the way in which the infection risk associated with diagnostic and therapeutic flexible cystoscopy was managed in one NHS trust, and to consider the impact that positive urinalysis rates prior to flexible cystoscopy had on service delivery.

Method

All appointments for both diagnostic and therapeutic flexible cystoscopy across the trust were audited prospectively for a two-month period.

Results

276 appointments were booked across this time period, of which 237 were attended and documented. Of these appointments, flexible cystoscopies went ahead in 219 patients and were completed in 215 patients, terminated early in 4 patients. Urinalysis was performed and recorded in 227 appointments. 18 asymptomatic patients tested positive for nitrites, indicating bacteriuria. 3 patients were symptomatic for urinary tract infection, including 1 patient who also underwent urinalysis and tested positive for nitrites. None of the patients who were symptomatic for urinary tract infection underwent flexible cystoscopy. Of the 18 asymptomatic patients who tested positive for nitrites, 9 were cancelled due to infection risk. Infection was the most common reason that a flexible cystoscopy did not go ahead. 72 appointments had no safety netting for infection risk documented.

Conclusions

There was an excellent rate of performing and recording urinalysis in this trust. There is room for improvement for the documentation of infection related safety netting. The decision to cancel appointments on the basis of infection risk in asymptomatic patients was taken on a case-by-case basis, though no symptomatic patients underwent flexible cystoscopy.
671 Neurosurgical Education and Training for Medical Students in the United Kingdom
Authors: Singh A , Baskaran R
Published: August 2024

Aim

Neurosurgical education in British medical schools varies due to the lack of a specialized curriculum. This study aims to evaluate the effectiveness of current practices for neurosurgical education among medical students. Acknowledging the perceived complexity for students, the primary goal is to identify obstacles to optimal learning and propose curriculum adjustments to address these challenges.

Method

A literature search was performed on Embase, Medline and Global Health using the search terms: medical student* OR medical school* AND teaching AND neurosurgery AND (United Kingdom OR UK OR England), including data from 1947 to 2023. The inclusion criteria were: (i) Neurosurgical education (ii) Medical-student (iii) United Kingdom. 8 studies were included and appraised by 2 blinded individuals. The results and conclusions were constructed into a narrative synthesis.

Results

Exposure to clinical settings such as neurosurgical operating theatres and wards plays a crucial role in augmenting students' learning and demonstrates favourable educational outcomes. While the effectiveness of neurosurgery-specific lecture series is discernible, disparities arise in the coverage of topics among medical schools due to variations in delivery methods and lecturer biases. Cumulative evidence indicates the requirement for a standardized curriculum to establish consistency and efficacy in the pedagogy of neurosurgical education.

Conclusions

The implementation of standardized guidelines is indispensable for the harmonization of neurosurgical pedagogy throughout medical schools. Augmented and structured exposure within clinical settings, alongside well-organized lecture series, constitutes an effective strategy for fostering interest and competence. This approach facilitates enhanced understanding and serves to incentivise medical students to contemplate neurosurgery as a prospective career.
131 Acute Injury of The Ulnar Collateral Ligament: Does Ultrasound Get a Thumbs Up?
Authors: Burton H , Goodarzi M , Chalmers R
Published: August 2024

Ulnar collateral ligament (UCL) injuries of the thumb constitute frequent trauma presentations. While clinical assessment proves valuable, instances arise in equivocal cases where imaging aids in determining optimal management. This project aims to assess the diagnostic efficacy of ultrasound in identifying UCL injuries.

A retrospective analysis was conducted utilizing online medical records system. Patients from the last five years who underwent thumb ultrasounds were identified and inclusion criteria encompassed: acute thumb injuries accompanied by ultrasounds indicative of full-thickness UCL tears and/or Stener lesions.

Fifty patients who underwent ultrasounds for acute thumb injuries with UCL concerns were identified. 31 were excluded with normal results or incomplete data. The remaining 19 patients had ultrasound reported complete UCL tears and/or Stener lesions and subsequently underwent operative intervention. The average age was 38.7 years; 58% were female. The median duration from presentation to ultrasound scan was 2 days, and from presentation to surgery was 4.5 days. Eleven patients (63%) exhibited a confirmed complete UCL tear during surgery; 6 patients (37%) had a normal intact UCL. Consequently, the positive predictive value of ultrasound in detecting acute UCL tears within this cohort was 63%.

It is known that accuracy of US is operator dependent and with over a third of patients in our cohort being identified as having false positive result following surgery, relying on US findings to proceed to surgery must be cautioned. It remains a valuable non-invasive investigation. For cases where the clinical picture is indeterminate, MRI is now our modality of choice.