bluuebunny/crossref_metadata_2025 huggingface dataset:
771 Heart Rate Variability as a Marker of Surgeon’s Stress and Cognitive Load Within Vascular Surgery
Authors: De Louche C D , Mandal M , Fernandes L , Lawson J , Pouncey A L , Bicknell C D
Published: August 2023

Aim

Surgeons experience significant stress levels in theatre. Acute stress can cause cognitive overload, worsening surgical performance. Chronic stress poses a substantial risk to surgeons’ health. Effectively identifying intraoperative stress may allow for preventative strategies that reduce surgeons’ stress and improve patient outcomes. Here, the feasibility of using heart rate variability (HRV) as a marker of stress during vascular surgery was assessed.

Method

11 senior surgeons were evaluated performing 3 distinct vascular surgery procedures. HRV metrics (low-frequency/high-frequency ratio and standard deviation of the normal-normal interval) were determined from single-lead ECG traces at pre-determined procedural performance points. Surgeon-reported stress was assessed using the State-Trait Anxiety Inventory-6 (STAI-6), a validated clinical stress tool. Subjective reports of procedural difficulty were also collected. One-way ANOVA compared HRV at key performance points to baseline. Pearson’s coefficient assessed correlation between HRV and subjective stress.

Results

Data was collected for 6 carotid endarterectomies, 6 open abdominal aortic aneurysm repairs, and 5 lower limb bypasses. HRV metrics indicating significantly greater stress were observed at key performance points in all procedures. Peaks in stress were consistent across different surgeons performing the same procedure. A significant correlation was observed between HRV metrics and subjective STAI-6 stress reports (r = 0.7680, p = 0.0003). HRV metrics displaying the greatest stress corresponded with the most difficult procedural steps reported.

Conclusions

HRV may present a feasible method to assess intraoperative stress and cognitive load in vascular surgery and could be used to evaluate whether a theatre intervention (e.g., timeout) could reduce stress in areas of surgical difficulty.
374 Cognitive Biases and Heuristics in Surgical Settings: A Systematic Review
Authors: Agarwal S , Aylmore H , Marcus H , Pandit A
Published: August 2023

Aim

Cognitive biases and heuristics represent mental shortcuts that can lead to errors in judgement. Both are noted in surgical settings and risk patient safety. Yet, up till now, the extent of biases in surgical settings has not been systematically reviewed.

Method

This PROSPERO registered (CRD42022334828) review was conducted in accordance with PRISMA guidelines. MEDLINE and four other major databases were searched from their inception to 28th August 2022 using “surg*” with “cognitive bia*” and “heuristics” terms. Original primary research studies in English were included, with blinded full text screening. Relevant risk of bias (RoB) tools were employed for each study.

Results

The search identified 26,640 papers. Following de-duplication and screening, 16 final papers were included. 34 biases were identified including three prospective experiments, three retrospective analyses, and 10 questionnaire studies. Confirmation and anchoring biases were the most represented. RoB analysis found broad heterogeneity, with four studies being deemed of high risk. All identified cognitive biases were found to influence relevant surgical outcomes and seven studies cited a negative impact on patient care.

Conclusions

Cognitive biases will continue to contribute to surgical errors and never events unless they are described and recognised with greater precision and de-biasing strategies are implemented. Of note, mindfulness-based training and deliberate reflection tested by two studies demonstrated reduced rates of surgical error. Nevertheless, our review demonstrates a lack of experimental studies which are crucial to understanding why and how biases contribute to negative outcomes and we suggest avenues for further research and systems change.
20 Predictors of Five-Year Recurrence and Five-Year Survival After Pancreatoduodenectomy for Ampullary Adenocarcinoma: An International Multicentre Cohort Study
Authors: Russell T , Labib P ,   RAW Study Collaborators, Aroori S
Published: August 2023

Aim

Pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence and five-year survival using a large multicentre cohort.

Method

Data were extracted from the Recurrence After Whipple’s (RAW) study, a retrospective study of PD outcomes (29 centres from 8 countries). Patients with AA who developed recurrence or died within five-years of PD were compared to those who did not experience these outcomes.

Results

A total of 394 patients had AA and five-year recurrence and five-year survival rates were 44.7% and 53.6%, respectively. The number of resected nodes, histological T stage I-II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin all had a significant association with both studied outcomes. The following correlated with reduced time-to-recurrence: ≥1 positive margin (median difference (MD): 144 days, p = 0.005), PPFI (MD: 214 days, p = 0.004) and PNI (MD; 124 days, p = 0.006). The following were predictors of reduced time-to-death: preoperative biliary stenting (MD: 119 days, p = 0.004), histological T stage >II (MD: 228 days, p<0.0001), histological N stage >0 (MD: 196 days, p = 0.004), PPFI (MD: 287 days, p = 0.007) and PNI (MD: 241 days, p<0.0001).

Conclusions

In our multicentre study of patients who underwent PD for confirmed AA, multiple predictors of five-year recurrence and five-year survival were identified. This information can guide postoperative management as those who are more likley to develop recurrence should arguably undergo earlier and more regular surveilance. In addition, ajuvant treatment is arguably more pertinent in this group.
1136 Modified Nuss Bar Procedure for Pectus Excavatum – Our Experience in Patients Aged 20 and Over
Authors: Bhat S , Pal S , Kolvekar S
Published: August 2023

Background

Pectus excavatum (PE) is a common congenital anterior chest wall deformity characterized by a sunken appearance. The incidence rate is approximately 0.1% with a male to female ratio of 4:1. It is associated with connective tissue disorders, neuromuscular diseases, and linked with some genetic conditions.

In 1987, the Nuss procedure was invented by Dr Nuss and his colleagues as a minimally invasive procedure to correct PE. This is a two-staged procedure and involved lesser hospital stays, smaller incisions, and early mobilisation. Applying this procedure to video-assisted thoracoscopic surgery (VATS), we present our experience on insertion as well as removal of the Nuss bar in patients aged 20 and over with PE.

Method

This is a single centre, retrospective study carried out in a tertiary cardiothoracic centre. A total of 104 patients, aged 20-57 years, who underwent Nuss bar insertions and removals between 2016 and 2021 (5 years) were included in our study. All the procedures were performed by a single consultant cardiothoracic surgeon using biotech stainless steel bars.

Results

A total of 24 bar insertions, 79 bar removals and 1 bar revision were performed between 2016-2021. The data included 95 male and 9 female patients. The average hospital stay was 2.5 days.

Postoperative complications for the procedure included pleural effusions (3%), pericardial effusion (0.9%), post-operative bleeding requiring re-operation (0.9%), bar dislodgement (0.9%) and wound infection (4%).

Conclusions

We can conclude that VATS-Nuss procedure is a safe procedure for adult patients resulting in shorter hospital stays and reduced post-operative complications.
1267 Application of the Low-Cost Laparoscopic Appendicectomy Simulation (LaApSi) Model for Laparoscopic Training in Low-Middle-Income-Countries (LMIC) and Its Comparison with the Laparoscopic Skills Session in the UK
Authors: Karki B B , Katuwal S , Walshaw J , Rao A , Rao M M , Satyal S
Published: August 2023

Aim

To assess the LaApSi Model’s effectiveness in the surgical simulation within and outside the UK. To assess the delegates' expectations while simulating Laparoscopic Appendicectomy (LA) using LaApSi Model.

Method

LaApSi models were developed using 3D printed mould & Silicon with a production cost under £5 pp. Within 6 months of model development, the quantitative assessment of LaApSi model was done by 18 trainees from LMICs (RCSEd endorsed Laparoscopic Course) and 29 within the UK, 2 Laparoscopic courses (LC) and 1 Intermediate Surgical Skills Course (ISS) evidenced by formal feedback which has further led to the production of the modified version.

Results

For LMICs Lap-courses, 88.9%, n = 16 delegates agreed that the LaApSi model was able to meet their learning objectives whereas it was around 80% for UK courses. Similarly, 90%, n = 16 delegates agreed they were able to understand the General Steps Involved in LA, were more confident with LA and felt the course was relevant whereas it was around 15% less in these domains during UK Lap courses. 80.3% n = 5 delegates responded that the LaApSi model was equally effective in simulating Open Appendicectomy (OA) in a recent ISS course.

Conclusions

There is an unmet need for the development of a Low-Cost simulation model in LMICs and these cost-effective LaApSi models can provide a safe and standardized method for simulation training before operating on real patients. Although the model expectations were found relatively higher among UK delegates, feedback establishes a positive impact of the model among the course delegates.
195 Outcomes of Emergency Groin Hernia Repair: 30-Months Experience of a Tertiary Care Hospital
Authors: Kumar D , Tan B , Guilbert M , Elsllabi M , Soomro F , Muthukumarasamy G
Published: August 2023

Aim

Repair of Emergency groin hernia is variable across different regions and even within same units. Mesh is increasingly used these days. We aim to evaluate peri-operative and long-term outcomes over last 30-months.

Method

Retrospective analysis of all emergency groin hernia repairs from January 2018- July 2020 in a tertiary Centre. Case notes and electronic patient records (clinical portal, PACS system etc.) used for data collection.

Results

Of 89 emergency groin hernia repairs 62(69.7%) males, 32/89 (35.9%) indirect inguinal hernia and 29 (32.5%) femoral hernia. Median age 72 years (range 20-95), 74(83.1%) primary hernia and 15(16.9%) recurrent hernias. Femoral hernia was most common in females 25/27 (92.5%) in contrast 58/62 males (93.5%) had inguinal hernia. All patients, except 1(1.1%) laparoscopic, had open repair, 11/89 cases (12.3%) required bowel resection, of those 10 (90.9%) had suture repair. Additionally, 6/89 cases (6.7%) needed laparotomy. Of 68/89 (76.4%) cases who had mesh repair, 52(76.4%) were inguinal and 23.5% (16/68) femoral hernia. Only 55% femoral hernias repaired with mesh. Median LOS was 3 days (range 0-54), 6/89 cases (6.74%) had wound complications (3 wound infections, 2 haematoma and 1 fluid collection). With median 19 months (range 6-36 months) follow-up, 1(1.1%) recurrence each in both mesh and suture repair groups, no mesh infection and 2/89 (2.2%) 30-day mortality recorded.

Conclusions

Mesh repair is increasingly used in emergency groin hernia repair without increased risk of mesh infection, although suture repair is still preferred in groin hernias requiring bowel resection.
219 Post-Skin Cancer Scalp Defect Reconstruction with Integra® as Single Stage Surgery: A Case Series
Authors: Locurcio L , Breen M , Haq J
Published: August 2023

Aim

Large post-surgical scalp defects represent a common challenge in skin cancer surgery reconstruction. Despite the multiple options available the patients, often elderly, may prefer to have the least amount of surgery done and/or have comorbidities that may impair adequate wound healing. In order to reduce the number of hospital appointments and the risks of COVID19 exposure for the frail patients we used Integra®, a very versatile Dermal Regeneration Template for the treatment of skin defects. Originally, Integra® was designed to be followed by a second-stage surgery with a full thickness skin graft (FTSG). We retrospectively collected, in our busy OMFS Unit, a 40-case series of post-skin cancer scalp defects reconstructed using Integra® as single-stage approach without any further surgery.

Method

We have carried out a literature review of its use on the scalp and examined a series of parameters from our experience including:defect sizedressing appointments and total healing timeanticoagulation, peri-operative antibiotics prescribingcomplications

Results

The total healing time for the scalp wounds treated with Integra® averages 3.8 months, requiring 7.8 hospital appointments for dressings and checkups. Two infections, 3 significant bleeds and 4 failures were reported.

Conclusions

The Integra® is a valid and optimal substitute for local flaps and FTSG in patients that may prefer a single-staged approach wishing to avoid a second surgical site and minimising hospital attendance. The drawbacks are the longer time to heal compared to flaps/FTSG, the costs and the risk of delaying radiotherapy if complete epithelialisation is not achieved.
284 Eye Protection Compliance in the Operating Theatres of a Regional Major Trauma Centre
Authors: McMahon D
Published: August 2023

Aim

Surgical procedures inherently involve risk of blood splatter. Various studies have consistently demonstrated significant (>40%) contamination of face masks worn by surgeons, though this may be macroscopically visible in fewer than half of cases; laparoscopic surgery is similarly not devoid of risk, with a comparable contamination profile. Nevertheless, routine use of eye protection by scrubbed surgical staff is inconsistent. This study audited the use of eye-protection by scrubbed surgical staff in a Major Trauma Centre.

Method

Local Trust guidelines mandated scrubbed surgical staff to wear eye-protection (namely disposable visor-masks or plastic glasses, not including spectacles). Operations over an initial 6-week cycle were audited to determine the rate of eye-protection use by surgical staff. Following a presentation to theatre staff, a further audit cycle was completed to assess for improvement in guideline compliance.

Results

98 operations were recorded in the first cycle, 39 of which were open procedures. Compliance rates were measured for different staff grades. Across all operations, 301 staff were scrubbed (183 surgeons). 52.2% of scrubbed staff (35% of surgeons) wore the requisite eye protection. Re-audit involved 88 operations, including 31 open procedures, with a total of 243 scrubbed staff (146 surgeons). A demonstrable increase in compliance occurred across all staff grades with a total compliance rate of 67.5% (49% of surgeons).

Conclusions

Conjunctival contamination presents significant risk to surgeons without adequate protection. The results of this study demonstrate the inadequacy of current protective practice; increasing awareness of the necessity for adequate eye protection is thus a clinical priority.
562 Retrospective Study on Pain Management Pathway for Patients with Suspected Renal/ Ureteric Colic in a UK Accidents and Emergency Department
Authors: Ojo C , Osunde U , Thapa S , Lim M L , Kelly M
Published: August 2023

Aim

To understand local compliance with the NICE guideline for pain management in suspected renal/ ureteric stones which includes use of NSAIDS, Intravenous Paracetamol and Opioids as first, second and third-line analgesics respectively and not offering antispasmodics.

Method

This was a retrospective single centre study wherein records of patients suspected to have renal/ ureteric colic between 18th July, 2022 and 30th September, 2022 were retrieved. Patients were identified by their presenting complaints of “loin-to-groin” pain at triage and “working diagnosis” from comprehensive history-taking and examination. We checked the first, second and third-line analgesics administered and, if Buscopan was given. Data was entered into Microsoft Excel and our pain management pathway matched against NICE guideline.

Results

78 patients were suspected to have renal/ ureteric colic. M:F = 1.2:1. CT-KUB confirmed 90% to have stones and 3% to have no stones. 6% did not have CT-KUB done because they were young patients and urinalysis showed no microscopic hematuria. One patient self-discharged before CT-KUB was done. Overall, compliance with the NICE pain management guideline for suspected renal/ ureteric stones was full in 22% of cases but poor in 78% of cases.

Conclusions

Clinicians ability to correctly diagnose renal/ ureteric stones is remarkable. However, the low compliance rate is concerning. This may be due to poor awareness of the NICE guideline or doctors having affinity for certain analgesics as compared to others. This information will be used to explore further with the clinical team, reasons for non-compliance, develop a teaching strategy and perform a re-audit thereafter.
640 Ambulatory Ultrasound - Could We Be More Efficient? Re-Audit -a District General Hospital Experience
Authors: Idama D , Shafi A , Lasheen O , O'Connor A
Published: August 2023

Aim

Right iliac fossa (RIF) pain is a common presentation to General Surgery departments and appendicitis is a possible cause. There are diagnostic challenges in these patients. Over a fifth undergoing appendicectomy have a histologically normal appendix (1). National guidelines recommend performing Ultrasound Scans (USS) in select patients (2). Aim is to review if there is better use of a limited service.

Method

A retrospective review of all ambulatory USS from June - December 2020 comparing to data from June 2019 - December 2019 for RIF/lower abdominal pain. We collected demographics, working diagnoses, imaging request details and outcomes.

Results

109 patients were included. 106 were female and 3 males. Of these, 35 had a working diagnosis of ovarian/ gynaecology pathology, whilst 25 had one of ‘appendicitis vs gynaecological pathology’. The USS was reported as no abnormality detected in 73 patients. 94(86%) had matching working diagnosis to USS request (41% in 1st audit). 22 (20%) had a working diagnosis matched with USS results (13%). In total 101 patients were discharged – there were 5 admissions (3 CT scans + 2 laparoscopic appendicectomies) and 3 referrals onwards to gynaecology.

Conclusions

We recommend using USS pelvis in women of childbearing age to identify gynaecological causes of RIF pain, more focused requests in order reduce requests of abdominal USS in lower abdominal pain, males should only receive hot clinic scans for biliary concerns, and increased use of CT for females >40 years old.
678 The Safe Use of Intraoperative Tourniquets in Orthopaedic Procedures
Authors: Chien D C S , Adewale Ad , Li X , Ramsingh V
Published: August 2023

Aim

The use of intra-operative tourniquets in orthopaedic procedures is required to provide bloodless fields, enabling surgical procedures to be performed with improved quality, accuracy, and safety. Documentation of tourniquet use is necessary for optimising patient safety, as this provides an essential medico-legal role, as well as ensures the continuity of care for patients.

Method

All patients who had orthopaedic procedures in the local hospital in November 2022 were reviewed. There were a total of 123 procedures. 40 procedures required intra-operative tourniquet use were included in our study. The primary outcome is the documentation of tourniquet use, which includes the site of the tourniquet applied, the pressure, and the duration of tourniquet use. The secondary outcome is compliance with tourniquet use according to the national guidelines set by BOA Standards for Trauma and Orthopaedics (BOAST). This states the maximum authorized pressure, depending on the age (below/above 16), and the type of procedures (upper/lower limb).

Results

All procedures (N = 40) recorded the site of the tourniquet attached. 68% (27/40) of procedures recorded the length of the tourniquet use and 63%(25/40) recorded the maximum pressure applied. From the recorded procedures, the length of tourniquet use (N = 27) and maximum pressure applied (N = 25) is compliant with the national BOAST guideline regardless of the age group and type of procedures.

Conclusions

Overall this study highlighted the importance of documentation of tourniquet use for medico-legal purposes while demonstrating high compliance with the BOAST guidelines. This could ultimately overcome the challenges associated with intra-operative complications, thus optimising patient safety.
733 ERAS Audit: Junior Doctor Compliance with the Elective Colorectal Enhanced Recovery After Surgery (ERAS) Pathway at Bristol Royal Infirmary
Authors: Memory K , Brennan L , Smith A , Simpson A , Kobetic M , Griggs R
Published: August 2023

Introduction

The Enhanced Recovery After Surgery (ERAS) pathway is an evidence-based protocol aiming to reduce morbidity and improve post-operative outcomes. Two important recommendations included are early prescribing of post-operative nutritional drinks and avoidance of post-operative opioids. Junior doctors are integral to ensuring the compliance of these guidelines. Therefore, this audit aimed to review junior doctor adherence to ERAS recommendations with regards to nutritional drink prescribing and opioid avoidance within the colorectal department at the Bristol Royal Infirmary.

Method

Inpatient data was collected retrospectively from all patients undergoing elective colorectal surgery on the ERAS pathway from January to June 2022. Patients’ notes were analysed on two parameters: post-operative opioid prescribing and prescribing of post-operative nutritional drinks (fortisips/fortijuice). Educational interventions were implemented; face-to-face education to new colorectal junior doctors, and posters displayed in the doctor's office.

Results

104 patients were identified, 16 excluded for insufficient data. Of those 88 included, early post-operative nutrition and/or solid food intake was achieved by 60 patients (68.2%) and nutritional drinks were prescribed for 39 patients (44.3%). The average time to prescribe nutritional drinks was 3 days. Avoidance of systemic opioids was achieved by 7 patients (7.9%).

Conclusions

This audit highlights that improvements are required to ensure better adherence to the ERAS protocol within our department. Junior doctors can facilitate this by ensuring nutritional support is promptly prescribed post-operatively, and by prompting discussions regarding opioid prescribing. A second cycle post intervention will allow review of our chosen outcomes to ensure we are optimising post-operative outcomes for elective colorectal patients.
906 A Prospective Clinical Audit of Pre-Operative Fasting Practices at a Tertiary Care Hospital in India
Authors: Mendonca J , Upadya M , Arora M
Published: August 2023

Aim

Even in the face of evidence-based recommendations, the ‘nil by mouth from midnight’ regimen has persisted because it is easy to administer and allows for theatre flexibility. We aimed to audit preoperative fasting practices at Kasturba Medical College Hospital Attavar, India against the Indian Society of Anaesthesiologists (ISA) national guidelines.

Method

Prospective clinical audit involving ASA 1 and 2 patients undergoing elective, non-obstetric surgery under general/regional anaesthesia or sedation. Data were collected from patient notes and from an interview on the morning of surgery (at least one hour prior to induction of anaesthesia).

Results

Baseline Data (N = 100) Median fasting durations of 10 hours and 12.5 hours from clear fluids and solids, respectively.

99% of patients gave an incorrect reason or did not know at all the reason for preoperative fasting.

Interventions:Patient information leaflets (in English and the local language) were made and distributed to every ward; to be shown to elective surgery patients on the day before surgery.Surgical trainees, anaesthesiology trainees and nurses were made aware of the audit findings.

Re-Audit (N = 40)

Median fasting duration of 3 hours and 11 hours respectively clear fluids and solids.

Thirty-five percent of patients knew the correct reason for preoperative fasting. 50% gave an incorrect reason, while 15% did not know the reason.

Conclusions

Prolonged fasting was observed initially despite guidelines. Significant reduction in clear fluid fasting duration was achieved (10 hours to 3 hours) by creating awareness.
1000 Handwritten Operative Note Compliance in Plastic Surgery
Authors: Ridgley J , Al-Hity S , Harper Machin A
Published: August 2023

Aim

Accurate and comprehensive documentation of operations is crucial to optimise patient care. Omissions may cause compromised management, or medicolegal issues. A closed-loop audit was completed at a plastic surgery centre to identify whether Royal College of Surgeons (RCS) standards were met. It aimed to identify and address limitations of hand-written notes, which were completed free-hand or on departmental proformas (burns, bite, Mohs, skin and hand).

Method

Mandatory operative note domains were taken from the RCS guidance within Good Surgical Practice (2013). Acceptable compliance in domains was agreed at 90%. Cycle-one included all operations performed by the department over three days in November 2021. In cycle-two, a twenty-operation sample was taken across one week in May 2022.

Results

Compliance was met in the domains of date (100%), surgeon (100%), procedure (92.7%), diagnosis (95.1%), findings (95.1%), closure (93.9%), antibiotics (100%) and post-operative instructions (100%). Domains below standard included: time (32.9%), anaesthetist (60.9%), incision (78.0%) and blood-loss (2.4%). As a result, proformas were modified to include domains below standard (if not already included). On re-audit, no new domain achieved agreed standard.

Conclusions

Whilst most domains met agreed standards, a lack of improvement on re-auditing demonstrates challenges in paper documentation. Paper-noting for some may be more time consuming and susceptible to omission of required information. Whilst not feasible in this instance, transitioning to e-noting may improve compliance, due to automations and the ability to mandate certain fields. In the interim, a generic paper template may be advantageous for operations not covered by proformas.
1010 Assessing Completion of Check Radiographs in the Trauma and Orthopaedic Department
Authors: Taiwo B , Menyah E , Garcia S
Published: August 2023

Background

Postoperative check radiographs are routine practice in Trauma and Orthopaedic surgery, allowing for radiographic assessment of components and evidence of bony injury (1). All trauma cases requiring postoperative imaging as per operation note should have this completed in a timely fashion.

Method

Patient records were assessed over 4 months across two sites within an NHS Trust to determine the following - Time from surgery to request of post-operative radiograph, time from request to completion of radiograph, and evidence of a documented review in patient notes.

Results

120 patients at site 1 and 134 at site 2 were assessed. At site 1, 11 patients did not have radiographs completed before discharge in comparison to 2 patients at site 2. The average time from surgery to radiograph request was 2.26 days at site 1, 1.07 days at site 2. The average time from request to completion of radiograph was 2.25 days at site 1 and 0.95 days at site 2. Documentation of review of radiographs was poor across both sites. A patient discharged prior to check radiograph re-attended hospital with a dislocation of hip hemiarthoplasty.

Conclusions

Numerous recommendations were made to ensure that good practice was established across sites. Operating surgeon or assistant should request post-operative imaging, at the same time as completion of the operation note. A trial of intra-operative fluoroscopy for hip hemiarthroplasty at Site 2 was started to see whether this could streamline current processes.
1028 Why Is Changing Old Habits So Hard?
Authors: Kronberga M , Suresan S , Cartner E , Khawgali M , Bonner C , Matias M , Saha A , Peter M
Published: August 2023

Aim

Acute uncomplicated diverticulitis (AUD) has been traditionally managed by inpatient admission for bowel rest, intravenous antibiotics, and fluids. World Society of Emergency Surgery (WSES) updated their guidelines in 2020 recommending that patients with AUD with no significant co-morbidities or immunocompromise should be treated in an ambulatory setting. This full audit cycle aimed to assess the compliance with these guidelines at our trust.

Method

Retrospective data collection was conducted from June 2021 to July 2021 (1st cycle). Inclusion criteria was applied: CT proven AUD, patients below the age of 80 with the ability to tolerate oral intake, had full mental capacity and were not immunocompromised. Educational sessions for clinicians and nurses were implemented to inform of current guidelines. Data was re-audited from June 2022 to July 2022 (2nd cycle).

Results

The first cycle included a total of 31 patients with AUD matching our inclusion criteria where 45% of patients were treated via ambulatory care. Two patients had re-presented but didn’t require admission. The second cycle had a total of 19 patients 47% of which were managed ambulatory. Average length of hospital stay between the inpatient and outpatient groups were 2-3 days versus 4.5 hours.

Conclusions

The compliance rate with current guidelines increased by 2%, however remained low. With low re- presentation rates and re-admission rates, this audit shows that patients with AUD could be safely managed in ambulatory setting. Shifting engrained mindsets and improving compliance with the current guidelines could greatly save NHS resources and alleviate existing bed pressures.
187 Master Students' Perception and Attitude on Methods of Anatomy Teaching and Assessment, Khartoum, Sudan 2014-2020
Authors: Hassan R , Awad K , Hassan R
Published: August 2023

Aim

Anatomy is the cornerstone of medical education; anatomical knowledge is undoubtedly essential for doctors regardless of their specialty. Teaching and learning anatomy are one of the most important and challenging subjects for both teachers and students. This study aimed at improving the postgraduate teaching and assessment methodologies by eliciting the perception and attitude toward anatomy teaching approaches among anatomy master students.

Method

A descriptive cross-sectional study was conducted among three consecutive batches of anatomy master students. A structured questionnaire was used as a tool of data collection and data was analysed using IBM statistical package for social sciences version 24 (SPSS 24).

Results

44 candidates responded to the questionnaire. Among them, 90.9% chose dissection room sessions as the best tool in attaining the intended learning outcomes. Practical dissection was the best teaching method with regards to interest 81.1%, enjoyment 70.5%, retention of information 65.9% and satisfaction 59.1%. 72.7% of the respondents think that practical dissection test was the best assessment method in fulfilling the intended learning objectives. Multiple choice questions were the most helpful in learning anatomy effectively and was the best tool for assessing knowledge.

Conclusions

The results have shown a strong positive perception towards the use of cadaveric dissection in teaching and learning anatomy. However, many did not seem to prefer lectures as a tool in anatomy teaching and learning. In addition, practical dissection test and multiple-choice questions were the best assessment methods in attaining the intended learning objectives and learning anatomy effectively respectively.
353 Targeted Axillary Dissection Does Benefit Patients with a Single Positive Node Prior to Neoadjuvant Chemotherapy
Authors: Ragunathan Janani , Ledwidge Serena
Published: August 2023

Aim

Targeted Axillary Dissection (TAD) is a procedure where positive axillary nodes are clipped with a view to sentinel lymph node dissection plus removal of clipped nodes post-neoadjuvant therapies (NACT) rather than axillary lymph node clearance (ANC), reducing morbidity. This study aimed to assess whether patients with a single positive node undergoing NACT would benefit from TAD.

Method

Patients planned for TAD post-NACT were identified from the surgical diary from March 2020 – July 2022. Data were recorded for age, histopathology, MRI response and surgical procedure.

Results

Eighteen women were identified, mean age 46.7 (33- 63 years). 44% (8) had ER positive, HER2 negative invasive ductal carcinoma (IDC), 28% (5) had HER2 positive IDC, 22% (4) had triple negative IDC and 6% (1) had ER positive, HER2 negative lobular carcinoma.

Treatment response on MRI was complete in 22% (4), near complete or very good in 11%(2), partial in 61% (11) with 6% (1) patient having stable disease. Four patients including the patient who had no response to chemotherapy opted for ANC post-NACT. Only 17% (1/6) patients with complete or good response had positive nodes post-NACT whereas 58% (7/12) of patients with partial or no response had positive nodes post-NACT.

Conclusions

Although the numbers in our study are small, TAD did benefit patients with a single positive node who have complete or good response to NACT. Larger multicentre studies are needed to confirm this and determine whether TAD is of benefit in patients who have partial or no response.
1124 Staging CT in the Work Up for Primary Breast Cancer – Indications, Incidentalomas, Metastases and the Impact on Patient Management
Authors: Clinton P , Rice L , Hickie C , McNally S , Prichard R , McCartan D , Rutherford C
Published: August 2023

Aim

There is considerable variation amongst units in the use of staging CT in breast cancer. The current ABS guidelines advise staging in those with >/ = N2, T3/4 or those with symptoms suspicious for metastatic disease. The aim of this study was to assess the indications for primary breast cancer patients undergoing staging CT scan, and the subsequent detection rate of incidentalomas and metastatic disease.

Method

This was a retrospective cohort study conducted in a high-volume tertiary referral centre of patients diagnosed with a primary breast cancer between January 2018 and December 2018 who underwent staging CT. Data was assessed for patient demographics, tumour characteristics and findings on CT.

Results

714 patients were diagnosed with breast cancer in this 12-month period, of which 120 had a staging CT. Twelve had recurrent disease and were excluded. There was an overall incidentaloma rate of 66.6% and metastases rate of 11.1%. The group was subdivided into those who fulfilled the guidelines and those who did not. 46 patients met the staging criteria, with metastatic and incidentaloma rates of 21.7% and 65.2% respectively. 62 patients did not meet the staging criteria, with metastatic and incidentalomas rates of 3.2% and 67.7% respectively.

Conclusions

This study demonstrates that the detection of metastatic disease in patients who do not meet the criteria is low with a rate of 3.2%. CT staging in primary breast cancer should be reserved for patients who meet the guidelines in order to better direct resource, avoid over investigation and mitigate patient anxiety.
151 How Do Mortality Rates From COVID-19 Differ Between Vaccinated and Unvaccinated People in a Tertiary Centre of Bangladesh
Authors: Noor M , Islam M F , Islam R
Published: August 2023

Aim

To find out the difference in mortality rates between vaccinated and unvaccinated COVID-19 positive patients who admitted in a tertiary center (Ward Vs Intensive care) of Bangladesh.

Method

Retrospective analysis of data over 6 weeks (February- March 2021).

100 confirmed COVID-19 positive patients were included- 50 from ICU (Intensive Care Unit) and 50 from ward irrespective of age, gender, vaccination status and comorbidities.

Results

75% of all confirmed COVID 19 positive patients were vaccinated. Mortality among vaccinated people was less compared to unvaccinated 41.3% Vs 52%.

Interestingly pregnancy was found to be the most significant risk factor in child-bearing age female group- 86.7% of pregnant and peripartum female required ICU admission and mortality was 40% although none of them had any co-morbidities. Again, mortality among vaccinated was significantly less (35.7%) compared to 100% mortality among unvaccinated.

Mortality rate among ICU admitted patients was significantly high- 72% Vs 16%.

83% of patients who died in ICU were vaccinated (90% had 2 doses, 10% had 3 doses). 87.5% who died in ward were unvaccinated.

Among the survivors from ICU - 93% were vaccinated (Vs 7% unvaccinated).

Overall, pre-existing comorbidities increased mortality by 18.1% (59% Vs 40.9%).

Conclusions

Vaccination against COVID-19 reduces mortality irrespective of co-morbidities or disease severity. Recovery rate was significantly increased in vaccinated ICU admitted patients.

Pregnancy was found to be the most important risk factor for ICU admission and mortality in otherwise healthy child-bearing age females and mortality was 100% (limited data availability) in unvaccinated.

These results require further revalidation on larger population.
133 Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Case Report.
Authors: Paudel S
Published: August 2023

Introduction

We present a case of chronic subdural hematoma refractory to burr hole surgery treated successfully with middle meningeal artery embolization.

Presentation of Case

61-year-old gentleman presented with a history of headaches and single episodes of vomiting. Neurological examination was normal. A non-contrast computed tomography (CT) scan of the head showed chronic subdural hematoma with midline shift. The patient was managed with burr hole surgery but there was no improvement in the symptoms and CT findings of recollection of blood in subdural space. The patient was then managed endovascularly with embolization of the middle meningeal artery (MMA), patient recovered fully after the endovascular treatment.

Discussion

Chronic subdural hematoma can present clinically with vomiting and headache, if refractory to burr hole surgery it can be managed with the embolization of the middle meningeal artery.

Conclusions

Subdural hematoma can be successfully managed by endovascular treatment.
518 Testicular Mass: A Rare Presentation of Richter’s Syndrome
Authors: Desouky E , Al-Salti W , Kalsi J
Published: August 2023

A 72-year-old male patient who presented with a painless right sided scrotal swelling for few months.

History of stage A Chronic Lymphocytic Leukemia (CLL) since 2015- under surveillance by hematology team.

On examination; 10 X 10 cm hard non-tender right-sided scrotal mass, normal left testicle, no peripheral lymphadenopathy or organomegaly.

WBC count = 17.5 × 109 /L with neutrophils of 4.39 × 109 /L & lymphocytes of 11.16 × 109 /L. Testicular tumour marker; within normal

CT chest, abdomen, and pelvis (CAP); some borderline enlarged left para-aortic and aorto-caval lymph nodes and unremarkable abdominal viscera.

Right inguinal orchiectomy

Histopathology and immunohistochemistry profile were consistent with a high-grade Richter’s transformation to diffuse large B cell lymphoma.

MDT plan with hematologist: 6 cycles of R-CHOP and IV as well as intrathecal Methotraxate for CNS prophylaxis. Patient was given the option testicular radiotherapy vs orchidectomy and he opted for orchidectomy.

After more than 24 months follow up, the patient had no relapse.

Richter’s syndrome (RS) is the transformation of CLL to an aggressive form of lymphoma mostly represented by diffuse large B cell lymphoma (DLBCL) in 2 -10% of CLL patients.

RS is clinically characterized by development of B symptoms (fever, night sweats and weight loss), rapid clinical deterioration and a rapid increase in the size of lymphadenopathy and /or splenomegaly.

RS commonly arises in lymph nodes or bone marrow and disseminates to other organs.

Presenting as a testicular mass, as in this case, is quite rare and our patient represents the 4th case reported in the literature.
663 Squamous Cell Carcinoma of the Scalp Following Synthetic Hair Transplantation: A Case Report
Authors: Shah J , Dunne J , Wood S
Published: August 2023

Androgenetic alopecia is the most common form of hair loss. Surgical treatment options include autologous and synthetic hair transplantation. Synthetic hair fibres can overcome the challenges of poor hair quality and density however there are reports of severe cutaneous complications following their use.

We report a case of an advanced squamous cell carcinoma (SCC) of the scalp in an adult male patient following chronic artificial hair transplants. The fungating mass eroded the inner cortex of the left parietal bone without intra-cranial extension on CT. Indeterminate lymph nodes in the parotid gland and level III of the left neck were identified on CT and MRI. Resection of the artificial hair fibres and SCC with a craniectomy, total parotidectomy with facial nerve preservation and upper neck dissection were performed. There was extensive dural involvement not detected on pre-operative imaging, which involved the superior sagittal sinus and was unresectable. The dural disease was fulgurated. The defect was reconstructed with a titanium plate and DIEP flap. Final histopathology showed a moderately differentiated pT4a N0 M0 SCC. The patient received adjuvant proton beam therapy and at 18 months post-operatively is recurrence free.

Development of scalp SCC following synthetic hair transplantation has been described, although a clear causation has not been defined. Clinicians should be aware of this presentation and aim to achieve an early diagnosis, timely referral to an appropriate specialist and prompt management.
773 Desmoid Tumor in the Cecum in a Pregnant Woman
Authors: Taniskidi A , Hassan Yare S
Published: August 2023

Desmoid tumors (DT) are benign growths that invade the mesenchymal tissue locally without metastasizing. Also known as aggressive fibromatosis, these tumors tend to affect the abdomen and limbs. The etiology is still unclear, but DT happens more frequently in women during or after pregnancy. Histologically, they consist of spindle cells that are damaging locally. The gold standard treatment is complete resection, however even with this DT has a high risk of local recurrence. Due to rarity and lack of specificity on imaging, spindle cell tumors can be misdiagnosed, especially with abdominal wall endometriosis.

A 36-year-old woman of Bangladeshi origin, gravida 3 and para 2, was booked into the antenatal clinic at 8 weeks gestation. This patient was thought to have a fibrothecoma, with plans to resect it during her elective cesarian. The lump was seen to be on the cecum instead and was removed. Immunohistochemical analysis of the resection pointed towards a desmoid tumor.

Apparent in this case was the delay in identifying the correct diagnosis for this patient, which has profound impacts on the management. This tumor was removed in a right hemicolectomy, delayed till after the cesarian. The delay was necessary as there was no consent for a hemicolectomy and the bowel was unprepared. Interestingly, the patient did present with pregnancy complications, including an unstable lie, which questions whether there is a correlation between DT and pregnancy. Due to the rarity of this disease, there is a high need for further research into investigations and appropriate management.
893 Posterior Location of the Facial Nerve in Vestibular Schwannoma: Report of a Rare Case and a Brief Literature Review
Authors: Bahuleyan B , Patel V T , Anto M , Madhavan G , Thomas S G
Published: August 2023

Background

The commonest location of the facial nerve on the surface of a vestibular schwannoma (VS) is ventral. The posterior location of the facial nerve on the surface of a VS is extremely rare and is reported to be between 0.6-3.8%. In this illustrative case report, we present a case of a large VS with posterior location of the facial nerve on its surface. The surgical strategy in this situation to preserve the facial nerve both anatomically and physiologically is discussed. Ours is the first illustrative case of the posterior location of the seventh nerve on these tumours.

Case Description

An elderly man presented with right cerebellopontine (CP) angle syndrome. MRI showed a partly cystic and partly solid right CP angle lesion extending to the internal auditory meatus. Electrophysiological stimulation of the tumour showed that the facial nerve was located on the posterior surface of the tumour. Under the microscope, the facial nerve was identified on the posterior surface of the tumour. Partial excision of the tumour was done with preservation of the facial nerve both anatomically and physiologically.

Conclusions

This case reiterates the fact that even though rare, surgeons should anticipate the posterior location of the facial nerve on the surface of VS. Electrophysiological stimulation of the posterior surface of the tumour should be done before tumour resection in all cases to look for the posterior location of the facial nerve. Careful microsurgical dissection should be done to achieve maximal cytoreduction of the tumour, preserving the facial nerve.
1212 Actinomycosis of the Middle Ear Mimicking Cholesteatoma – a Case Report and Literature Review
Authors: Modi S , Kiverniti E
Published: August 2023

Introduction

Actinomycosis, a rare infection of the middle ear, has less than 50 documented cases worldwide. Actinomyces are an anaerobic, filamentous bacterium causing granuloma formation and suppurative infection.

Case

We present a young male with a nine-month history of unilateral, yellow coloured otorrhoea and hearing loss. Swabs showed no growth, with infection not responding to oral or topical antibiotics. CT temporal bones was consistent with cholesteatoma and ossicular disruption. Surgical exploration revealed a yellow, cystic mass within the middle ear. Cortical mastoidectomy and washout were performed. Histological diagnosis confirmed actinomyces clusters with positive Gram stain.

Discussion

Actinomyces typically presents as chronic otitis media. It likely reaches the middle ear via the Eustachian tube. It is often misdiagnosed due to culture insensitivity; however clinical suspicion can aid labs in providing an optimum culture environment. Tympanomastoidectomy allows for histopathological diagnosis. Surgical resection should be followed by a prolonged course of antibiotics.
1219 A Rare Case of EBV Infection Presenting as Acute Appendicitis with Septic Shock - a Case Report and Review of the Literature
Authors: Westby K
Published: August 2023

18yo male presented to the emergency department (ED) with a 2-week history of progressive lower abdominal pain, weight loss of 8kg & diarrhoea. On examination he looked dehydrated, was tachycardic and had a large, tender, palpable mass in his lower abdomen up to the umbilicus. Blood investigations of note were white cell count (WCC) 29.7 and CRP 187.

Computerized tomography (CT) reported an extremely large abscess occupying the lower abdomen and pelvis resulting in bilateral hydronephrosis and hydroureter. The appendix was not visualised.

On the night of admission, the patient went into septic shock on the ward and was taken to theatre from emergency laparotomy. 4 litres of a large abscess were evacuated, the appendix was identified with an inflamed appearance and an appendicetomy performed.

His post operative course was complicated by an ileus and slow resolving, inter-loop abscesses that required multiple courses of antibiotics and eventual return to theatre for further washout.

During his early admission, EBV serology was recommended by the microbiology team on foot of a positive monospot test. Serology was also positive for EBV. Histopathological results of the appendix and lymph nodes showed EBV associated changes.

Acute appendicitis can be considered a complication of EBV infection with the proposed mechanism being obstruction of the appendiceal lumen due to swollen lymphoid tissue, this most commonly occurs in the acute phase of EBV infection.

In this case it has been shown that EBV and subsequent Infectious mononucleosis can cause acute appendicitis and may be its initial presentation.