bluuebunny/crossref_metadata_2025 huggingface dataset:
272 Clinico-Pathological Factors Determining Recurrence in Phyllodes Tumour of the Breast: The 25-Year Experience at a Tertiary Cancer Centre
Authors: Sain B , Gupta A
Published: August 2023

Aim

The study aimed to assess the clinico-pathological features, diagnostic modalities and therapeutic interventions with their outcomes leading to recurrence in Phyllodes tumour (PT) of breast.

Method

A retrospective observational study entailing clinico-pathological data of patients who were previously diagnosed or presented with new PT of the breast between 1996-2021 was done. Data included- total number of patients diagnosed with PT, age, type of tumour on initial presentation and biopsy, side, size, therapeutic interventions- surgery (mastectomy or lumpectomy) and adjuvant radiotherapy, final biopsy type, recurrence and its type and time to recurrence.

Results

Among the total 87 patients who were pathologically proven to have PT, 52.87%(n = 46) were found to have recurrence. All patients were recorded to be in the female gender with a mean age of diagnosis at 39 years (range 15–70). Age<40 years had the highest incidence of recurrence (54.35%) followed by age>40 years with 45.65%. 55.4% patients presented with primary phyllodes and 44.6% had recurrent phylloides at presentation. Average time of local recurrence from the time of completion of treatment were 13.8 months whereas for systemic recurrence it was 15.29 months. Surgery(mastectomy/lumpectomy) was the major determinant for local recurrence(p<0.05) followed by adjuvant radiotherapy(p = 0.04) and initial biopsy type for systemic recurrence(p<0.05).

Conclusion

Patients who received adjuvant radiotherapy had minimal recurrence. Patients who were found to have malignant tumour on initial biopsy were prone to systemic recurrence over local recurrence. Surgery played a determining factor leading to an increased rate of local recurrence following lumpectomy over mastectomy.
236 The Hypercoagulable State in COVID-19 and Implications for Free Flap Surgery in the Lower Limb
Authors: Stark D , Hendrickson S , Dejsupa C
Published: August 2023

Aim

COVID-19 associated coagulopathy is widely documented in severe COVID-19 infection and COVID-19 Vaccine-Induced Thrombotic Thrombocytopaenia. However, much of this evidence relates to macrovascular thrombosis with limited evidence on the impact of previous mild, asymptomatic COVID-19 infection, or vaccination on microvascular thrombosis in free tissue transfer. We compared the rate of thrombotic complications in traumatic lower limb injuries requiring free flap reconstruction in the pre- and post-COVID era.

Method

Adult patients undergoing lower limb free flap reconstruction were identified at a single centre over two three-month periods (2019 and 2021). Standard thromboprophylaxis was used for all patients (intraoperative intermittent pressure devices, post-operative thromboembolic deterrent stockings, and prophylactic low molecular weight heparin until discharge). Thrombotic complications were recorded and compared using a chi-squared test.

Results

In the pre-COVID cohort, 51 patients underwent 52 free flaps. One flap (1.9%) suffered anastomotic thrombosis resulting in flap compromise. Post-COVID, 39 patients underwent 43 free flaps. Nine flaps suffered anastomotic thrombosis (21%) and one patient suffered a pulmonary embolus. This increase was statistically significant (p = 0.002). In the post-COVID cohort, four patients had a COVID-19 infection and 25 patients (64%) had at least one dose of a COVID-19 vaccine before free flap surgery. No patients had an active COVID-19 infection on admission.

Conclusions

In the post-COVID era there was an increased rate of thrombotic complications in lower limb free flap patients. Further research is required to delineate the best course of action when planning free tissue transfer for patients who have had previous COVID-19 infection or vaccination.
727 The UK Targeted Lung Cancer Screening Pilot Programme: The Southampton Experience
Authors: Amo-Afful S , Harrison O , Woo E
Published: August 2023

Aim

Performance of the community-based targeted lung cancer screening pilot.

Method

22,829 people between the age of 55 and 75 with a smoking history were invited to attend a one stop assessment inolving a questionnaire-based interview with a nurse, cardio-respiratory observations, and then spirometry. The patient’s risk of developing lung cancer was quantified using the Liverpool Lung Project (LLP) or PLCOm2012. Participants were offered low dose CT-scan (LDCT) if the calculated risk was greater or equal to 2.5% or 1.51% respectively. Pulmonary nodules found was followed up in a protocolised fashion.

Results

As of June 2022, 7754 patients had attended. Of these 4562 (59%) were invited for a follow-up scan and 820 (11%) of the follow-up patients required a second follow-up scan. 1,163 (25%) of the attendees have been referred onward as 2-week lung cancer or other specialities such respiratory and vascular. 117 (1.5%) of screened patients were diagnosed with lung cancer and staged histogically. 83 (73%) of confirmed lung cancer were in stage 1, while 10, 15, and 7 people in stages 2, 3 and 4 respectivey.

Conclusions

Targeted community-based lung cancer screening programme can detect curable early-stage lung cancer at risk groups.
132 Pseudoaneurysm of the Facial Artery After Tonsillectomy Managed with Endovascular Coiling: A Case Report
Authors: Khanal D
Published: August 2023

Introduction

We present a case of pseudoaneurysm of the facial artery after tonsillectomy managed with successful endovascular coiling.

Presentation of Case

41-year-old lady presented with a history of throat pain and 3 episodes of hematemesis on the 3rd, 4th, and 7th postoperative days after tonsillectomy and styloidectomy. She had undergone the operation 20 days back. Neurological examination was normal. Contrast-enhanced computed tomography scan of the neck showed – contrast-filled dilatation of a branch of the right facial artery in the right palatine tonsillar fossa within the operative bed – likely pseudoaneurysm which was managed endovascularly. The patient recovered fully after treatment.

Discussion

Tonsillectomy can have various complications among which one is the pseudoaneurysm of the facial artery which can be managed with coiling in the catheterization laboratory.

Conclusions

Pseudoaneurysm of the facial artery is a rare complication of tonsillectomy. Endovascular treatment of a pseudo aneurysm can be done.
179 Postpartum Uterus Causing Mechanical Bowel Obstruction
Authors: Mohammed A , Wagner B , Chambers A , Doe M , Randall J
Published: August 2023

Background

Intestinal obstruction is a common surgical emergency. Common causes of mechanical large bowel obstruction include malignancy, sigmoid volvulus, and diverticular disease. Due to the risk of bowel ischaemia and perforation, large bowel obstruction requires urgent recognition and treatment to prevent morbidity and mortality.

Case Presentation

35-year-old female developed nausea, vomiting and abdominal pain two days post emergency cesarian section at 39+5 weeks gestation. An abdominal X-Ray showed distended loops of large bowel and mechanical large bowel obstruction with a sigmoid transition point was diagnosed on CT. She was referred to the surgical team for further management and a flexible sigmoidoscopy under general anaesthetic was performed for decompression.

Results

The patient was reviewed the following day. She was asymptomatic and had opened her bowels. She was discharged from surgical follow-up at this stage following successful treatment and was able to return home with a healthy baby.

Conclusions

Mechanical compression from a postpartum uterus is a rare cause of mechanical large bowel obstruction, with just one previous case documented in the literature. Acute colonic pseudo-obstruction (Ogilvie syndrome) is a recognised postpartum complication, more common after cesarian section and an important differential with similar treatment options.

The recommend diagnostic imagining includes abdominal x-ray and/or CT scan with early surgical referral for consideration of interventional or surgical management in patients presenting with symptoms of bowel obstruction in the postpartum period. Conservative management should include lateral decubitus position.
261 Bilateral Femoral Neck Stress Fractures in an Active Adolescent Female: A Case Report
Authors: Nichols M , Aggarwal A , Duke K
Published: August 2023

Bilateral femoral neck stress fractures are uncommon injuries in adolescents. We present such a case in a 15-year-old athletic female with no preceding trauma or underlying metabolic bone abnormality. The patient presented to Accident and Emergency with a three-week history of left buttock and lateral thigh pain and one-week history of right lateral thigh pain. The pain developed during physical activity and was relieved upon rest. Activities included running, dancing, and attendance at a six-week cadet marching course. Simple analgesia did not alleviate the pain. History revealed low caloric intake and previous secondary amenorrhea. The patient was previously managed by the General Practitioner and physiotherapist for suspected atypical sciatica.

Physical examination showed a minimally antalgic gait and pain on palpation of the left groin. Both hips had full range of motion. Bone profile was normal. Radiographic films were initially interpreted as normal, however, formal reporting revealed sclerotic appearances to both femoral necks and a subtle break in the left femoral neck cortex. MRI confirmed the diagnosis of a complete displaced left femoral neck fracture and incomplete right inferomedial femoral neck fracture. Trace bilateral hip joint effusions were noted.

The patient underwent bilateral fixation with cannulated screws. One-month post-operative, she engaged in walking and swimming without pain. Radiographic appearances were satisfactory.

Early radiographic changes associated with stress fractures are subtle. This case highlights the importance of prompt formal radiological reporting and the early use of MRI as a diagnostic tool, particularly in patients with risk factors.
550 CSF Leak or Ear Wax? Logical Thinking in Emergency Management of a Collapsed Patient with Heat Stroke
Authors: Hern D
Published: August 2023

A man in his 60s presented to RESUS by ambulance on the hottest day of the year with suspected STEMI and collapse at home.

The patient was intubated and unresponsive (GCS 5), with global rigors. Hospital ECG showed sinus tachycardia. Body temperature was in excess of 41°C, confirmed on central temperature monitoring. Bilateral clear fluid was noted to be discharging from both ear canals.

Query CSF leak was indication for CT head, which was unremarkable. Considering this, efforts were focused on optimising body temperature. This was done with the use of ice packs and fans as well as continuous misting of cool water over the exposed patient. Improvement was shown with temperatures decreasing to 38°C.

In questioning the cause of the “clear fluid,” a swab of it placed on an icepack swiftly returned the fluid to its natural consistency of ear wax. As a result of the extraordinarily high body temperatures, ear wax had melted in both ear canals and started to leak out, giving the impression of a CSF leak.

This was simply identified at the bedside to refute the idea of a CSF leak. As CSF leak was the indication for a CT head, this could have been avoided with rapid cooling initiated earlier.

Unfortunately, this patient later died due to heat stroke.

Whilst avoiding the delay of a CT head most likely would not have changed the prognosis for this patient, it is useful to note the importance of logical thinking in an emergency setting.
851 Necrotising Otitis Externa Secondary to Ear Syringing in an Otherwise Healthy Patient: A Case Report
Authors: Hyland L
Published: August 2023

Introduction

Unrelenting unilateral otalgia in an elderly or diabetic or immunocompromised patient is clinically suspicious for necrotising otitis externa (NOE). This is an advancement of normal diffuse OE that can complicate into a number of severe neurological pathologies, and it is becoming increasingly common1. We report a case here of NOE that became acutely apparent following ear syringing, due to the introduction of micro-organisms into the external auditory canal (EAC). Literature review shoes only 3 previous articles that have explored this pathological link.

Case presentation

A lady in her 90s with no known diabetes or immunocompromise, presented with a combination of otalgia, otorrhea and profound hearing loss. This plethora of symptoms had developed and persisted following ear syringing she underwent for chronic wax impaction. A diagnosis of NOE was made based on the clinical symptoms, presence of a polyp on the anterior aspect of the external auditory canal (EAC) as well as positive Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) findings. Prompt administration of intravenous (IV) antibiotics was initiated in addition to biopsy of the polyp to send for histological analysis. Her overall clinic status improved, and she was ultimately discharged with a prolonged IV antibiotic course alongside outpatient antibiotic team (OPAT) support and advice given on the avoidance of ear syringing/aural irrigation or at least a reduction in frequency of its use.

Conclusions

This rare case emphasises the significance of ear syringing in precipitating NOE by the transmission of Pseudomonas aeruginosa via irrigation fluid or lavage instrumentation.
1146 Laparoscopic Retrieval of a Retained Video Endoscopy Capsule: Case Report and Review of Literature
Authors: Mian A , Georgiades F , Rajaratnam K
Published: August 2023

Video-Capsule-Endoscopy (VCE) is a non-invasive method and a useful tool in determining the aetiology of obscure gastrointestinal bleeding and in the diagnosis of Crohn’s disease. Despite its proven utility, VCE carries risks, primarily capsule retention (CR). This refers to the failure of the capsule passing by day 14. CR may suggest underlying pathology, but in the process can lead to several sequelae including obstruction. We report the case of a 28-year-old patient with suspected Crohn’s disease requiring laparoscopic bowel-resection and retrieval of the capsule. The patient presented in 2019 with bloating, crampy abdominal pain and altered bowel habits. Initial endoscopic and blood investigations were unremarkable, however subsequent tests revealed raised calprotectin and anaemia. OGD and colonoscopy remained negative. In April 2021, he underwent VCE, demonstrating an inflamed distal ileum with structuring. However, the capsule failed to pass. After a period of watchful waiting and multidisciplinary discussion resulting in a trial of infliximab and steroid therapy, the capsule remained in-situ as confirmed by sequential X-rays and CTs. In March 2022, he underwent uncomplicated 3-port laparoscopic small bowel resection and retrieval of the retained capsule and was discharged 2 days later. Our case demonstrates an optimal approach in the management of CR. An initial conservative trial with medical therapy was attempted. MDT discussion ensured both gastroenterologists and surgeons were involved in the decision-making. Finally, our literature review demonstrated a lack of concise guidelines. Thus, based on the latest evidence we developed an algorithmic flow chart for the management of retained VCE.
1226 The Role of Extracorporeal Membrane Oxygenation in William’s Syndrome Following Cardiac Surgery: A Case Report
Authors: Ali F , Cvetkovic M
Published: August 2023

Williams-Beuren Syndrome (WS) is a genetic syndrome seen in childhood, characterised by intellectual disabilities, outgoing personalities, elfin-like faces and cardiovascular complications. We report the story of a girl with WS who underwent complex cardiac surgery requiring extracorporeal membrane oxygenation (ECMO), to raise awareness of the perioperative challenges with WS.

At 2 years old, a cardiac murmur was incidentally discovered. Further investigations revealed WS with cardiac manifestations including peripheral pulmonary artery stenosis (PPAS) and supravalvular aortic stenosis (SVAS). Isolated SVAS repair was feasible, however the severity of pulmonary artery hypoplasia deemed her inoperable. Her care was redirected to palliation. 18 months later, she remained in good clinical condition which prompted the multidisciplinary team (MDT) to change their decision and proceed with complex SVAS repair surgery (Brom technique) at the age of 5. Postoperatively, 3 failed attempts to wean from cardiopulmonary bypass preceded veno-arterial ECMO, which lasted 7 days. She stayed in intensive care for 17 days, and in hospital for 28 days. Frequent MDT decision making was crucial during her complex care. The patient is currently 15 years old, in good clinical condition, albeit exercise restrictions.

WS patients have a known increased risk of perioperative sudden cardiac death and increasing use of paediatric ECMO, hence great attention and thorough preparation is required. Clear perioperative care guidelines for WS are essential to secure good outcomes in this patient population. This case demonstrated that MDT involvement and regular communication with the patient were key to deliver the appropriate care throughout her life.
455 Fine-Needle Aspiration, Ultrasound and Thyroidectomies in Patients with Thyroid Nodules Presenting to a District General Hospital – a Retrospective Audit
Authors: Hirayama Y , Kochilas X
Published: August 2023

Aim

To determine whether fine-needle aspiration, ultrasound and thyroidectomies were being performed appropriately in patients with thyroid nodules, and to compare the percentage of malignant cases for each histological classification with the national standards.

Method

Patients undergoing thyroidectomy in Northwest Anglia Trust (East of England) between October 2021 – October 2022 was identified retrospectively using the OPSC-4 codes. Medical records of 132 patients were retrieved, and data points extracted.

Results

We identified 103 female and 29 patients. The female cohort had a younger age distribution (median 52y) compared to the male cohort (59y). 42 patients underwent total thyroidectomy, 89 underwent hemithyroidectomy and 1 underwent lobectomy. 21% of the specimen was reported to be malignant, of which 74% was papillary cell carcinoma, 15% follicular cell carcinoma and 11% Hurthle cell carcinoma. Our percentage of malignancy in the Thy1a/c category was higher (5%) compared to the national figures of malignancy risk reported by RCPath (4%), whilst the rest were lower than the national figures (Thy2 = 0%, Thy3a = 13%, Thy3f = 19%, Thy4 = 50%, Thy5 = 94%). 100% of Thy3, Thy4 and Thy5 patients underwent diagnostic hemithyroidectomy. 15 patients did not have documentation of the U classification prior to thyroidectomy. There was 84% compliance with repeat FNAC requirements prior to surgery and 97% compliance with MDT discussion.

Conclusions

Current BAETS guideline states that thyroid nodules with benign appearances (U1 and U2) do not need to be followed-up, however we found a 15% of malignancy in these patients. Costs, risks and benefits of regularly undertaking fine needle aspiration in these patients must be considered.
809 Direct Referral Pilot- Speech and Language Therapy-ENT, Ninewells Hospital
Authors: Ganesh V , Thompson C , Kaighin S , Haddow K , Kennedy C
Published: August 2023

Aim

Ear, nose, and throat (ENT) specialists and speech and language therapists (SALT) work very closely together in management of speech and language disorders. Here at Ninewells Hospital, we have created a pilot project for a direct referral system, where voice referrals which have been vetted are referred directly to SALT, in which patients receive the necessary treatments and are then referred to ENT specialists if required.

Method

This is a retrospective audit. Patients who were referred directly to SALT were included in this study. A questionnaire was developed to assess patient’s satisfaction with this pathway via telephone. Five questions were asked about their satisfaction with different aspects of this study, including waiting times, concerns addressed, provided with clear explanations, patient involved in plans and overall satisfaction with ratings of between very good, good, fair, poor, very poor and prefer not to answer.

Results

41 responses were obtained, out of 67 patients included in this study. Majority of patients responded with very good and good in all aspects of the questionnaire 48.8% had a very good overall satisfaction from this project. 29.3% had a good outcome and 4.9% responded with fair and poor respectively.

Conclusions

This study highlights that SALT play a significant role in not only improving quality of treatment for patients but also the quality of streamlining to specialist care as and when needed. More work is required to look into this pathway further and to assess its feasibility for implementation in the future and in other hospitals across the UK.
1230 A Case of Intratonsillar Abscess Presenting as a Non-Resolving Acute Tonsillitis With Dysphonia, With Learning Points
Authors: Dar T , Tornari C
Published: August 2023

Peritonsillar abscess (quinsy) and tonsillitis are two commonly diagnosed and treated pathologies in ENT departments. However, intratonsillar abscess is rarely reported in medical literature and textbooks, therefore understanding of when to clinically suspect such pathology is likely less known amongst junior ENT doctors. We present a case of a healthy adult treated for a large intratonsillar abscess, at a district general hospital in the United Kingdom.

A 27-year-old man with one previously treated quinsy, presented with 6 days of worsening sore throat, fevers, and dysphonia. Clinical examination showed mild trismus, tonsillitis with an asymmetrically large right tonsil, appearance of right peritonsillar swelling, and a normal neck exam. Clinically this was initially treated as a right peritonsillar abscess, with needle aspiration of the peritonsillar space, however 3 aspiration attempts revealed no pus.

He was admitted and treated as tonsillitis with peritonsillar cellulitis by antibiotics, but over four days little improvement was seen with rising inflammatory markers. Particularly the “hot-potato voice” dysphonia did not improve at all. Given the smoothly enlarged right tonsil and absence of peritonsillar swelling, suspicion for an intratonsillar abscess was raised. Needle aspiration into the tonsil revealed 7 millilitres of thick pus, causing immediate improvement in voice and symptoms.

We suggest that intratonsillar abscess could be suspected in patients appearing as quinsy but with dry aspiration attempts, or in unilateral unresolving tonsillitis. Direct tonsil aspiration can sometimes avoid radiation from CT scanning in patients who are systemically well with no suspicion of deep neck infections.
330 Use of Percutaneous Cholecystostomy - Mission Creep or a Genuine Bridge to Surgery?
Authors: Ninkovic-Hall G , Zardab M , Digne-Malcolm H , Javed S , Magee C
Published: August 2023

Aim

Appropriately used, percutaneous cholecystostomy (PC) can be lifesaving. We have noted an increase their use. This may be due to an increasing population frailty combined with delayed presentations or treatment from the COVID pandemic. We sought to audit the use of PC in our Trust.

Method

Retrospective analysis of prospectively collected data from 2020-2022 at a large DGH with comparison to PC insertion standards (failed antibiotic response & not fit for surgery, septic/too unstable or PC as definitive treatment).

Results

PC performed 67 times in 64 patients (F = 36.5%. mean age 72 (45-92yrs)).

31 (48.4%) were definitive treatment. 36 (53.7%) were not definitive, 19 subsequently underwent surgery (5 as readmissions, 12 elective & 2 same admission).

25 patients did not meet criteria for PC and potentially could have been considered for emergency laparoscopic cholecystectomy.

35.8% (n = 24) had a DNACPR in place at the time of drain insertion. 25.4% (n = 17) had died at the time of analysis.

In the same timeframe n = 168 emergency laparoscopic cholecystectomies were completed.

Conclusions

PC is an effective treatment strategy but our data suggest that some patients may have been suitable for operative intervention, indicative of “mission creep”.

However, the reasons for this are unclear, but may include availability of hot list slots, presentations before a weekend where subspecialty UGI surgeons may not be at hand or a genuine belief that PC is a beneficial bridge to surgery.

The wider role of PC requires further evaluation, especially if subspecialty cover is not available.
632 Return to Pre-Hospital Residence Following Emergency Laparotomy
Authors: Rugendyke A , Holmes M , Ming Y J , Gani J , Pockney P
Published: August 2023

Aim

Poor outcomes following emergency laparotomy include death and the loss of independent living. A widely held apprehension is the ‘salvage’ of a previously independent patient, only to render them reliant on long-term dependent care. We aimed to establish the proportion of patients who returned to their pre-hospital residence following emergency laparotomy, measured at discharge, 90 and 365 days.

Method

Data was collected on all patients over 18 years of age who underwent emergency laparotomy across four Australian hospitals between 1 January 2018 and 31 December 2019. Data recorded included pre-hospital residence, discharge destination, mortality and place of residence at 90 and 365 days.

Results

782 patients underwent an emergency laparotomy during the study period. The mean age was 64 years (range 18-96). Prior to hospital admission, 95.5% of patients lived in their own home, while the remainder resided in supported living facilities. 7% of patients died during their hospital admission. Of those alive on discharge, 77.6% were discharged to their pre-hospital residence. At 90 days, mortality was 10.6% while 97.1% of surviving patients had returned to their pre-hospital residence. By 365 days, mortality was 17.0% while 98.0% of surviving patients had returned to their pre-hospital residence, and 94.0% were living in their own home.

Conclusions

Patients who survive 90 and 365 days following an emergency laparotomy nearly all return to their pre-hospital residence, with only a small proportion of previously independent patients entering dependent care. This should inform shared decision-making regarding emergency laparotomy in the acute setting.
1193 Review of Pre-Operative Antibiotic Prophylaxis (POAP) in National Emergency Laparotomy Audit (NELA) Patients in a Regional Acute Tertiary Hospital
Authors: Pattarukuzhyil Jose J , Davis E , Bateman K , Lewandowski D
Published: August 2023

Aim

The current World Health Organization recommendation for timing before incision (TBI) is that one dose of intravenous pre-operative antibiotic prophylaxis (POAP) should be given on starting anaesthesia, within 120 minutes, to reduce surgical site infections. The Scottish Intercollegiate Guidelines Network suggests TBI of 30-60 minutes for full dosage administration. The aim was to review POAP, including TBI, in NELA patients.

Method

Emergency laparotomy patients were identified on the Trust theatre system over 73 days, and the NELA database reviewed. Data was collected retrospectively through anaesthetic and operation records and if still inpatient, drug charts and clinical notes.

Results

46 patients were identified, and 83% had documented POAP (53% on anaesthetic record, 31% on operation note and 16% before surgery). Of these patients who had a documented POAP, 68% had a recorded TBI; mean time was 99 minutes (range 19 to 386). Of the patients who had a recorded TBI, 77% received POAP within 120 minutes; mean time of these was 59 minutes (range 19 to 112).

Conclusions

The majority of patients received pre-operative antibiotic prophylaxis, although the documentation was variable, and many doses were not given in the optimal time before incision to reduce surgical site infections. Further work includes liaising with the multidisciplinary team to raise awareness of these results and amending the clerking proforma. A further subgroup analysis focusing on septic patients is underway, as well as a long-term review looking into surgical site infection rates.
754 Impact of BRAFV600E Mutation on Clinicopathological Features in Patients with Concomitant Hashimoto Thyroiditis and Papillary Thyroid Carcinoma: A Meta-Analysis
Authors: Janicki L , Patel A , Hellmann A , Kobiela J
Published: August 2023

Aim

The aim of this meta-analysis is to identify the rate of BRAFV600E mutation among Hashimoto thyroiditis (HT) concomitant with papillary thyroid carcinoma (PTC) versus PTC patients alone. The secondary aim is to evaluate the impact of BRAFV600E mutation on clinicopathological features in both cohorts.

Method

Using a predefined search strategy, Medline, Cochrane Library, Scopus, and Web of Science were searched from inception till 16.09.2022. A total of 227 unique articles were found, of which nine studies met the inclusion criteria. Of those, six were retrospective and three prospective cohort studies. Data on patient demographics, BRAFV600E mutation and clinicopathological features was collected. Summary estimates using fixed or random effects models were generated with Review Manager 5.0.

Results

6395 patients were included in this review. The weighted arithmetic mean for BRAF mutation was 71.6% and 82.8% in HT-PTC and PTC patients, respectively. HT-PTC patients had significantly less BRAFV600E mutation than PTC patients (Odds Ratio (OR) = 0.45, 95% Confidence Interval (CI): 0.35 to 0.58). In addition, BRAFV600E positive HT-PTC patients were more likely to have multifocality (OR = 0.71 95% CI: 0.53 to 0.95), lymph node metastasis (OR = 0.59 95% CI: 0.44 to 0.78) or extrathyroidal extension (OR = 0.72 95% CI: 0.56 to 0.92) compared to BRAFV600E negative HT-PTC patients.

Conclusions

Patients with concomitant HT and PTC have less BRAFV600E mutation, which may be one of the factors responsible for less aggressive course of PTC in this cohort.
478 Career Transition Experience of International Medical Graduates (IMGs) Within the NHS Post-COVID19: Evaluation of Challenges and Support
Authors: Lubbad H
Published: August 2023

Aim

The main purpose of this research is to identify the challenges facing international medical graduates (IMGs) during their career transition into the National Health Service (NHS), particularly post-pandemic, and evaluate the organisational support offered to them, its significance, and its effectiveness in easing their transition, based on the practice of inclusion.

Method

A cross-sectional retrospective study was conducted with a mixed-methods design, quantitative data were collected firstly by online questionnaires (n = 72), followed by semi-structured interviews with part of the first-stage participants (n = 4). Quantitative data were analysed in SPSS whereas thematic analysis was used for qualitative data.

Results

The findings show positive insights regarding the support offered to IMGs throughout the pandemic, particularly from seniors and colleagues. It points out the crucial role of the support, organisational support as well as seniors' and colleagues' support, in facilitating the career transition of the IMGs into the NHS in order to fulfil their capabilities and benefit the service as well as move up the career ladder. The equality of support was a point of concern when it comes to the nature of IMGs’ starting position (training/non-training).

Conclusions

The study reveals that it is beneficial to have a higher level of support for the IMGs right from the early stages. Organisational support interventions should be sustained by ongoing seniors’ and peers’ support to get the functional adjustment level of the newcomer IMGs and assist them in their progression.
871 Audit on Compliance and Documentation of GMC Guidelines Regarding the Use of Chaperone During the Intimate Examination
Authors: Singh A , Siby J , Subramanian A , Janakan G
Published: August 2023

Aim

To assess the compliance of GMC guidelines with respect to chaperones during intimate examination and their appropriate documentation.

Method

Analysis of patient notes documented by members of the general surgery department in the surgical assessment unit, or ED, for the month of October 2022.

We checked the patient notes for the following dataset: Chaperone - offered/not offered, name and position of chaperone and signature of chaperone.Area examined – Perineum, Abdomen, Breast or perineum and abdomenGender of patient, doctor and chaperone.Time of the day and place of examination

The data was analyzed (results below). As part of the audit cycle, the results were shared with the department, and education on the seriousness of this issue was discussed. Stickers for chaperones with their name, position, and gender will be attached to the patient notes.

Results

168 patients were reviewed totally. 9/168 (5.3%) – documentation present, 1/9 (11%) had complete documentation. 23 patients had perianal examination – 1 (4.3%) had documentation 141 patients had abdomen examination – 8 (5.6%) had documentation 9/9 (100%) documentation done by male doctors for female patients

Conclusions

We found a lack of adequate documentation for chaperone presence during the examination. It was agreed that chaperone presence was always adhered to, but documentation was lacking. Necessary changes have been initiated, and we are collecting prospective data after the intervention.
406 Review of Consenting Practice at the Tertiary Centre for Emergency Inguinal Hernia Repair
Authors: Karki B B , Nadjarpour A , Akram S , Katuwal S
Published: August 2023

Aim

To compare standardised consenting practice for Emergency Inguinal Hernia Repair amongst various grades in the General Surgery department at the Tertiary Centre. To ensure improvement in the consenting practice and documentation of the risks associated with the procedure.

Method

A proforma was devised which included ten recognized complications following Emergency Inguinal Hernia Repair after a review of literature, BHS Guidelines, and GIRFT which were then cross-referenced with the consent forms of 20 patients: retrospectively & prospectively for the first & second cycles respectively between the period of August 2021 to July 2022.

Results

Out of 11/20 forms completed by junior doctors in the first cycle: FY2(3/11), CT (8/11), documented 6/10 and 6.75/10 risks resp. Speciality Registrar 8/20 (40%) & Consultants (1/20) both documented 6/10 risks which concluded on the wide variation in risk documentation practice. Following to this, consenting workshops were carried out including peer-to-peer teaching & development of the consenting posters. Furthermore, a re-audited result showed a satisfactory increase in risk documentation by 19%, 10%, and 25% among Junior Doctors, Registrars and Consultants along with >10% increase in the documentation of post-op complications like chronic pain, and orchidectomy.

Conclusions

There was a marked improvement in the consenting practice achieved via workshops, posters and peer-to-peer teaching sessions. Further review will be carried out for introducing procedure-specific consent forms in the Emergency setting which will not only act as a source of information for the patient but also a prompt for the doctors to discuss the risks.
597 Incivility in the Operating Theatre
Authors: Tupper L , Miller R
Published: August 2023

Aim

To establish the prevalence of incivility within operating theatres, understand its impact on wellbeing, team performance, training, and direct future studies.

Method

A systematic search was conducted using keywords for incivility in healthcare. Studies reporting incivility from all operating theatre MDT members were included. Data extraction was designed to establish prevalence of incivility, compare experiences in different specialties, assess the potential impact on performance and wellbeing and establish questions for inclusion in a national cross-sectional study.

Results

Incivility can be defined as ‘un-civil behaviour, characteristically rude and discourteous, displaying a lack of regard for others.’ 62 papers discussing incivility, bullying and harassment within healthcare settings were identified. 14 focused specifically on incivility in surgical teams. 48-98% of healthcare staff reported experiencing incivility, with surgeons being the most likely perpetrators. It was more commonly experienced by female, non-heterosexual, and inexperienced members of staff, including trainees. Incivility was associated with reduced performance, higher complication rates, workplace withdrawal, reduced organisational commitment, productivity, and wellbeing. Reduction strategies largely focused on education surround incivility, which appears to have minimal impact.

Conclusions

Incivility has only recently been discussed within a healthcare setting. Its consequences can have a significant impact on teams, and it warrants attention to improve performance, wellbeing and retention. Surgical theatres offer unique challenges from a teamwork perspective and should therefore be studied at an MDT level. These results have informed the design of a national, cross-sectional mixed methods study of incivility in the operating theatre MDT, which will be conducted throughout 2023.
1285 Management of Acute Cholecystitis – Evaluating the Timing of Laparoscopic Cholecystectomy
Authors: Quaunine M , Wilkins A , Chang L , Walshaw J , Lykoudis P
Published: August 2023

Aim

Current National Institute for Health and Care Excellence Quality Standards (NICE QS104) recommend adults with Acute Cholecystitis (AC) have Early Laparoscopic Cholecystectomy (ELC) within 1 week of diagnosis. If this is not achievable, a Delayed Laparoscopic Cholecystectomy (DLC) should be performed more than 4 weeks after the initial episode. This study evaluated current practice in a tertiary hospital General Surgical department.

Method

All patients presenting with their first presentation with AC between November 2021 and March 2022 were identified from prospectively maintained surgical handovers. Patients admitted with acalculous cholecystitis, under different specialities, residing out of the area, and who self-discharged were excluded. Data was collected from electronic patient records retrospectively.

Results

81 patients were included in the study, 29 males and 52 females. The mean age of included patients was 64. 61 patients were fit for surgical intervention. 14.8% (9) of patients had an ELC within 1 week of diagnosis. 85.5% (52) of patients were planned for DLC after discharge. 13.5% (7) of DLCs were performed within 3 months of discharge and a further 50.0% (26) of DLCs were performed within 6 months of discharge. 21.2% (11) of patients were readmitted to hospital with gallstone-related presentations within 6 months of their discharge whilst awaiting DLC.

Conclusions

This study shows that national standards are currently not being achieved. This is likely due to multifactorial causes, including increasing pressures due to the pandemic. We plan to expand our data and utilise these findings to produce a business case for a regular dedicated ELC list.
387 A Multidisciplinary Approach to the Sequelae of Dental Trauma in a Child: A Radicular Cyst
Authors: Chapman S , Kabban M , Woods M
Published: August 2023

Background

A radicular cyst is an inflammatory cyst of odontogenic nature, formed by cells of Malassez in the periodontal ligament, which are stimulated and proliferate, following insults such as dental trauma. First stage treatment is commonly orthograde root canal treatment (RCT), followed by apicectomy or extraction and enucleation of the lesion +/- bone grafting and replacement tooth.

Presenting problem

This case illustrates the sequelae of a repeated dental trauma to a LR1 in a child, which was endodontically treated and obturated with Mineral Trioxide Aggregate (MTA). After a second dental trauma, a painful intra-oral swelling developed with mobility and tenderness of adjacent teeth. The swelling increased after extraction of the LR1, leading to enucleation by the Oral and Maxillofacial Surgery Surgeon (OMFS).

Investigations

Plain radiographic films, cone beam CT (CBCT) imaging revealing a radiolucent area extending from LR3 to LL3, 2 x 1.1 x 1.9cm, with buccal perforation and thinning of the lingual cortex.

Clinical management

Across a 6-year period restoration and orthograde RCT was completed LR1. A second dental trauma 4 years later necessitated extraction of LR1.

Subsequent acute swelling and pain lead to further radiological assessment which was consistent with a giant cell lesion. Following enucleation, histopathology confirmed a radicular cyst, with pulse granuloma and reactive changes. Bony infill was noted and the LR1 was replaced with a resin-retained bridge.

Discussion

This case aims to raise awareness of the sequelae of dental trauma in children and the multidisciplinary approach to their care.
582 Head & Neck Skin Cancer Figures 2020 – in the Midst of the COVID-19 Pandemic
Authors: Sawhney S , Kwaskowski T , Gower R , Mumtaz S , Jefferies C
Published: August 2023

Aim

COVID-19 had a profound effect on the healthcare system in the United Kingdom, in particular the diagnosis of cancer. During the first wave of the COVID-19 pandemic, the diagnosis of early-stage cancer in England fell by 33%.

The aim of our analysis was to assess the impact of the pandemic on the head and neck skin cancer (HNSC) pathway by assessing the number of patients treated by our Oral & Maxillofacial Surgery (OMFS) department.

Method

Treated cases were retrospectively totalled each month and then analysed to produce time-series data that reflects the impact COVID-19 on the treatment of HNSC.

Results

In 2020, a total of 273 cases of HNSC were treated in our OMFS department. Between January and March 2020, the average number of HNSC cases treated monthly was 34. This dropped to 2 cases in April 2020, which corresponds with the first wave of the COVID-19 pandemic. Between May and August, the number of treated cases peaked at 16 in the months of July and August, with an average of 10 cases treated per month. Between September and December, the number of treated cases recovered to an average of 30 per month.

Conclusions

Our data shows the significant impact COVID-19 had on the number of treated cases of HNSC within our OMFS department. Further long-term and multi-site studies may reveal the wider impact that this has had on patient outcomes and the healthcare system.
846 Bone Grafting as an Alternative Approach to Treating Severe Hypodontia in a Child
Authors: Chapman S , Woods M , Harrison M
Published: August 2023

Background

Severe hypodontia (developmental absence of teeth) can have significant functional and cosmetic impact, causing dietary restrictions, speech delay and bullying. Management in childhood is usually with removable dental prostheses, but retention and stability are often compromised by hypoplastic dento-alveolar bone ridges in the edentulous areas.

Presenting problems

A 3-year-old child was referred to Paediatric Dentistry with no erupted primary teeth. Radiographs revealed developmental absence of the entire primary dentition. Genetic investigation was negative for changes in genes known to be associated with hypodontia. In the permanent dentition only first molars were radiographically present. The child was struggling with bullying and self-confidence related to his dental appearance and speech.

Investigations

Plain films and cone beam computed tomography (CBCT) revealed agenesis of all canines and incisors in both jaws, an atrophic edentulous anterior maxilla, and soft tissue communication with the nasal fossa floor.

Clinical management

Despite provision of a retentive upper removable prosthesis was made impossible by a fleshy anterior maxillary ridge with severe atrophy of the dento-alveolar bone and inadequate sulcus depth. Multiple removable prostheses were fabricated, but retention and stability were poor. He was referred to maxillofacial surgery for excision of redundant fleshy tissue in the anterior maxilla and placement of corticocancellous block graft from the hip with Sonic Weld (KLS Martin) to augment and consolidate the ridge. A successfully retentive prosthesis was subsequently fabricated.

Discussion

This case presents an unusually invasive, but effective alternative approach to treating severe hypodontia in childhood, where hypoplastic dental ridge and sulcus depth can restrict treatment options.
110 HPV-Positive Oropharyngeal Cancer: A Review of De-Escalation Strategies Used to Improve Outcomes for This Patient Cohort
Authors: Shaw A
Published: August 2023

Aim

Human Papillomavirus (HPV) positive oropharyngeal cancer (OPC) has been shown to provide improved survival compared to HPV negative patients with similar disease. This has led to a new staging criteria for these patients and attempts to de-escalate treatment for this group, to maintain high survival and reduce associated side effects. This review aims to assess current research into treatment techniques and compare results of these studies.

Method

Pubmed online database was used to gather studies containing primary research dated from within the last 10 years detailing the study design, the striation of patients into higher and lower risk groups, and the outcome of de-escalation of treatment to these groups.

Results

Published studies vary in their definition of their ‘low risk’ group, however minimal smoking history, smaller tumour size and increased HPV DNA expression within the tumour are all identified as good prognostic indicators and could be and have been used to identify suitable candidates for treatment deintensification. The combination of radiotherapy and chemotherapy are often used with good success however, no consensus has been reached regarding dosing of these. Transoral robotic surgery may also be used in conjunction with chemoradiotherapy, however large ongoing studies regarding this are yet to publish their final results.

Conclusions

This is an evolving area of oncology with an increasing evidence base improving prognosis and minimising side effects for this group of patients, however more research is necessary to gain consensus on the gold standard treatment for these patients.
510 What Is the Posterior Condylar Offset Ratio for Both the Medial and Lateral Femoral Condyles?
Authors: Mikova E , Beaumont H , Slade G , Walton E , Murray J
Published: August 2023

Aim

Traditionally, the posterior condylar offset ration (PCOR) has been calculated from lateral radiographs however new evidence suggests that a measuring technique based on 3D imaging may be superior. MRI has been trialled, but no protocol has been standardised and evaluated for reliability. This study aims to create a reproducible and reliable MRI technique as well as exploring whether there are any morphological differences in PCOR.

Method

A team of 5 researchers collaborated to create 2 novel ways of evaluating PCOR on healthy knees, one based on the transepicondylar axis (TEA) and one on the posterior condylar axis (PCA). The hospital database was searched for all MRI scans reported as having no internal derangement. From the 103 eligible scans a sample of 10 scans was selected and analysed by 4 independent reviewers in order to assess inter-rater reliability. The same sample was also analysed by one reviewer on two separate occasions in order to establish intra-rater reliability.

Results

Both methods demonstrated no significant difference in morphology between the condyles. Gender was found not to be a significant factor in condylar morphology. When calculating the PCOR the TEA method has a good intra-rater reliability and shows a higher degree of inter-rater reliability than the PCO protocol, yet consensus was not achieved among all reviewers using either method.

Conclusions

No significant morphological differences between condyles or genders were found. A TEA method may be superior for measuring PCOR nevertheless it is difficult to establish an easily applicable, reliable, and reproducible protocol.