bluuebunny/crossref_metadata_2025 huggingface dataset:
257 Ethics of International Medical Student Electives and Their Impact on Local Students’ Learning Opportunities
Authors: Chmura Magdalena
Published: November 2022

Aim

International electives are often considered a valuable learning opportunity for medical students. Yet, as travelling to low- and middle-income countries (LMICs) becomes more common, ethical considerations of such practices emerge. We conducted a literature review to assess the extent to which five ethical themes are addressed in existing literature about electives.

Method

We searched PubMed database and identified 35 papers which discussed international electives to LMICs, undertaken by medical students, and included discussion of ethics. On reading these, we noted whether or not there was discussion of any of the five chosen themes. A further focus area was explored in more detail: the impact of electives on host students’ access to learning opportunities.

Results

The most commonly addressed ethical theme was exceeding clinical competence (discussed in 26 papers), second was one-sided benefits in partnerships (in 20 papers). Respect for patients and local culture was addressed in 12 papers, local resource use in 10, and working with local community/colleagues in 10. Interestingly, 6 papers identified a negative impact of visiting students on local students’ learning opportunities. Reasons for this were: visiting students requiring local clinicians’ supervision, interference with teaching programmes, and being prioritised over local students.

Conclusions

It appears that while there is awareness of some ethical shortcomings of electives, the negative impacts on local students’ access to medical education are addressed infrequently. We recommend that this notion should be further explored in pre-departure elective teaching courses, to increase travelling students’ awareness of the impact of their presence on the host community.
129 Development of a Post-Op Analgesic Regimen for Patients Undergoing Local Anaesthetic Hand Trauma Surgery
Authors: Shah Savan , Bedford James D
Published: November 2022

Aim

Post-operative pain was a recurrent issue reported at the dressing clinic following local anaesthetic (LA) hand surgery at our regional centre. In the absence of a local protocol, we aimed to standardise advice and analgesic prescriptions following LA hand surgery to observe whether pain could be more optimally managed.

Method

In cycle 1, day 1 and 7 pain scores were recorded for ∼30 patients using a validated visual analogue scale (VAS).

In cycle 2, an analgesia advice leaflet and standardised prescription were provided, and the same data points were collected, with the addition of day 0 (evening of surgery).

Results

Cycle 1 revealed generally high day 1 pain scores (M = 5.91/10). Day 7 scores were considered acceptable (M = 2.16). There was no significant difference in pain scores when we compared fracture fixation to soft tissue surgery (p= 0.64), and patients prescribed codeine versus those with paracetamol alone (p = 0.53). Most patients provided with codeine did not co-administer paracetamol and ibuprofen (n = 14, 70%). A large proportion of patients were only taking analgesia PRN rather than regularly for prophylaxis (n=12, 43.75%).

In cycle 2, all patients were provided with codeine 30–60mg PRN QDS and the advice leaflet. Day 1 pain scores (3.43) were significantly lower for cycle 2 than cycle 1 (p < .00001).

Conclusions

Codeine, paracetamol and ibuprofen taken regularly and correctly can be effective in managing pain post-operatively for LA hand surgery patients. Information sheets can be an effective means of facilitating this.
872 The Role of Clinical Core Biopsy in Palpable Breast Lumps with Normal Imaging: 10 Year Experience of a Tertiary Symptomatic Breast Service
Authors: O'Hanlon Emily , Moynihan Alice , Barry Mitchell , Kell Malcolm , Stokes Maurice , Siun Walsh , Heeney Anna
Published: November 2022

Aim

Patients presenting with a palpable breast lump with normal imaging presents an investigative challenge. While the reported sensitivity of US and mammogram is high, radiologically occult cancers do occur. Traditionally these patients have undergone clinical core biopsy. The aim of our study was to examine the use of clinical core biopsy in our department over a 10-year period and assess its efficacy in diagnosing radiographically occult malignancies.

Method

We performed a retrospective review of a prospectively maintained database of all clinical core biopsies performed from 2010–2019 in a symptomatic tertiary breast cancer unit. Patients who underwent fine needle aspiration or skin punch biopsy without breast clinical core biopsy were excluded. A number of patients underwent clinical core biopsy despite abnormal radiological findings for clinical reasons, these patients were excluded from the final analysis. Clinical examination findings, radiological findings and ultimate pathological findings were reviewed.

Results

370 clinical core breast biopsies were performed over the study period. 11 patients were excluded as they underwent clinical biopsies despite abnormal imaging. Of the remaining 359 biopsies, 349 (97.21%) were benign and 9 (2.51%) required further investigation. Of these patients, 6 underwent excisional biopsy with one patient being diagnosed with DCIS. The remaining excisional biopsies were benign. 1 patient (0.29%) with normal imaging was diagnosed with a malignancy on clinical core biopsy.

Conclusions

The management of patients with palpable breast lumps despite normal imaging is challenging. Clinical core biopsy, in the context of normal imaging, has a low rate of detection of malignancy.
256 The Effect of Intraperitoneal Drain Placement on Postoperative Outcomes After Emergency Colorectal Surgery: A Propensity-Score Matched Analysis
Authors: Collaborative EuroSurg
Published: November 2022

Introduction

The use of intraperitoneal drain placement after emergency colorectal surgery is controversial. While the general consensus recommends against their routine use, there remains a paucity of evidence supporting this in the setting of emergency colorectal surgery. This study aimed to describe the efficacy and safety of intraperitoneal drain placement.

Method

This was a prospective, international, cohort study including consecutive adult patients undergoing emergency colorectal surgery (February-March 2020). Outcomes included: rate and time to diagnosis of intraperitoneal postoperative collections; rate of drain-related complications; and 30-day major postoperative complications (Clavien–Dindo grade ≥3). After propensity-score matching, multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement.

Results

Some 730 patients were included (353 females; median age 68.5 years, IQR 20) and the drain-placement rate was 53.6% (391/730). After matching, drains were not associated with lower rates of intraperitoneal postoperative collections (OR 1.30, 95% CI: 0.62–2.75, p=0.486) nor did they allow for earlier detection of such collections (HR 0.76, 95% CI: 0.19–3.05, p=0.698). Although not associated with worse major postoperative complications (OR 1.10, 95% CI: 0.63–1.90, p=0.740), drains carried an increased surgical site infection (SSI) risk (OR 3.41, 95% CI: 1.78–6.52, p<0.001).

Conclusions

This is the first study on the role of intraperitoneal drains in emergency colorectal surgery. Drains did not confer any clear clinical benefits after emergency colorectal surgery, but they were associated with increased SSI risk. Further trial evidence is needed to establish their net overall benefit or harm.
854 The Establishment of a National Peritoneal Surface Malignancy Programme: The Success, Pitfalls and Difficulties of the Moroccan Experience
Authors: Essangri Hajar , Bahaoui Nezha El , Souadka Abdelilah , Majbar Mohammed Anass , Benkabbou Amine , Mohsine Raouf , Souadka Amine
Published: November 2022

Aim

Peritoneal surface malignancy (PSM) programmes offer curative options to previously terminal cases through cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). However, this requires special expertise and resources, which may not be available to low- and middle-income countries (LMIC). The study aims to document the Moroccan experience of a national PSM programme.

Method

This is a mixed method study involving the retrospective assessment of patients with PSM following CRS between 2004 and 2018, alongside interviewing the founding surgeons leading the programme establishment to depict the pitfalls, difficulties, and processes of a PSM programme creation. This operation extended on an initiation, transition, and consolidation phase. Progress was demonstrated by outcome comparison of incomplete cytoreductive surgery (ICRS) rate, serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) between periods.

Results

In total, 198 CRS procedures were performed in the three phases with outcome assessment showing significantly better results with lower ICRS (34%, 18% and4% p=<0.001), serious complications (30.6%, 20% and11.2%, p=0.019), and EOF (38.8%, 23.3% and12.4% p=0.002). Programme founders highlighted the importance of project initiators’ motivation and leadership qualities, team readiness to overcome resource’ restrictions while improving their surgical expertise in CRS techniques, and collaborations development to reinforce multidisciplinary and institutional progress before adding HIPEC.

Conclusions

Implementing a PSM programme in a LMIC can be a challenging process, which motivation, training and good resources usability can help overcome.
939 Enhancing Core Surgical Training with the Implementation of Key Performance Indicators: A Closed Loop Quality Improvement Project
Authors: Goh En Lin , Tsui Adrian , Quinn Dominic , Gilling Jessica , Emery David
Published: November 2022

Aim

The COVID-19 pandemic has brought innumerable challenges to surgical training, especially with regard to theatre opportunities for core surgical trainees. This study aims to evaluate the implementation of training-oriented key performance indicators (KPIs) in supporting trainees to meet the Joint Committee on Surgical Training (JCST) quality indicators for core surgical training.

Method

A six-month long closed-loop quality improvement project. Two KPIs were developed following discussion with trainees and departmental leads, evaluation of the rota, and review of the JCST quality indicators: theatre/normal-working-day-attendance (T/A) ratio and missed-theatre-sessions/normal-working-day-attendance (M/A) ratio. Our calculations projected a T/A ratio of 1.00 and M/A ratio of 0.20 to be fully compliant with the JCST quality indicators. Data were collected prospectively from eight trainees, who provided feedback on training opportunities and allocation equitability.

Results

Following implementation of the KPIs, there was a significant increase in the mean T/A ratio from 0.70 (range=0.55–0.82) to 1.00 (range=0.95–1.17) (p=0.03), and a significant decrease in the mean M/A ratio from 0.55 (range=0.45–0.70) to 0.20 (range=0.11–0.22) (p=0.01). There were significant improvements in trainee satisfaction with training opportunities from 50% to 85% (p=0.02) and allocation equitability from 66% to 95% (p=0.01).

Conclusions

The development and implementation of training oriented KPIs led to increased allocation and fewer missed theatre sessions, enabling trainees to meet the JCST quality indicators. Furthermore, our data demonstrate smaller variances between trainees, thus, highlighting greater equitability of training opportunities. These findings are supported by the improved trainee satisfaction with training opportunities and allocation equitability reported.
371 Topographical Anatomy of the Annulus of Zinn
Authors: Lacey Hester , Oliphant Huw , Smith Claire , Koenig Michael , Rajak Saul
Published: November 2022

Aim

The anatomy and even existence of a common tendinous origin of the extraocular eye muscles, or annulus of Zinn, has widely been debated in anatomical literature. This study explored the anatomical origins of the recti muscles, their course into the orbit and the dural connections of the common tendinous origin with the skull base.

Method

Twenty orbits of ten adult human cadavers were dissected. The orbital apex and its dural connections were photographed. Histological examination of apical specimens was performed.

Results

In all cadavers, extraocular muscles were observed to have a common tendinous origin at the orbital apex, continuous with dural connections extending into the skull base. Accessory slips of the medial rectus were observed across all cadavers. Dual heads of the lateral rectus were observed in fourteen orbits of seven cadavers. The origin of the levator palpebrae superioris appeared to be contiguous with the superior rectus at the common tendinous origin in all but one cadaver.

Conclusions

These results support the existence of a common tendinous origin of the extraocular muscles, that is continuous with the skull base dura. In addition, they support the existence of variations in orbital anatomy including dual or accessory muscle slips of the extraocular muscles.
52 Functional Outcomes and Return to Sport Following Anterior Cruciate Ligament Reconstruction in Recreational Athletes: A Systematic Review
Authors: Brzeszczyński Filip , Forsyth Kirsty , McLelland Colin , McDonald Donnie , Lawson Graham , Hamilton David
Published: November 2022

Introduction

Outcomes of anterior cruciate ligament reconstruction (ACLR) are well reported in athletic populations, however surprisingly little information is available for outcomes in the recreational athletes that make up the majority of cases. The aim was therefore to assess post-operative outcome and return-to-sport in recreational athletes following ACLR.

Method

A systematic search was conducted in Ovid MEDLINE, CINAHL, AMED and the grey literature according to the PRISMA guidelines. Studies involving a clear definition of recreational athletes who underwent ACLR and recorded postoperative outcomes were included. Publication quality was assessed using Newcastle-Ottawa Scale.

Results

107 studies were identified, 19 full-text records reviewed and 13 included, reflecting 1342 patients with an average age of 31.7 (SD 9.8). Mean follow-up was 43.6-months (SD 42.8). Functional activity change was reported in 92% (12/13) papers. Functional outcome was assessed with the Tegner activity score in seven studies, with 43% (3/7) reporting a post-operative improvement. The Lyshom score was used in five, of which, 60% (3/5) showed post-operative improvement, 20% (1/5) showed no difference and 20% (1/5) showed a decrease. 69% (9/13) studies reported return-to-sport, with a mean rate of 55% (S.D. 19.2) at a mean follow-up of 32-months (SD. 34.8). Reported return-to-sports rate increased with length of follow-up.

Conclusions

Approximately only 50% of recreational athletes increase activity level and return-to-sport following ACLR. There is wide variation in return-to-sports timeframes reported, and the link between return-rate and post-operative timeframe suggests that longer follow-up periods may be required to accurately capture return-to-sport rates in recreational athletes.
194 ORIEL (Mortality Risk Prediction in Emergency Laparotomy): A Comparison of Mortality Risk Prediction Tools
Authors: Matias Nadia , Shehata Zak , Thomson Jack , Fegredo Daniel , Baltatzis Minas
Published: November 2022

Aim

Emergency laparotomies carry significant risk of morbidity and mortality. Risk calculation tools are essential to identify high-risk patients and inform clinicians in decision making. As part of a multi-centre research initiative, a retrospective study of all emergency laparotomies in a major trauma centre was conducted to determine the most accurate predictor of thirty-day mortality by comparing four, internationally recognised, risk assessment tools.

Method

Patients who underwent emergency laparotomy were identified using hospital databases. National Emergency Laparotomy Audit (NELA) was used to record pre- and post-operative mortality scores. The Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM); American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Surgical Outcome Risk Tool (SORT) were used to calculate risk of mortality for each patient. The Receiver Operating Curve (ROC) statistical method was chosen to compare the results of each in order to establish the tool most pertinent to prediction of local mortality.

Results

274 patients underwent emergency laparotomies at the Trust between December 2017 to December 2019. Of these, 96.7% (n=265) survived the 30-day post -operative period and 3.3% (n= 9) died. The ROC comparator demonstrated 100% sensitivity for the calculation of NELA, P-POSSUM and ACS-NSQIP and specificity of 77%, 76% and 63% for NELA, ACS-NSQIP and P-POSSUM respectively. SORT was found to be the poorest indicator of post-operative mortality.

Conclusions

NELA is the most accurate predictor of 30-day mortality in patients who undergo emergency laparotomy. Comparison with the outcomes of other centres will help confirm our results.
159 Current Practice of Intra-Operative Sampling During Revision Surgery of the Knee for Prosthetic Joint Infection at a High-Volume District General Hospital
Authors: Sehmbi A , Ali A , Shah S
Published: November 2022

Aim

Successful treatment of prosthetic joint infection (PJI) involves surgical interventions and identification of infecting organisms to enable targeted antimicrobial therapy. Current PHE guidelines recommend 3–5 intra-operative samples to be taken using separate instruments for each, swabs are discouraged. We audited the revision arthroplasty practice at Barking, Havering, Redbridge University Trust (BHRUT), specifically comparing intra-operative sampling for infected revision knee procedures with these guidelines.

Method

Retrospective cohort study of all prosthetic knee infection cases, as defined by the Musculoskeletal Infection Society criteria, at BHRUT between December 2011 to May 2020. A review of case notes collected various key data points, focusing on intraoperative sample, type, number, and technique. Point biserial correlation analysis was performed to determine statistical significance.

Results

119 revision knee arthroplasty procedures were performed in the 8.5-year study period. 31 (26%) were for prosthetic joint infection (n=29 patients), n=2 patients had re-revision procedures for second PJI. Number of samples taken ranged from 1–12 with a mode of 6. N=27 (87%) cases had the recommended number of total samples taken, of these n= 20 (65%) had five or more samples taken, N=24 (77%) cases had three or more samples taken and n=18 (58%) had five or more samples.

Conclusions

Current management of infected knee arthroplasty presents great variability in intra-operative sampling technique. Sample collection adheres to national guidelines in 77% of cases. We recommend implementation of a standardised approach to sampling through inclusion of a five scalpel and five forceps pack specifically for sampling in theatre for all suspected PJI's.
429 Clinical Audit Ankle Fractures
Authors: Ghauri AU , Ijaz O , Sabir N , Chaudhery MI , Saleem MM , Ahmed R
Published: November 2022

Aim

Ankle fractures are common among adult age group with an incidence of 174 per 100000 per year and they pose serious problems in management of geriatric age group because of osteoporotic bone. Our aim of current clinical audit was to introduce changes in current clinical practice by recommendations according to Standard BOAST guidelines of management of Ankle Fractures.

Method

Clinical Audit was carried out in Department of Orthopedics Benazir Bhutto Hospital in Outdoor and Emergency in March 2021 in patients of age group 20–70 years taking 50 patients for pre- and post-audit assessment. Emergency, Outdoor Slips were evaluated according to Standards of Practice formulated. Then a presentation was given to medical staff on Guidelines of Ankle fractures management, and they were informed about the deficiencies in their documentation and management. Panaflexes of Guidelines were displayed in ER, ward and then re-evaluation was done after 4 weeks in April 2021 using proformas in which clinical notes, discharge certificates and emergency slips were used for data analysis and observing improvement.

Results

The results of asymmetric data were calculated by Fischer Exact Test and with a p-value of <0.05 considered as significant. Results were very pleasing as they showed great improvements in documentation as well as management of patients in accordance with the set guidelines and protocols.

Conclusion

Clinical Audits should be carried out on regular basis in hospital settings as they help to improve the standards of care as well as proper documentation which has medico-legal importance.
644 Improving VTE Prophylaxis in Spinal Patients – a Closed Loop Audit
Authors: Ziolkowska K , Ismail N
Published: November 2022

Aim

Venous thromboembolism (VTE) prophylaxis is one of the key components of safe patient care and can be particularly challenging when it concerns spinal admissions to the orthopaedic trauma ward. The first cycle of our closed loop audit aimed to assess the safety of VTE prescribing in spinal admissions at a district general hospital. The current cycle aims to evaluate guideline compliance following our interventions.

Method

Quality of VTE prophylaxis prescribing was measured against NICE (NG89) recommendations as well as local guidelines. Patients were identified based on prospectively maintained admission lists. The initial audit cycle was presented locally, and the following measures were introduced in order to improve prescribing: staff teaching sessions, nomination of a VTE guardian, inclusion of VTE plans in op-notes, publication of a dedicated spinal guideline and addition of a spinal section into the trust principal VTE guideline. The current audit cycle identified 22 spinal admissions.

Results

Out of the 22 patients, only one (4%) received inadequate VTE prophylaxis which is a significant improvement compared to the initial data (8 cases - 18%). Minor prescribing concerns were noted in three cases (14%) versus 15 cases (34%) in the first cycle. Overall, the re-audit proved that following departmental interventions the majority of patients received appropriate VTE prophylaxis with no prescribing or documentation errors (82% in the current cycle vs 48% initially).

Conclusions

We have demonstrated that significant improvement in VTE prophylaxis prescribing can be achieved by the means of educating staff and introducing simple and cost-effective measures.
735 Day Case Hemithryroidectomy Audit
Authors: Akbar S
Published: November 2022

Aim

Post-operative haematomas are a serious complication of thyroid surgery, causing potential airway compromise and fatality. Over time, hemithyroidectomy operations are increasingly being carried out as day case procedures to encourage enhanced recovery programmes post-operatively as well as reduce bed pressures on an overwhelmed National Health Service due to the COVID-19 pandemic.

Method

Hemithyroidectomy procedures carried out from 2018–2021 were analysed in 3 separate audit cycles. Outcome measures included total length of stay (LOS) in hospital, average time of operation note documentation, admission reason and any complication during or after the procedure, including complications within a 10-day period of the procedure.

Results

The percentage of same-day discharges increased reliably from audit cycle 1 (2018) to audit cycle 2 (2019) to audit cycle 3 (2021); it was found that same-day discharges increased from 48% to 64% to 70%, respectively. It was further found that if operation notes (assumed to act as a proxy for approximate time-out for procedure) were documented towards the end of the working day i.e., 5pm in most units, it was more likely for patients to be admitted overnight. There was one patient from the period of 2018–2021 that was deemed to have had a serious post-operative event.

Conclusions

There was a reliably increase in same-day discharges for each successive audit cycle. There is a limited requirement for patients undergoing hemithyroidectomy procedures to have a surgical drain placed. Hemithyroidectomy operations can be carried out safely as day case procedures based on the observations of this audit.
594 Reporting of Weight Loss Outcomes Following Bariatric Surgery in Comparison to ASMBS Guidelines
Authors: Shahwan S , Oochit K , Kourounis G
Published: November 2022

A large volume of literature supports bariatric surgery as an effective therapy. The heterogeneity of weight loss (WL) outcomes significantly limits synthesis and meta-analysis. In 2015, the American Society for Metabolic and Bariatric Surgery (ASMBS) published reporting standards to achieve consistency in the literature. We aim to assess the effect of the ASMBS guidance in the bariatric surgery literature.

Nine PubMed journals focusing on bariatric surgery were screened for articles published in the first six months of 2015 and 2021. Of 1807 articles, 105 and 158 articles in 2015 and 2021 respectively, reported on WL outcomes following bariatric surgery.

Overall ASMBS compliance increased from 5% to 20%, p<0.05. Initial weight and BMI were reported in all studies but clarification of this as the immediate preoperative weight reduced from 15% to 6%, p<0.05. Percent Total WL (%TWL) increased from 17% to 61%, p<0.05. Change in BMI (ΔBMI) stayed 41%. Percent BMI or Excess WL (%EBMIL or %EWL) did not significantly change from 76% to 69%, p=0.203. In 2021, two of the nine included journals gave guidance on reporting WL in their instructions to authors. 30% (n=42/142) of articles did not comply with the journal's WL reporting guidance. Other unique reported WL outcomes increased from 44 to 55.

Significant heterogeneity in reporting WL outcomes remains hindering robust meta-analysis of published articles. Use of referral weight instead of preoperative weight can inflate WL in those with mandated preoperative WL, clarifying initial weight is needed. Other non-standard measures of WL have increased.
870 The Efficacy and Safety of Bariatric Surgery in Kidney Transplantation Candidates: A Systematic Review and Meta-Analysis
Authors: Varma J , Fernando S , Dengu F , Menon V , O'Callaghan J
Published: November 2022

Introduction

Kidney transplantation (KT) remains a high-risk procedure which requires extensive pre-operative assessment and optimisation. Obesity is known to increase the risk of adverse post-operative consequences. Bariatric surgery (BS) is an effective solution to obesity. The authors aim to summarise the evidence for the efficacy and safety of BS in KT candidates.

Method

We performed a systematic review and meta-analysis to determine the efficacy and safety of BS in patients KT candidates. A literature search of MEDLINE, EMBASE and Web of Science was conducted from inception to April 2021. The methodological quality of selected studies was assessed using the Newcastle-Ottowa tool. Our primary outcome was change in BMI, with secondary outcomes including adverse events, graft outcomes and KT rate.

Results

Nine observational studies met the inclusion criteria with a total of 179 patients (48% male). Mean change in BMI following BS was -11.2 (-12.9 to -9.5, p < 0.001) within a median follow up time of 43 months (IQR 36 to 47 months). Sleeve gastrectomy (44.7%, n=80) and gastric bypass (46.9%, n=84) were the most common procedures. Median time from BS to KT was 17 months (IQR 6 to 18 months) with a mean KT rate of 80.1% (SD = 14.9).

Conclusion

This review highlights that BS is both safe and efficacious for KT candidates and can be an effective means of optimising BMI prior to transplantation.
703 Is the Grass Always Greener on the Other Side? – How Do Breast Cancer Patients Feel About Moving to a ‘Green Hub’?
Authors: Ribbits A , Bowyer C , Kori R , Uddin S , Subramanian A , Shah L
Published: November 2022

Aim

Between January and September 2020 our base hospital recorded zero COVID-19 incidence in breast surgery patients, in 30 days post-op, with stringent admission protocols including 14 days self-isolation, PCR testing, ‘green’ wards and designated ‘green’ theatres. However, as the UK entered its third lockdown in January 6th2021 the decision was made to move breast cancer surgery off-site to a ‘green hub’ 43 miles away. The aim of this study was to assess the impact this had on patients.

Method

Patients who had surgery moved off-site were requested to anonymously complete a questionnaire which was either posted or handed to them at follow-up. The questionnaire contained 11 Multiple Choice questions and a comments section.

Results

16 of 19 patients (84.21%) responded to the questionnaire. 16 of 16 (100%) understood the reason for the move. 2 (12.5%) stated that it increased anxiety/stress levels while 3 (18.75%) reported the opposite, and the remainder were neutral. 14 (87.5%) said the move made them feel safer, 1 (6.25%) did not feel safer, with the remaining 1 (6.25%) unsure. 15 (93.75%) felt they received enough information at base and 16 (100%) received sufficient discharge information at the ‘green hub’. All 16 (100%) were satisfied with the move off-site but only 15 (93.75%) supported the decision.

Conclusions

The responses indicate that the decision to move breast surgery off-site was supported and well understood. And while for a minority of patients this increased pre-operative anxiety/stress levels, it did make the majority feel safer.
773 Standardising Autologous Breast Reconstruction Referrals – a Quality Improvement Project
Authors: Hardwick E , Rutherford C , Johnson L , Oezdogan Y
Published: November 2022

Aim

Autologous breast reconstruction should be discussed with all suitable patients undergoing mastectomy, reinforced by the most recent Oncoplastic guidelines. This generates a large volume of referrals to the Plastics team, which are variable in content, and may neglect pertinent information. The aim of this project was to prospectively audit the quality of plastics referrals prior to the introduction of a standardised proforma with the aim of streamlining the patient pathway.

Method

A prospective audit of 19 consecutive referrals for autologous breast reconstruction was performed in December 2021 in a single centre. Referrals were assessed for the following essential data: immediate or delayed surgery, BMI, smoking status, neoadjuvant chemotherapy, and planned adjuvant treatment, specifically chemoradiotherapy.

Results

Immediate or delayed reconstruction status was reported in 18 (94.7%) of referrals made. Neoadjuvant chemotherapy was mentioned in 13 (68.4%) referrals. Plans for likely adjuvant treatment, including radiotherapy was mentioned in 15 (78.9%) referrals. Co-morbidities were reported in 6 (31.6%) referrals. Only 2 (10.5%) referrals reported on BMI and 4 (21.1%) on smoking status.

Conclusion

There is significant variability in the detail and quality of referrals for autologous breast reconstruction. Consequently, a standardised proforma was introduced to the unit which was presented at the Trust Audit Day. The proforma information was felt to be crucial in assessing the patient's appropriateness for surgery and its timing. This referral was introduced as an online tick-box form sent to a shared Plastics email. This has since been widely adopted allowing for efficient time-saving referrals with relevant information included.
819 Management of Maxillofacial Trauma Emergency Department Presentations in an Evolving Pandemic. Did COVID-19 Change Our Practice?
Authors: Owen A , Brewer E
Published: November 2022

Aim

Trauma encompasses a significant proportion of referrals to Oral Maxillofacial Surgery (OMFS). COVID-19 called for clinicians globally to tailor practice and follow-up patterns. Multiple government-imposed lock downs saw changes in patterns of emergency department (ED) attendances nationally.

The aim of this audit was to examine the impact of COVID-19 on Maxillofacial trauma presentations, admissions, and existing practice in University Hospital of Wales (UHW).

Method

Data was collected using an electronic patient database “Team Talk”. Patients filtered by pathology (Soft tissue trauma, fractures) and location (ED). Annual data collected for 2019, 2020 and 2021, to compare pre-pandemic (2019), evolving pandemic (2020) and established pandemic (2021) figures.

Results

Trauma made up 74%, 73% and 78% of total OMFS referrals (2019, 2020, 2021). There was an 83% decrease in the number of trauma referrals between 2019 and 2020, despite UHW becoming a major trauma centre. No correlation identified between trauma presentations and lockdown events (2020) but lifting of restrictions (September 2021) showed an increase in presentations. 16.8%, 16.4% and 16.2% (2019, 2020 and 2021, respectively) of ED referrals were offered follow up follow up. Percentage of follow up appointments used for removal of sutures (ROS) decreased by 30% (2019–2020).

Conclusions
941 The Effect of COVID-19 on Orthopaedic Trauma Theatre Efficiency and Surgical Training in the North and East of Scotland Major Trauma Centres – a Year On
Authors: Lim JW , Lindsay E , Rehman H , Tong EYH , Ammen bin Badekrizaman M , Withall A , Dalgleish S , Mitchell M , Boddie D
Published: November 2022

Aim

To determine the orthopaedic trauma theatre efficiency in two large major trauma centres (MTCs) in Scotland before and after the outbreak of Coronavirus disease (COVID-19) pandemic.

Method

All trauma patients presented to the North and East of Scotland's MTCs prior to the outbreak of COVID-19 (7th May to 7th June 2019), during the first peak of COVID-19 (7th May to 7th June 2020), after Aerosol Generating Procedures updates (7th November to 7th December 2020) and the ‘new normal’ (7th May to 7th June 2021) were retrospectively reviewed. Training opportunities and theatre time were compared. The Kruskall-Wallis test was used.

Results

There were no significant differences in the length of hospital stay (p=0.117, 0.065) and time from injuries and surgery within groups in both MTCs (p=0.508, 0.384). The pandemic has negatively affected the anaesthetic and surgical preparation time, time between end of procedure and send for next case, and turnover time, with more profound effect on the North of Scotland's MTC. The trainee's involvement as main surgeon had decreased with the outbreak of the pandemic, with the junior trainees being affected most severely in North of Scotland. The time taken for patient to arrive to theatre after sending and total downtime were twice as long in the North of Scotland.

Conclusion

The COVID-19 pandemic has negatively impacted the orthopaedic trauma theatre efficiency and training opportunities. Actions should be taken to improve the turnover time to maximise theatre efficiency while prioritizing training opportunities.
353 Patients with N2 Non-Small Cell Primary Lung Cancer, Does Surgery Offer an Advantage?
Authors: Jackson D , Badran A
Published: November 2022

Background

Non-small cell lung cancer (NSCLC) is one of two histological types of lung cancers. Evidence-based guidelines recommend radical resection in early-stage lung cancer, N2 disease is when there is moderately advanced lymph node spread of the cancer, recommendations for surgery at this stage are more contested.

Aim

This was a service evaluation of the management of patients with NSCLC N2 disease. We aimed to evaluate the management and outcomes of these patients to see whether surgery offers an advantage over other modalities.

Method

This was a retrospective cohort study reviewing patients treated at University Hospital Southampton (UHS) who were diagnosed with N2 NSCLC before the start of treatment from 2016–2018 and comparing survival of surgically managed patients with those treated in other ways.

Results

50 N2 patients were included, 32 had radical treatment and 11 of these underwent surgery. Kaplan-Meier survival analysis showed no significant statistical difference (Log rank = 2.342 p = 0.679) between surgery and other treatments, the survival plots showed a slightly better initial survival for chemoradiotherapy. Men were statistically more likely to have squamous cell carcinomas than women who had more adenocarcinomas. PS was shown to have significant effect on survival with higher PS having a worse survival.

Conclusions

We didn't find a statistically significant difference in the survival between patients managed surgically and other modalities. PS's effect on survival reiterates its importance when deciding on treatments to offer patients.
374 Thoracotomy vs Video-assisted Thoracoscopic Surgery in the Treatment of Vascular Rings
Authors: Campbell I , McCulla A
Published: November 2022

Aim

This review aims to investigate the procedure itself, post-operative complication rates and long-term outcomes of both VATS procedures and thoracotomy procedures in the treatment of VRs.

Method

A literature search of the MEDLINE and SCOPUS databases were performed at the projects inception to present. From the 361 articles retrieved, 271 were excluded. After applying the exclusion criteria and thorough manual screening, 14 studies were included in the review. 6 of these studies investigated the outcomes using thoracotomy, 3 case reports plus 2 studies that investigated the outcomes using VATS and 3 studies that directly compared the two procedures. All 11 studies were retrospectively performed with 4 studies collecting data for over 20 years, 2 studies over 10 years and the remaining studies collected data for 2–8 years.

Results

Overall, 590 cases in this review focused on using thoracotomy operations and 190 cases used VATS. The main themes from the results of the literature included: type of vascular ring identified, case and collection period of the studies, the surgical approach, post-operative complications, length of stay in hospital, symptom resolution, reoperation rates and mortality. In this review, VATS demonstrated reduced length of stay in hospital, lower reoperation rates and a lower mortality rate than the thoracotomy studies. The results indicated similar rates in operating time and rates of post-operative complications between the two procedures.

Conclusions

This review provides insight into the encouraging outcomes in the use of VATS compared to the thoracotomy cases which is the gold standard approach in vascular ring surgery.
420 Thoracic Physiotherapy Requirements in Anatomical Lung Resections
Authors: Lee A , Badran A , Alzetani A
Published: November 2022

Objective

Consideration of the effectiveness of thoracic physiotherapy interventions in anatomical lung resections.

Method

Prospective cohort of 119 anatomical lung resections and assessment of physiotherapy interventions in a busy teaching hospital over a 6-month period.

Results

119 patients were included, with median age of 69 (28–89). There was no obvious difference between genders (F: 52% vs M: 48%). 56% were assessed to be of performance status 0. Most were resections for adenocarcinoma (48%) and squamous cell carcinoma (10%). 61% were resected by VATS and 39% through other approaches (including open thoracotomies). A minority had no comorbidities (18%), with hypertension (41%) and previous solid tumours (33%) being most common. Average length of stay was 4 days for the cohort (3.4 for VATS and 4.9 for others). The average length of stay for patients who were seen day 1 post-op on a weekend is 4.4 (vs 5.1 if there were not seen on day 1). This is also in contrast with the average length of stay of 3.5 days if they were seen day 1 post-op on a weekday, as opposed to 4 days of average stay if they were not seen. The biggest barrier to closing this discrepancy remains weekend physiotherapy staffing.

Conclusion

We found that elective thoracic patients are more likely to have a reduced length of stay when reviewed day 1 post-op. This highlights the need for potential service developments within our weekend and Level 2/3 elective thoracic caseloads to optimise our care.
454 Sinus of Valsalva Rupture
Authors: Kucheria A , Reddy A , Bahl R , Ahluwalia V , Sadighi A
Published: November 2022

Background

Sinus of Valsalva (SVA) rupture is a rare cardiac pathology which is important to recognise and diagnose early.

Case Summary

This case report details a 30-year-old gentleman who presented with a 3-day history of dyspnoea and palpitations on a background of previous congenital heart disease. The patient's examination highlighted a continuous harsh pan-systolic murmur as well as an ECG finding of sinus tachycardia. Transthoracic echocardiography identified a ruptured Sinus of Valsalva. The patient was transferred to a cardiothoracic surgery centre and definitively treated with an aortic root and ventricular septal defect repair.

Discussion

This case highlights the clinical findings of a patient with an acute left to right shunt and the importance of early diagnosis and urgent surgery. This case emphasises the factors required to decide which surgical approach is appropriate such as the presence of aortic valvular pathology size, size of Sinus of Valsalva aneurysm, any simultaneous cardiac anomaly and the cardiac chamber involved.

Learning Points
163 Anterior Sacral Meningocystocele Manifesting as Vague Gastrointestinal and Urinary Syndromes – Two Case Reports
Authors: Khan AA , Javed S , Yaqoob E , Wellington J
Published: November 2022

Aim

Anterior Sacral Meningocystocele (ASM) carries a unique place in the current literature regarding its rarity. The condition arises in association with a congenital defect of the sacrum and coccyx through which the caudal part of the meninges may herniate to form a cyst-like structure. The disorder derives from a genetic defect of the coccyx and sacrum of which some meningeal segments protrude or herniate, forming a cyst-like entity.

Method

We report two cases of ASM. The first is a 65-year-old male with active complaints of urinary retention and hesitancy for two weeks and chronic constipation associated with lower back pain. The second, a 17-year-old girl, was presenting with abdominal bloating, pain, and backache. Magnetic resonance imaging (MRI) of the pelvis and lumbosacral spine was conducted for both patients, respectively, each scan exhibiting evidence of ASM development. Surgical correction and closure of the ASM's were performed via a posterior midline approach, which successfully alleviated the symptoms presented clinically by both patients.

Conclusions

ASM may develop asymptomatically, often with incidental discovery. Although ASM is well-regarded as a rare anomaly, diagnosis of such a defect must always be kept pertinent when a cystic structure in the pelvis is unveiled on ultrasound or during surgery. Puncture or aspiration of the cyst should be avoided if the diagnosis is in doubt. A posterior midline approach with careful obliteration of the meningocele sac opening may be curative.
219 A Rare Case of Simple Appendiceal Mucocele
Authors: Gopikrishna D , Leong WJ , Paroan M , Chiphang M
Published: November 2022

An Appendiceal mucocele is described as a dilated and abnormal accumulation of mucin in the appendix, most commonly as a result of epithelial proliferation. However, it can also be caused by an obstruction or inflammation of the appendix. It is a rare disease and sometimes it can present like an acute appendicitis. Computed tomography should be used vastly to prevent serious complications such as pseudomyxoma peritonei, if underlying pathology is neoplasm, or ileocolic intussusception

We present here a case study on patient with an appendiceal mucocele, together with its radiological, endoscopic as well as histological features. 74-year-old gentlemen was referred for a colonoscopy due to symptom of anaemia. He had an incidental finding of abnormal appendix orifice bulging into the lumen for about 15mm with an appearance of submucosal cystic lesion. He subsequently had a CT thorax, abdomen and pelvis which showed a 7–8cm appendiceal mucocele with 1.8cm diameter. An urgent Laparoscopic Appendicectomy was performed, which revealed an intact but large distended appendix with 9cm in length. The appendiceal lumen was filled with mucus material. No polyps or tumour identified. Histological examination revealed that this was a simple appendiceal mucocele with no evidence of malignancy. The patient was well post-operatively with no complication noted.
396 A Rare Encounter of “Forgotten Disease”
Authors: Sengupta S , Bose S
Published: November 2022

With the advent and prompt use of antibiotics after throat infections, the rare entity of Necrobacillosis has almost disappeared in clinical practice. Here we present a case of a fit and well 27-year-old lady who was brought into A&E with septic shock, DIC and MODS after initial diagnosis of a sore throat 4 days ago which was treated by oral antibiotics. She was found to have bilateral patchy consolidations which later became necrotic cavities, empyema thoracis, peritonitis and abscess cavities in abdomen with evolving splenic abscess, prolonged QT and ectopics and type 2 respiratory failure. She was resuscitated, intubated, and transferred to the ICU. With an isolate of Fusobacterium necrophorum from blood culture Meropenem, clindamycin and metronidazole were started. However, over the next few days of treatment, lack of clinical response prompted antibiotics changing, and surgical drainage of abscesses in chest and abdomen. Eventually after a considerable period of abdominal abscess drainage and about 3 weeks of metronidazole and other antibiotics followed by Piperacillin and tazobactam for another 3 weeks the patient recovered from sepsis and was stepped down to ward. This case though rare is a good example of the benefits of surgical drainage and prolonged antibiotics for septic patients with collections. A rapid weaning only results in re-collection and clinical deterioration, or recurrent collection as happened to this patient. This is a rare case of Lemierre's syndrome which depicts the surgical difficulties faced due to recurrent abscess cavities formed in this condition.
543 Bouveret Syndrome: A Rare Presentation of Gastric Outlet Obstruction
Authors: Peiris B , Elmasry M , Middleton S
Published: November 2022

A 76-year-old lady presented with a 5-day history of lower abdominal pain and vomiting. She had not opened her bowels for 3 days and 24 hours prior to admission had coffee ground vomitus. A CT abdomen and pelvis showed gastric outflow obstruction secondary to a large 3.5cm gallstone within the pylorus (Bouveret syndrome).

She was initially treated conservatively for bowel obstruction and underwent an OGD where attempts to retrieve the stone were unsuccessful. A subsequent laparoscopic gastrotomy revealed a large stone in the duodenum and was successfully removed.

This case highlights how this rare syndrome can present with non-specific symptoms, diagnosis can be challenging and relies on imaging, therefore patients should be worked up thoroughly to ensure a correct diagnosis. There are currently no standardised management guidelines for Bouveret syndrome, mainly due to its rare prevalence and this case demonstrates a variety of management options.