bluuebunny/crossref_metadata_2025 huggingface dataset:
338 Biceps Metastasis Presenting as A Presumed Abscess in Patient with An Undiagnosed Non-Small Cell Lung Cancer - An Unusual Presentation
Authors: Shah K , Hagiga A , Saleem O , Elfishawi M , Bashir T
Published: May 2021

Lung cancer is the most common cancer worldwide and has highest cancer mortality. Around 50% of cases present with metastasis, however skeletal muscle metastasis is rarely reported.

In this case we describe a fifty-nine-year-old male patient who presented complaining of fever and a mass on the distal biceps and proximal forearm over a five-month period, with no reported improvement despite debridement and antibiotics spanning three presentations to the emergency department. Subsequent biopsy at various anatomical sites showed adenocarcinoma, later identified as metastatic from a primary non squamous-cell lung cancer (NSCLC).

Metastases from lung cancer are more commonly limited to liver and adrenal glands. Presentation of such a mass in skeletal muscle would raise suspicion for the more-commonly seen soft-tissue sarcoma or hemangiomas. This case illustrates a rare example of lung cancer metastatic to skeletal muscle, more specifically, the biceps. Presentation of the mass was also unique in its morphology of an abscess with purulent discharge, raising the importance of cytology and suspicion for malignancy in an abscess unresponsive to antibiotics.

Non-small cell lung cancer can present with skeletal metastasis. A work-up of a mass or abscess of the muscle should include the possibility of soft tissue metastasis.
343 A Systematic Review of Symptomatic Hamartomas of The Jejunum and Ileum
Authors: Conroy M , Farkas N , Baig M
Published: May 2021

Introduction

Gastrointestinal hamartomas are rarely encountered benign growths made of an abnormal mixture of tissues normally found in the body where the growth occurs. Most hamartomas are asymptomatic and diagnosed incidentally. Evidence regarding symptomatic hamartomas of the jejunum and ileum is limited.

Method

The search terms ‘small bowel,’ ‘small intestine,’ ‘jejunum’ and ‘ileum’ were combined with ‘hamartoma.’ EMBASE, Medline, PubMed searches and Google Scholar hand searches were conducted. All English language papers from 01/01/2000-01/06/2020 were included.

Results

A total of 39 cases were reviewed, 29 adults and 10 paediatric (0-16 years). Presenting symptoms included: abdominal pain (87%), vomiting (56%), gastrointestinal bleeding (20.5%) and weight loss (5%). Stricturing was noted in 7 cases. 36/39 (92%) presented as emergencies. Diagnostic investigations included: Abdominal X-ray (49%), endoscopy (38%) and CT (56%). Initial management strategy was either open (30) or laparoscopic (7) surgery or endoscopy (2). All cases required surgery for definitive management. 9/39 cases were associated with hamartomatous syndromes. 2 mortalities were recorded.

Conclusions

This is the first review addressing symptomatic hamartomas of the jejunum and ileum. New data relating to demographic cohort, symptom profile, investigations, management strategies and morbidity and mortality provide greater insight to those encountering this challenging clinical finding in the future.
361 An Epidemiological Study into The Incidence of Facial Fractures Presenting to Addenbrooke’s Emergency Department
Authors: Hatoum A , Khokher Z , Basyuni S , Santhanam V
Published: May 2021

Introduction

Our aim was to present the epidemiological estimates of facial fractures within East Anglia.

Method

We recorded all patients presenting with facial fractures to our Emergency Department between 2014-2019. All features relating to the patient profile and injury were recorded. We used the English Indices of Deprivation, along with the UK Census (2011), to assess for a correlation between factors such as deprivation status and age with specific causes of facial fractures.

Results

2022 cases were collected totalling 2551 fractures. Mean patient age was 39. The overall leading causes of fractures were falls, assaults and sporting incidents (29.9%, 27.3%, and 17.1% respectively). Towns such as Newmarket and Cambridge demonstrated a distinct leading cause as a result of town-specific recreational activities; horse-riding and cycling respectively. We discovered a positive correlation between deprivation status and fractures due to assault. There was also a relationship between an older population and incidence of fractures due to falls.

Conclusions

Facial fractures reflect a significant cost-burden on the NHS, as well as an emotional burden on patients, which can be reduced by public health interventions and liaison between healthcare professionals and local county authorities. Sharing of these findings with the relevant parties may allow the implementation of location-specific interventions.
386 Proximal Femoral Nail (PFN) Versus Dynamic Hip Screw (DHS) In Unstable Intertrochanteric Fractures of Femur -A Comparative Clinical Study
Authors: Dubey V , Spiegelberg B , Shahane S , Samant A
Published: May 2021

Introduction

The goal of treatment of an intertrochanteric femoral fracture is restoration of patient's mobility as early as possible. The dynamic hip screw (DHS) has been used for several decades to treat these fractures. Proximal femoral nails (PFN) are reported to have an advantage in such fractures. This study aims at comparing the results of unstable intertrochanteric fractures femur treated with PFN and DHS.

Method

This was a prospective, randomized study which includes sixty patients. All patients were available for follow up with 30 patients in each group. The data about intraoperative blood loss, time to union, leg length shortening was collected. The functional outcome at the end of one year was evaluated using Harris Hip Score.

Results

Blood loss, duration of surgery, time to union and leg length shortening was significantly less in the patients treated with PFN (p < 0.05). The mean harris hip score for patients managed with PFN was significantly more than in DHS group, 12 months after surgery (p = 0.05).

Conclusions

PFN requires a smaller incision, lesser operative time, less blood loss and has improved functional results. In our opinion PFN may be a better fixation device for most of the unstable intertrochanteric femur fractures.
388 Detection of Cytomegalovirus Infection in Infants with Biliary Atresia: A Meta-analysis
Authors: Elhassan A B E , Mohamed S , Ali A , Elbathani M , Abdallah O , Mohamed A , Ibrahim A , Salman M , Elni M , Elhassa M , Elkhidi I , Abuzie A
Published: May 2021

Introduction

Biliary atresia (BA) is the most common indication of liver transplantation in children. Several reports attributed BA to both prenatal and perinatal aetiologies, including a viral infection-induced auto-immune response that targets the bile ducts. Cytomegalovirus (CMV) remains the most common virus being linked to BA. This meta-analysis estimates to what extent CMV infection is detected in patients with BA.

Method

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases of MEDLINE/PubMed, WHO-Virtual Health Library (VHL), ScienceDirect, and Google Scholar were used for the systematic search. Random effects model was used to estimate the pooled prevalence estimate with the corresponding 95% confidence interval (CI) using StatsDirect statistical software.

Results

A total of 13 studies (covering 419 patients) that fulfilled the eligibility criteria were included in the meta-analysis. The pooled overall prevalence of CMV infection in patients with BA was 24.5% (95% CI 11.9 %– 33.9%).

Conclusions

The available data demonstrate that the detection of CMV infection is common in infants with BA. There is still a need for large studies with appropriate controls to examine various aspects of the association between CMV infection and BA.
393 What Are the Risk Factors for Anastomotic Stricture After Bile Duct Injury Repair? A Systematic Review and Meta-Analysis
Authors: Hall L , Halle-Smith J , Hodson J , Roberts K
Published: May 2021

Introduction

Hepaticojejunostomy (HJ) is the standard repair following major bile duct injury (BDI), but anastomotic stricture can result in long-term morbidity. There is a need to assimilate high-level evidence to establish risk factors for the development of anastomotic stricture after HJ for BDI.

Method

A systematic review of studies reporting the rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Meta-analyses of proposed risk factors were then performed.

Results

Meta-analysis included five factors (n = 2,198 patients, 17 studies). Vascular injury (OR 2.71; 95%CI 1.37-5.35; p = 0.004), postoperative bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003), previous repair (OR: 5.36; 95%CI 1.04-27.76;p=0.05) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p < 0.0001) were associated with HJ stricture after BDI. Strasberg injury grade was not associated with HJ stricture (OR: 1.05; 95%CI 0.63-1.75; p = 0.86). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate.

Conclusions

This meta-analysis identifies factors that significantly increase the rate of anastomotic stricture after HJ for BDI. Knowledge of these risk factors will allow risk stratification in terms of follow-up for individual cases, better informed consent, and guidance for medico-legal cases.
401 Three Birds with One Stone: Ureteric Calculus Precipitates Diagnosis and Resection of Three Primary Neoplasms
Authors: Collins P , O'Connell C , Omer S A , Inder M S , Madden A , Smyth L , Casey R , Manecksha R , Thomas A , Browne R , O'Neill A , Tierney S , Flynn R
Published: May 2021

A 67 year-old female presented to our centre with a 2 day history of right flank pain, clinically suggestive of ureteric colic. Computed tomography (CT) confirmed a 6mm right ureteric calculus. However, CT also revealed a large 13cm ipsilateral renal mass, concerning for renal cell carcinoma (RCC). At ureteroscopy for management of the obstructing calculus, a small papillary lesion was noted in the bladder, and excised. Histology confirmed pTa low-grade transitional cell carcinoma.

Following discussion at the Urology multidisciplinary tumour board, MRI venogram (MRV) was recommended to delineate the extension of tumour into the renal vein, and to characterise a pelvic mass seen on original CT. MRV showed enhancing material extending into the IVC, consistent with tumour thrombus. However, it also identified a concerning 6cm solid ovarian mass.

The patient proceeded to open right radical nephrectomy and IVC thrombectomy, hysterectomy, bilateral salpingo-oopherectomy, and omental biopsy, with combined input from Urological, Gynaecological and Vascular surgical teams. Post-operative course was uneventful. Histology showed an 11cm pT3a G2 clear cell RCC, and 7.5cm ovarian fibroma, both fully excised. This case demonstrated the serendipity of a simple ureteric calculus precipitating a cascade of investigations, that ultimately led to complete resection of three primary neoplasms.
413 Posterior Stabilisation Without Formal Debridement for The Treatment of Non-Tuberculous Pyogenic Spinal Infection in A Frail and Debilitated Population – A Systematic Review and Meta-Analysis
Authors: Elmajee M , Munasinghe C , Aljawadi A , Elawady K , Shuweihde F , Pillai A
Published: May 2021

Background

Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary for severe cases where there is evidence of spinal instability or neurological compromise. The primary surgical procedure focuses on the anterior approach with aggressive debridement of the infected tissue regions. We aim to evaluate the effectiveness of the posterior approach without debridement.

Method

Several databases including MEDLINE, NHS evidence and the Cochrane database were searched. The main clinical outcomes evaluated include pain, neurological recovery (Frankel Grading System, FGS) post-operative complications and functional outcomes (Kirkaldy-Willis Criteria and Spine Tango Combined Outcome Measure Index, COMI).

Results

From the four papers included in the meta-analysis, post-operative pain levels were found to be lower at a statistically significant level when a random effects model was applied, with the effect size found to be at 0.872 (p < 0.001, 95% CI: 0.7137 to 1.0308). Post-surgical neurological improvement was also demonstrated with a mean FGS improvement of 1.12 in 64 patients over the included articles.

Conclusions

Posterior approach with posterior stabilisation without formal debridement can results in successful infection resolution, improved pain scores and neurological outcomes. However, Larger series with longer follow-up duration are strongly recommended.
419 Endovascular Aortic Repair of Abdominal Aortic Aneurysm Early Re-Intervention Outcome, A District General Hospital Experience
Authors: Soliman H , Girish G , Shahed S
Published: May 2021

Introduction

Endovascular repair (EVAR) transformed abdominal aortic aneurysm (AAA) management. However, it is associated with higher re-intervention rate compared with open repair. This audit evaluates the early re-intervention rate at Watford General Hospital relative to the 4-yearly average rate in the draft evidence review by NICE (16.89%).

Method

EVAR procedures performed in 2015 and 2016 were retrieved. The follow up was analysed to identify re-intervention procedures performed to address complications related to the initial EVAR or sac expansion.

Results

108 patients underwent EVAR during the 2-year inclusion period. 21 re-interventions (19.4%) were recorded, irrespective of type or cause of re-intervention. 30 patients (28.6%) developed endoleak but only 17 (56.7%) had a re-intervention. Type 1 endoleak was the main cause for re-intervention (28.6%). The majority of re-interventions were executed endovascularly (57%). 47.6% of the re-interventions were done during the first year following EVAR.

Conclusions

Even though our re-intervention rate was relatively above the international average, EVAR is still considered safe for AAA repair with low morbidity and mortality. As re-interventions are frequently required, long-term surveillance is essential. Conversely, most of re-interventions can be performed with minimal morbidity. We recommend discussing all cases in a formal MDT before surgery and any re-intervention.
454 Brace Brace: Modified Brsotrom-Gould Procedure with and Without Internal Brace for the Treatment of Chronic Lateral Ankle Instability
Authors: McGuigan J , Pillai A , Hall A
Published: May 2021

Introduction

The most common ankle injury is a sprain. Surgical management is only indicated when nonoperative treatment fails. Modified Broström-Gould (MBG) is the gold standard surgical technique. MBG technique may be augmented with an internal brace. This study aims to compare the clinical outcomes of MBG with and without internal brace for the treatment of chronic lateral ankle instability using validated patient recorded outcome measures.

Method

Retrospective analysis of patients that underwent lateral ankle ligament reconstruction between January 2012 and June 2019 were reviewed at and asked to complete the Manchester oxford foot and ankle questionnaire (MOXFQ). 29 patients (30 ankles) underwent lateral ligament reconstruction between these dates and completed the questionnaire, 20 patients (21 ankles) without internal brace and 9 patients with internal brace.

Results

The group with internal brace displayed significantly better results in the MOXFQ summary index score (20.49 ± 13.15 vs 43.53 ± 34.72, P = 0.014) and standing/walking subscale (15.48 ± 13.00 vs 45.92 ± 36.60, P = 0.023) compared to group without internal brace. There was no significant difference between Pain and Social interactions subscales.

Conclusions

Our results show that the addition of an internal brace to the MBG procedure for the management of chronic lateral ankle instability improves clinical outcomes.
465 No Role for Postoperative Antibiotics in Uncomplicated Appendicitis
Authors: Ayoub N , Tryliskyy Y , Baig M K
Published: May 2021

Introduction

Several studies have shown benefit from use of preoperative antibiotics in reducing postoperative infection after appendectomy as well as efficacy of postoperative antibiotics in complicated appendicitis (defined as perforated appendix or presence of pus in peritoneum). While for uncomplicated appendicitis, several studies showed no benefit from antibiotics postoperatively but there are no clear NICE guidelines till now and so surgeons have different practice based on their preferences.

Method

This study included patients who had appendectomy for uncomplicated appendicitis in Worthing hospital from 1st July 2019 till 30th June 2020. The end point was 30-day follow up postoperatively for wound infection or collection.

Results

90 patients were admitted with uncomplicated appendicitis with age 6-80 years (mean of 31.3). 46 patients (51%) did not receive postoperative antibiotics (group A) and 44 (49%) received postoperative antibiotics (group B) with a variable practice from one dose to 8-day course. postoperatively, only 1 patient (2.1%) in group A developed wound infection requiring drainage while none in group B developed complications (p-value=1).

Conclusions

Administration of postoperative antibiotics in uncomplicated appendicitis showed no superiority over non-administration. in addition, they add extra cost on NHS. So, their routine use postoperatively is not recommended, however, larger studies are required to confirm this.
470 Could Covid-19 Change the Way We Do Clinics for The Better? A Comparison of Remote Versus Outpatient Clinic Follow-Up for Surgical Patients: A Meta-Analysis of Randomised Controlled Trials
Authors: Oates Emily , Hui Chin Lim Grace , Nevins Edward J , Kanakala Venkatesh
Published: May 2021

Introduction

As the Covid-19 pandemic hit the UK, the way the NHS operates changed overnight. One change was the move to remote appointments (RA) by video or telephone. This meta-analysis (MA) of randomised controlled trials (RCTs) looks at existing evidence on RA and aims to discover if surgical patients are satisfied with them.

Method

A literature search of RCTs of surgical patient satisfaction of RA versus conventional outpatient clinic (OPC) was performed. The PubMed, EMBASE and Google Scholar databases were searched to include articles from January 2000 to 2020. A random effects MA model was used to compare outcomes.

Results

All 5 RCTs showed that patients were as satisfied with RA as OPC (RR = 1.00, [0.97-1.03] p = 0.96). Furthermore, both patient cohorts would prefer RA for future follow-up (RR = 2.28 [1.85-2.82] p < 0.00001). 1 RCT performed a cost analysis and found the cost to institutions was less in the RA group ($19.05 vs $52.76). All other RCTs suggested cost to patients and institutions would be less for RA.

Conclusions

Surgical patients are satisfied with RA and in fact would prefer them, thus indicating that out with the Covid-19 pandemic RAs could be continued, and in doing so may well save money for patients and the NHS.
486 Are Surgical Resection Margins A Risk Factor for Crohn’s Disease Recurrence?
Authors: Haiduc A A , Patel R , Karim A
Published: May 2021

Despite advances in treatment, Crohn’s disease (CD) recurrence is still high. Various factors correlated with recurrence are studied however, there is no consensus regarding the importance of disease-free resection margins. Our goal was to ascertain whether surgical margins predict recurrence rates of CD and identify other potential factors correlated with recurrence.

This is a retrospective cohort study on patients who have had a colonic resection for CD from December 2016 to November 2019. Demographics, surgical procedure details, disease activity at resection margins and number of readmissions were recorded. Clinical recurrence was defined as readmission to hospital for a Crohn’s related flare-up within 12 months of surgical resection. Positive disease activity at the resection margins was defined histologically. We compared the readmission rate between all categories.

Of the 55 patients identified, 52 (22 female) were included. Of these, seven were readmitted, six are smokers, 19 had mesenteric excision and 33 had Crohn’s positive resection margins. Chi-squared tests showed there are no significant correlations between patient and procedure variables, and readmission rates (p > 0.05).

We have not found sufficient evidence to conclude that a disease-free resection margin post colonic resection or any other patient-related factors are associated with decreased recurrence of CD.
501 Lateral Rectus Muscle Palsy Secondary to Sphenoid Sinusitis: A Case Report and Literature Review
Authors: Leong W S , Mulla O
Published: May 2021

Background

Isolated sphenoid sinus disease (ISSD) is a rare, often misdiagnosed condition of the paranasal sinus. If left untreated, it can lead to complications involving pituitary gland, cavernous sinus, neurologic, and vascular structures nearby.

Case report

We present a case of a 60-year-old female with a history of severe left-sided headache, facial pain, diplopia, and left lateral rectus palsy. She was initially referred to ophthalmology and rheumatology for possible giant cell arteritis. MRI scans revealed opacification in left sphenoid sinus consistent with left sphenoid sinusitis. There were no signs of cavernous sinus thrombosis. She was then referred to ENT and underwent endoscopic transnasal sphenoidotomy procedure. Culture results showed Haemophilus Influenza and fungal pseudohyphae. Her palsy and headaches recovered completely 3 months later with a course of antibiotics and antifungals.

Literature review for lateral rectus palsy secondary to sphenoid sinusitis without cavernous sinus thrombosis showed it is not a common condition and this case report should serve as a reminder to consider paranasal sinus disease when assessing these patients.

Conclusions

The onset of ISSD is often insidious and diagnosis of this condition remains a challenge. MRI and CT imaging remain the gold standard for recognising and managing this condition.
511 A Case Report of A 16-Year-Old Girl with Peritoneal Tuberculosis
Authors: Fabelurin C , Arora D
Published: May 2021

Peritoneal Tuberculosis (PTB) is a rare extra-pulmonary manifestation of Mycobacterium tuberculosis infection. It usually presents with non-specific symptoms that can mimic other intra-abdominal pathology. Therefore, a high index of suspicion is needed for diagnosis and early treatment of PTB. Some of the intra-abdominal conditions in young patients that may have similar presentations to PTB include Crohns’ disease, ovarian pathology and acute appendicitis. Diagnosing PTB in the paediatric population tends to be even more challenging as an obvious history of exposure may be difficult to obtain. Diagnostic laparoscopic biopsy and histopathology provides definitive diagnosis. Most studies recommend a 6-month course of anti-TB therapy for abdominal tuberculosis with a planned regimen using Isoniazid, Rifampicin, Pyrazinamide and Ethambutol.

This case report presents the case of a 16-year-old girl who presented with a history of recurrent abdominal pain, vomiting and pyrexia. Radiological, laparoscopic, and histopathological findings were used for final diagnosis of this condition. The patient was treated using the anti-tuberculosis therapy for 6 months following which, she was able to make a full recovery.
544 Vasculitic Subglottic Stenosis: A Question of Immunosuppression?
Authors: Zammit M , Hardy S , Harper J , Panarese A , Webb C
Published: May 2021

Introduction

Subglottic stenosis (SGS) is the commonest manifestation of tracheobronchial disease in granulomatosis with polyangiitis (GPA) and carries a high degree of morbidity.

Management of SGS-GPA is a double-edged sword. Delayed treatment may cause respiratory compromise and infectious complications. However, aggressive surgical management may initiate a systemic inflammatory response, reactivating the vasculitic cascade and potentially lead to long-term complications including renal vasculitis and consequential end-stage renal failure.

There is currently no internationally agreed management strategy for this disease.

Method

This retrospective review was undertaken to analyse our unique combination of surgical dilatations and immunosuppressive-focused adjuvant management strategy between years 2011-2020.

Results

Sixteen of our one hundred and nine GPA patients (14.7%) had SGS and were included in our analysis. Whilst three patients (18.8%) improved solely on medical treatment, thirteen (81.3%) required combined surgery and immunosuppression (consisting of cyclophosphamide or Rituximab regimens). Thirty-nine surgical dilatations and two tracheostomies were performed over a mean 53-month follow-up period, with a calculated mean procedure rate of one every 24.8 months (2.7 - 89 months).

Conclusions

Our current management strategy affords a lower procedure rate at every 24.8 months compared to other published studies with combined procedure rate at every 14.9 months.
560 A Rare Case Report of Cartilaginous Choristoma In Base of Tongue
Authors: Karadakhy O , Aziz M , Salama H
Published: May 2021

Introduction

Choristomas are rare, benign, tumour-like growths with histologically normal morphology in an ectopic location. Choristomas can constitute of various tissue types including cartilage, bone and muscle. Chondroid tissue choristomas are referred to as cartilaginous choristomas.

Case Presentation:

A 69 year old gentleman presented with three weeks’ history of foreign body sensation in his throat. No other red flag symptoms were present. Fine nasal endoscopy was unremarkable. Magnetic resonance imaging (MRI) scan revealed mild bilateral prominence of the lingual tonsils. Patient underwent Panednoscopy and biopsy. This confirmed the presence of a cartilaginous choristoma in base of tongue.

Discussion:

This is a rare case of cartilaginous choristoma in base of tongue. It was investigated as per potential head and neck cancers. The majority of previous cases in the literature were managed using surgical resection of the lesion. In this particular case, the patient was discussed in multi-disciplinary team (MDT) meeting and managed conservatively due to the benign nature of the lesion and symptoms.

Conclusions

Cartilaginous choristomas are rare benign lesions, which can present similarly to malignant head and neck tumours. Their size and symptoms should be carefully considered before management. There is a role for conservative management in select cases.
586 Subxiphoid Incisional Hernias Post Median Sternotomy: A Literature Review
Authors: Chan J , Oo S
Published: May 2021

Background

Subxiphoid incisional hernias are one of the complications following a median sternotomy, a surgical procedure to provide access to the mediastinum. Incidence has been reported between 1-4%, although the true incidence is not well known due to its asymptomatic nature.

Method

A comprehensive search was performed on multiple sites. Keywords included “incisional hernia OR Subxiphoid hernia” AND “Median sternotomy OR Cardiac Surgery OR Coronary artery bypass graft OR Transplant OR Valve replacement”. Articles up to 1st of August 2020 were included in this study.

Results

8 articles were included in the study, with a total number of 132 patient identified. The incidence ranged from 0.81% to 3.44%. There was a mixture of repair method and follow up period reported. Recurrence post-repair ranged from 10% to 43%.

Conclusions

Subxiphoid incisional hernias are rare, however, remain challenging to manage. A mixture of open and laparoscopic techniques was reported with a mixed recurrence or failure rate. Further work should be done with a large patient cohort comparing both the open and laparoscopic technique.
588 An Audit on CT Staging of Patients Prior To Robotically Assisted Radical Cystectomy
Authors: Umolu A , Quraishi M , Calleja E
Published: May 2021

Introduction

Muscle invasive bladder cancer(MIBC) is a complex disease requiring aggressive management. CT of the Thorax, Abdomen and pelvis is the optimal form of staging including CT urography for complete examination, according to the European Association of Urology. Cure is unlikely in the presence of metastases. The aim was to assess if patients were appropriately staged prior to Robotically Assisted Radical Cystectomy (RARC)

Method

Retrospective review of medical records of all RARC between Jan 2020 – June 2020 at our district general hospital. Demographics, date of cystectomies and date of imaging was collected.

Results

Seventeen patients were recruited. Median age of patients was 73years and the male to female ratio was 7:3. All (100%) of them had CT Thorax, abdomen and pelvis done prior to RARC. Of the patients studied 24% of them did not have CT Urography done. CT staging of 53% of patients was within 30 days prior to Cystectomy, 35% had CT staging between 30 – 90 days and 12% had CT staging between 90 and 200 days.

Conclusions

Findings showed good adherence to the guidelines requiring CT staging prior to RARC. To prevent understaging of MIBC prior to RARC, clarifications of timeframe between CT staging and RARC is required.
590 False Positives Bladder Scan in Anuric Patient with Ascites: A Case Report
Authors: Alamassi A
Published: May 2021

Introduction

Urinary retention is one of the common presentations. Sometimes the clinical examination is unreliable, especially in patients with high BMI, ascites or anasarca. This makes the diagnosis uncertain and the bladder scan readings should be interpreted with caution. Thus, radiological imaging might be required before planning further intervention.

Case presentation

An 83-year-old woman was admitted under the medical team for sepsis secondary to soft tissue infection. She had multiple comorbidities and morbid obesity with a BMI of 58. Lab results showed an AKI. Initial Bladder scan showed 900 cc. Five uneventful attempts of urinary catheter insertion by the medical team, but still, no urine output and the bladder scan showing positive readings. Supra public catheter was considered. On review, the urinary catheter was in place, no evidence of blood per urethra and the bladder scan showed a reading of around 900 cc. Based on patient’s significantly high BMI, background history, uneventful catheterization and persistent reading on bladder scan. False reading on bladder scan was suspected. Out of hours CTKUB showed significant amount of ascites.

Discussion:

Bladder scan is sensitive for detecting any fluid in the abdomen not specifically urine in the bladder.Formal imaging should always be considered to confirm diagnosis.
599 Acute Abdomen Secondary to Appendiceal volvulus: A Case Report
Authors: Alamassi A
Published: May 2021

Introduction

Appendiceal torsion is an uncommon precipitating factor for acute appendicitis. It is found to be in association with appendiceal mucocele.

Case presentation

A 38-year-old lady presented with acute peritonitis. CT Scan showed tubular fluid collection. This was suggested to be a torsion/volvulus of the appendix. The intraoperative finding were a distended appendix filled with mucus and twisted 720° at the base. Appendectomy was done. The histopathology showed low grade mucinus neoplasia.

Discussion:

Approximately, 50% of mucoceles are asymptomatic and incidentally discovered, whilst 40% present with acute appendicitis. There are two suggested pathogenesis: one being an obstructive mechanism causing high pressure in the appendix, resulting into gross mucinous accumulation and second being a neoplastic process. Appendiceal mucinous neoplasms are classified into LAMN, HAMN and mucinous appendiceal adenocarcinoma. It is important to differentiate between the pathological subtypes as the risk of occurrence of PMP may vary according to that. This would affect the treatment modalities; follow up planning, prognosis and risk of recurrence. It is important that extra precautions should be taken whilst handling the specimens intraoperatively to avoid spillage of the content as that might lead to implantation of neoplastic cells in the peritoneum and that might affect the overall survival rate.
613 Microsurgical Salvage of Neonatal Upper Limb Ischaemia Subsequent to Intrauterine Brachial Vessel Constriction
Authors: Clements J , McBride M , Fogarty B , Lewis H
Published: May 2021

Introduction

We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular, and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

Description

A male baby at (36 + 6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post-delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft.

Discussion

Neonatal limb ischaemia is a rare disease entity with devastating morbidity- including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.
646 Appraisal of International Guidelines for Malignant Melanoma Management Using the AGREE II Assessment Tool
Authors: Jacklin C , Harrison C , Tan M , Sravanam S
Published: May 2021

Background

Recently, the widely accepted NICE guidelines for melanoma management have been challenged by a UK-based expert consensus statement. A review of alternative clinical practice guidelines (CPGs) could guide future CPG updates and developments. The AGREE II tool assesses CPGs across six domains: ‘Scope and purpose’, ‘Stakeholder involvement’, ‘Rigour of development’, ‘Clarity of presentation’, ‘Applicability’, and ‘Editorial independence’.

Method

We conducted a systematic search of Pubmed, Medline and online CPG databases to identify melanoma CPGs published between January 2014 and March 2020 providing recommendations for: adjuvant treatment, radiotherapy, surgical management, or follow-up care. Three authors independently assessed the quality of identified CPGs using the AGREE II assessment tool. Inter-rater reliability was assessed by Kendall’s coefficient of concordance (W).

Results

Twenty-nine CPGs were included and appraised with excellent reliability (Kendall’s W for overall GPC score 0.85, p < 0.001). Overall, melanoma CPGs scored highly in the scope and purpose and clarity of presentation domains, and poorly in the applicability domain. The NICE guideline achieved the best overall scores.

Conclusions

The NICE melanoma CPGs are higher quality than alternatives but should be updated to reflect recent landmark trials. The AGREE II tool is currently limited by its incapacity to compare guidelines to latest evidence.
653 DRAFFT Dodging? Fixation Methods for Distal Radial Fractures Since 2014 In A UK Trauma Unit
Authors: Gilbert J , Akehurst H , Mutimer J
Published: May 2021

Introduction

The 2014 randomised, controlled Distal Radius Acute Fracture Fixation Trial (DRAFFT) compared K-wires to internal fixation for management of dorsally displaced distal radius fractures. The authors found no clinical difference between the two fixation methods, concluding ‘The results of this trial will reverse the trend towards locking-plate fixation for this injury’. Our study aimed to measure local change in practice since 2014.

Method

From the DRAFFT CONSORT diagram, we calculated just 10.7% of eligible cases required locking plate fixation. 300 patients, 50 per year from 2014-19 meeting DRAFFT eligibility criteria undergoing fixation, were randomly selected from an electronic trauma database. Radiographs were reviewed to see whether patients received internal fixation or K-wires.

Results

Age and sex distributions of the study sample were not significantly different to the DRAFFT population (p < 0.05). Over 60% of recruited patients received internal fixation each year. No increasing trend in use of K-wires was detected (p = 0.27). No trend was observed in either fixation method adjusting for intra versus extra-articular fractures (p = 0.36).

Conclusions

Local practice remains unchanged in fixation of dorsally displaced distal radius fractures since 2014. Internal fixation remains the most prevalent surgery, and there has been no detectable increase in use of K-wires.
659 Unilateral Infarction of Adrenal Gland During Pregnancy: A Case Report and Important Learning Point
Authors: James S , Lafaurie G , Hafeez R
Published: May 2021

Background

Abdominal pain in pregnancy offers a challenge for the General surgeon. Unilateral adrenal infarction is an extremely rare event.

Case presentation:

We report the case of an obese 23-year-old pregnant female G4 P1 + 2 diagnosed with unilateral adrenal infarction and hemorrhage. She presented at 34 + 5 weeks with severe RUQ and flank pain under the obstetric team. After initially being discharged, she later returned with intractable pain. Examination and initial investigations (USS KUB and abdomen) were inconclusive. She was empirically treated for pylonephritis. During the night she underwent emergency c-section due to uncontrollable pain. Subsequently, a CT abdomen demonstrated a unilateral right adrenal infarct with hemorrhage.

Discussion:

Unilateral adrenal infarction often leads to a delay in diagnosis and should be part of differential diagnosis in patients with severe RUQ pain (1.3%). It is a rare event diagnosed generally by CT or MRI scan showing attenuation or swelling of adrenal glands. Physiologically it is due to the state of venous circulation during pregnancy alongside others coagulation risks factor.

Learning point:

To consider adrenal infarction with severe RUQ pain when first line diagnosis normal.

Key Investigations:

MRI during pregnancy and CT AP after. Discussion in MDT and screen for coagulation disorder.
698 A Systematic Review of Smartphone Applications for Enhanced Recovery After Surgery (ERAS) Following Colorectal Surgery
Authors: Aseem R , Cribb E , Liccardo F , Daulatzai N , Smith J , Pawa N
Published: May 2021

Introduction

Length of stay (LOS) following colorectal surgery has reduced due to enhanced recovery after surgery (ERAS) programs. Telemedicine has shown potential for patients to remotely access support, communicate progress with their medical team and enhance patient empowerment. We conducted a systematic review of smartphone applications for ERAS following colorectal surgery measuring patient outcomes and experience.

Method

The review was performed adhering to PRISMA guidelines, using search terms pertaining to ERAS, colorectal surgery, and mobile applications via electronic databases. All peer-reviewed English articles were assessed for inclusion and quality by two reviewers. A qualitative analysis was conducted to evaluate methodologies, patient experience, and outcomes.

Results

206 abstracts were identified from which 5 articles (2 RCTs and 3 cohorts) were included in the analysis. Studies surveyed patient adherence to ERAS, LOS, readmission, intra and postoperative complications. Four studies recorded patient satisfaction, whilst one assessed quality of life and application validation.

Conclusions

The review highlights paucity in the use of smartphone applications after ERAS in colorectal surgery but demonstrates high patient satisfaction levels. Service delivery in the NHS has increasingly moved to a virtual platform during the coronavirus pandemic. More research and engagement in the development and use of smartphone applications would enhance care for patients.
700 Audit on Antibiotic Prescriptions in Neuro-Rehabilitation Wards (C2 And L1) Of Salford Royal Foundation Trust
Authors: Ugwu O , Cheng L
Published: May 2021

Background

Antibiotic-guidelines protect patients by reducing the burden of antibiotic-resistant strains. Some also contain charts for safe dosage and monitoring. Adherence to guidelines promotes patient safety.

Method

Data was collected retrospectively. Electronic records of all in-patients in Neuro-rehab wards on 24/7/2020 were initially analysed. Patients who had not received antibiotics from 1/5/2020 to 24/7/2020 were excluded. Data was analysed using tally chart.

Results

23 patients received antibiotics. Antibiotics were prescribed 45 times over study period. Urinary Tract Infections (UTIs) accounted for 37.8% of cases. Chest infections and skin infections accounted for 22% and 15% respectively. Sepsis of unknown origin and Other-Causes each accounted for 8.9%. In 95% of prescriptions, an indication was documented. Also, 100% compliance was recorded in Allergy status review and documentation of course-length of antibiotics. However, only 53.4% met clinical criteria for antibiotics administration. Of the cases which did not meet the clinical criteria, only 52.3% had been discussed with microbiology department /senior clinician.

Conclusions

Neuro-rehabilitation patients present with complex conditions and are sometimes non-communicative. This makes it difficult to adhere to clinical criteria as some of these require symptoms from patients. Such cases must be discussed with microbiologist/senior clinician.
701 Combined Endovascular and Percutaneous Treatment of Traumatic Pseudoaneurysm of Profunda Femoris Artery: A Case Report
Authors: Malik P , Makar R , Joshi S , Balakrishnan A
Published: May 2021

Pseudoaneurysms of the profunda femoris artery are rare complications of femoral fractures, seen especially after orthopaedic interventions for the same.

We present a case of an 89-year-old Caucasian male with a left neck of femur fracture, repaired with a dynamic hip screw. He presented to us a month later with a painful swollen thigh and deep vein thrombosis. The patient underwent arterial duplex and CT angiogram scans and was found to have a pseudoaneurysm in his left profunda femoris artery, measuring 3x3x4.5cm. This was treated with balloon angioplasty and stenting. However, his stent surveillance duplex scan, a month later, showed that the pseudoaneurysm was largely thrombosed with a patent core that was being fed by a communicating vessel from the superficial femoral artery. A subsequent angiogram showed no obvious feeding vessel. The patent pseudoaneurysm was then treated by percutaneous injection of thrombin. Exclusion of the pseudoaneurysm was confirmed by a follow-up duplex scan.

It is essential to treat all feeding vessels of pseudoaneurysms in the presence of a rich collateral supply. Profunda femoris false aneurysms can thus be treated entirely by endovascular/percutaneous methods and so, potentially avoid open surgery.
726 Return to Sport, Patient Reported Outcomes and Satisfaction Following Anterior Cruciate Ligament Reconstruction
Authors: Simpson C , MacDonald D , Keating J
Published: May 2021

Introduction

Anterior Cruciate Ligament(ACL) rupture is a common sporting injury. Return to sport is a key objective for patients.

The aim of this study was to investigate return to pre-injury level sport at 12- and 24-months post reconstruction and to relate this to types of sport and to patient satisfaction.

Method

A questionnaire was developed, piloted, and then completed by 77 patients that had undergone ACL reconstruction between 2013-2016.

Results

30% of patients returned to pre-injury level of sport at 12 months and 43% by 24 months’ post ACL reconstruction. There was a significant(P = 0.037) relationship between the type of sports that participants played prior to injury and the return to pre-injury level. Sports that involved jumping, hard pivoting and cutting were associated with a lower rate of return to sport. General health profile of the patients was found to be significantly higher in patients that returned to sport(P = 0.024). There was a significant association with return to sport and higher satisfaction and healthcare experience score(P = 0.001).

Conclusions

Patient satisfaction correlated with return to sport. This was inversely related to sports involving jumping, hard pivoting and cutting. Which further illustrates how patient satisfaction post ACL reconstruction was linked to type of sport.
728 Histomorphology Of the Subregions of The Scapholunate Interosseous Ligament and Its Enthesis
Authors: Liew M Y , Mortimer J W , Paxton J Z , Tham S , Rust P A
Published: May 2021

Introduction

The scapholunate interosseous ligament (SLIL) is commonly ruptured following a fall onto the outstretched hand. This ligament has three subregions: dorsal, proximal, and volar. The SLIL enthesis, a specialised region where this ligament attaches to the scaphoid and lunate, has not previously been studied despite its important mechanical function in the wrist joint biomechanics. This study therefore aims to compare the histomorphological differences between the three SLIL subregions, including at their entheses, to inform subregion prioritisation during surgical reconstruction.

Method

Twelve fresh-frozen human cadaveric wrists were dissected and the gross dimensions of the SLIL subregions measured. Subregions were histologically processed for analysis, including quantification of enthesis calcified fibrocartilage (CF) area.

Results

From the gross measurements, the dorsal subregion was the thickest (dorsal=3.04 ± 0.26mm, volar=1.69 ± 0.08mm, proximal=1.51 ± 0.06mm). The dorsal and volar subregions had fibrocartilaginous entheses while the proximal subregion was attached to articular cartilage. The dorsal subregion had significantly more CF than the volar subregion.

Conclusions

The dorsal subregion is the thickest and has the greatest CF area, which is consistent with the greatest biomechanical force subjected to this subregion. These results confirm that the dorsal subregion is the strongest subregion, suggesting important implications in the study of graft incorporation during SLIL reconstruction.
793 The Giant Hogweed as A Rare Cause of Chemical Burns: A Case Series
Authors: Lim S K , Clements J , Khan K
Published: May 2021

Introduction

The Giant Hogweed (Heracleum mantegazzianum) is a rare cause for chemical burns in humans and animals and is acquiring growing recognition in mainstream media as a relevant public health concern.

Injuries attributed to this plant range from innocuous superficial irritation to full-thickness chemical burns. A vast majority of cases will resolve with conservative measures and effective first aid, but these case series demonstrate the clinical course of more severe injuries.

Description

We present a case series of 2 patients requiring admission to the Royal Group Hospitals for management of mixed thickness hogweed burns. Injuries were sustained by two separate infestations of giant hogweed in the Western Trust Area. Both patients responded to observation and conservative measures, namely effective analgesia, UV light protection, topical hydrocortisone, and dressings.

Discussion

Cutaneous burns induced by giant hogweed are caused by contact with its photoactive sap containing plant furocoumarins. On exposure to sunlight, the sap initiates a damaging process known as phytophotodermatitis (PPD). This process can be managed effectively with topical steroids; however, prolonged contact and subsequent sun exposure may lead to more severe skin damage. In extremely rare instances, damage may progress to full-thickness skin burns warranting operative intervention.