bluuebunny/crossref_metadata_2025 huggingface dataset:
1275 Machine Learning for Outcome Prediction in Epilepsy Surgery: A Systematic Review
Authors: Chia C W L , Bhatia S , Shastin D , Chamberland M
Published: October 2021

Aim

A third of epilepsy patients suffer from medically refractory seizures. In patients eligible for surgical treatment, seizure freedom rates remain variable. Machine learning (ML) utilises large datasets to detect patterns to make predictions. We systematically review studies employing ML models for prediction of outcome following resective epilepsy surgery to evaluate their efficacy, applicability and value in determining surgical candidacy.

Method

MEDLINE, Cochrane and EMBASE databases were searched for literature published between 2010 – 2020 according to PRISMA guidance. Non-refractory epilepsy, non-clinical outcome prediction, or non-human studies were excluded. Clinical and demographic data, ML features, discrimination and prediction accuracy metrics were extracted.

Results

15 studies were included. Median cohort size was 49 (range 16 – 4211). Heterogeneous input data sources were utilised: MRI (n = 10) , electrophysiology (n = 4), PET (n = 2), clinical data (n = 2), and neuropsychological testing (n = 1). The most common ML model used was support vector machines (n = 7). All studies had good discrimination (AUC > 0.70, range: 0.79 [95% CI NR] - 0.94 [95% CI 0.92 – 0.96]), and good prediction accuracy (> 0.70, range: 0.76 [95% CI NR] – 0.95 [95% CI NR]). Limitations included small sample sizes, limited external validation and lack of comparison with clinician-predicted outcomes.

Conclusions

Machine Learning for outcome prediction could enhance clinical decision-making for surgical candidacy in epilepsy, and lead to improved precision medicine delivery. Outcome reporting remains inconsistent, and further work is required to externally validate such models to implement these to large-scale clinical populations.
1679 An Unusual Case of Hypoplastic Internal Carotid Artery with Segmental Aplasia of The Anterior Cerebral Artery: A Case Report and Systematic Literature Review
Authors: Whitley H , Skalicky P , Malik J , Charvat F , Benes V , Bradac O
Published: October 2021

Aim

Hypoplasia of the internal carotid artery (ICA) is a rare morphological variant with potential implications in disease and clinical decision-making. We describe an unusual case of ICA hypoplasia in a 50-year-old female who presented with an acute episode of vertigo. CT angiogram showed an unusually short common carotid artery (CCA) on the right side, hypoplasia of the right ICA, and agenesis of the A1 segment of the right anterior cerebral artery (ACA). We provide a short review of the available literature.

Method

The literature review was performed according to PRISMA guidelines. Three databases (Pubmed, Web of Science, and Ovid) were searched using the terms “ICA” and “Hypoplasia”. Case reports published in English in the last 10 years were considered eligible for inclusion. Reports of acquired ICA hypoplasia or ICA agenesis were excluded.

Results

Our systematic literature search revealed that 19 cases of congenital ICA hypoplasia have been reported in the last 10 years. Of these, 14 were unilateral hypoplasia, including nine cases in which the anomaly was on the left, and five cases in which the anomaly was on the right. Two cases had additional aplasias; one with aplasia of the ACOM and another with aplasia of segment C6 of the ICA.

Conclusions

We conclude that ICA hypoplasia remains a rare anomaly, despite the increasing incidence due to the availability of imaging technology. Clinicians should be aware of these variations, as they are frequently associated with haemodynamic changes, aneurysms, and fenestrations. Such variations have important implications for planning angiographic and surgical approaches.
555 Should All Acutely Presenting Gallstone Disease Be Managed Surgically?
Authors: Rehman S , Khan A , Wunnava R
Published: October 2021

Aim

This audit aims to assess if gallstone complications can be prevented by performing an emergency cholecystectomy in acutely presenting gallstone disease. Factors taken into consideration include number of presentations to hospital before surgery, secondary admissions of pancreatitis or cholangitis, subsequent requirements of ERCP as well as complication rates of elective and emergency surgery.

Method

Retrospective audit looking at 387 cholecystectomies carried out, within a year, at Walsall Manor Hospital.

Results

Approximately 20% of patients had an emergency cholecystectomy. A total of 192 patients had at least one admission, with 17% having a minimum second. Seven patients went on to develop gallstone pancreatitis subsequently, as well as eight requiring at least a minimum of one ERCP. The complication rate in elective surgery was higher at 4.1% compared to 2.7% in emergency cases. Long waiting times for surgery put patients at greater risk of complications. 96% (26/27) of elective cholecystectomy patients, who suffered an attack of pancreatitis, had to wait more than four weeks. Furthermore, 39% (47/119) of those who had a minimum of one admission had to wait more than 20 weeks. On the other hand, three-quarters of patients who were operated in emergency went home within 48 hours, with the figures being not too dissimilar from elective cases with a history of admission (76%).

Conclusions

Performing emergency cholecystectomies in the same admission or on a dedicated hot list would not only decrease the risk, but also the potential risk of developing gallstone complications.
1134 Incidence of Bile Acid Diarrhoea Post-Cholecystectomy - A Single Centre Cohort
Authors: Sallam M , Patel R , Sun W , Ali R , Windle R , Shalaby S , Ward J , Bond-smith G
Published: October 2021

Aim

Bile acid diarrhoea (BAD) can occur as a result of enterohepatic circulation interruption following cholecystectomy. Although up to 57.2% of patients are reported to develop post-cholecystectomy diarrhoea, this is not always because of BAD. The aim of this study was to determine the incidence of post-cholecystectomy BAD diagnosis and evaluate the current practices.

Method

This study was conducted as part of BADCAP study. The electronic records of patients underwent cholecystectomy operation at Oxford University Hospitals between January 2013 and December 2017 were retrospectively analysed. Records were matched with patients who underwent 75SeHCAT testing during the same time period. A positive 75SeHCAT testing was defined as a seven-day retention time of < 15%.

Results

A total of 4327 patients underwent cholecystectomy operation. 2.05% (N = 89) investigated for diarrhoea by 75SeHCAT. Alongside 75SeHCAT, 69.7% (N = 62) had colonoscopy, 37.1% (N = 33) had CT abdomen and pelvis and 3.4% (N = 3) had MRCP/MRE. Gender wise statistics revealed females were 74.5% (N = 73) and males were 19.1% (N = 17). Median time from cholecystectomy to 75SeHCAT test was 780 days (SD +/-510 days). 70.8% (N = 63) had a positive 75SeHCAT test for BAD. IBD was confirmed in 2.2% (N = 2).

Conclusions

A small number of patients were investigated and only 1.5% were diagnosed with post-cholecystectomy diarrhoea. There was a significant time delay from operation to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher and clinicians need to have an increased awareness of this condition. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.
1438 The Past, Present and Future Management of Complex Chyle Fistulae
Authors: Temperley H , Waters C , Carey J , Donlon N E , Donohoe C L , Ravi N , Reynolds J V
Published: October 2021

Background

Chyle leak/fistula is a rare complication of oesophageal surgery, usually consequent on an unintended breach of the thoracic duct, its tributaries, or the cisterna chyli. For high volume persistent leaks further surgery has been the traditional approach, however two cases have resulted in a new management approach at this Centre.

Case Series

The first patient, a 49-year-old, developed high volume drain output post three stage oesophagectomy. His jejunostomy feeding was discontinued, total parenteral nutrition and a somatostatin analogue, were commenced. Despite these measures, the drain output remained >1.5litres per day and an exploratory thoracotomy was performed. The second patient, an 81-year-old underwent a transhiatal-oesophagectomy. On postoperative day 10 he developed acute onset shortness of breath, CXR demonstrated a large left sided pleural effusion. CT thorax demonstrated multiloculated complex pleural effusions. US guided pig tail drain was placed in the largest targetable effusion. The fluid was chylous in appearance. In both cases, an interventional radiological approach, not previously performed at this centre, provided definitive management. Lymphangiography was performed via injection of 1mL of Lipoidol® every 5 minutes into the inguinal lymph nodes to identify the cisterna chyli. A guidewire was advanced via the cisterna chyli with coils and glue used to embolize the leaking tracts.

Discussion

The lessons from this experience provide an algorithm for the management of chyle leaks, that will change practice at this centre. Embolization or disruption of thoracic duct and cisterna chyli leaks will be first line therapy for complex chyle leaks, with surgery reserved for where this fails.
1622 Peri-Operative Blood Use in Upper GI Surgery
Authors: Mercer A
Published: October 2021

Aim

One group and hold sample costs approximately £18 to process while it costs £170 to prepare and administer 1 unit of cross matched blood. We aimed to quantify the amount of blood cross-matched for elective oesophagectomy and gastrectomy cases and compare this to the number of units transfused.

Method

Retrospective cohort study comparing number of crossmatched blood units requested. Baseline data collected over a 10-week period (08/07/19-16/09/19). A new blood ordering protocol made in agreement with oesophago-gastric and anaesthetic consultants with criteria for blood ordering. Blood was only to be requested if: antibodies on group and hold, pre-op Hb < 120g/l, operative team concerns or previous radiotherapy. Data recollected using the same parameters post -intervention over a 10-week period (23/12/19-08/03/20).

Results

Pre-intervention 24 patients were included, mean age 67. 47 units were requested with only 1 transfused. Post intervention 27 patients were included, mean age 69. 36 units were ordered and 3 transfused. The new protocol was correctly implemented in 19 patients (70%) therefore saving a potential of 24 units and approximately £4080.

Conclusions

Patients were cross matched far in excess of their transfusion needs. There was significant reduction in the number of patients being cross-matched post intervention. Rationalising this is important to reduce waste, reduce cost and cut down on delays to maximise theatre time.
19 10 Years of Tertiary Paediatric Centre Experience of Females Undergoing Surgery for Ovarian Torsions
Authors: Fryer S
Published: October 2021

Aim

Review role and accuracy of imaging, and subsequent management, of patients with ovarian torsion managed at a tertiary paediatric centre.

Method

Retrospective review of notes for patients undergoing surgery for ovarian torsion over 10 years (2010-2019).

Results

23 patients underwent surgery for ovarian torsion (one excluded due to lack of data). Median age 12 years[range 1-15]. 18/22 patients underwent imaging; 15/18 had USS, 12/15(80%) were diagnostic for ovarian torsion. 3/15 showed ovarian pathology prompting further imaging/surgery. 2/22 had initial MRI, 1 diagnostic for torsion. Time from symptom onset to surgery was assessed, data was incomplete for 4 patients. 10 patients were referred from ED/primary care; 5(50%) underwent theatre within 12 hours, 3(30%) 12-12hours and 2(20%) >24hours. 8 patients were referred from external hospitals; 2(25%) underwent theatre within 12 hours, 4(50%) 12-12hours and 2(25%) >24hours. Those having surgery>24 hours from symptom onset were awaiting imaging or had suspected other pathology. 4/22 underwent oophorectomy (open:laparoscopic=3:1) and 18/22 had detorsion +/- cyst aspiration/excision (open:laparoscopic:converted=2:15:1). Follow up imaging was performed in 13/18 patients who underwent detorsion and 2/5 who underwent oophorectomy. Of 3 patients undergoing oopherectomy who did not have follow up; 2 had benign cysts and 1 had a simple tubo-ovarian torsion.

Conclusions

We advocate early USS in females with presentation concerning for ovarian torsion, though a high index of suspicion is often required owing to non-specific symptoms. Imaging and transfer should be performed promptly to prevent delays in surgical management.
671 Fetus-In-Fetu Found at Excision of An Antenatally Diagnosed Abdominal Mass: Multi-Disciplinary Approach
Authors: Smith K , Moore A , Popov S , Adams M , Folaranmi E , Sekaran P
Published: October 2021

We present a case of antenatally detected abdominal mass and an alternative diagnostic course for suspected neonatal neuroblastoma as a result of investigative findings. A female infant presented antenatally with a left upper quadrant mass initially managed as a suspected neonatal neuroblastoma; further cross-sectional imaging suggested a wider differential including teratoma and aided surgical planning. The multi-disciplinary team (MDT) decision was for an early excision at 31 days and post-operative histology identified a diagnosis of fetus-in-fetu (FIF). We describe this case as a compliment to the current literature and an example of a necessary variation to recognised diagnostic and treatment pathways as a result of investigative findings.
745 Prospective Evaluation of Virtual Consultations in Paediatric Surgery and Urology: Lessons from the Pandemic Times
Authors: Awolaran O , Robotin-Pal A M , Douglas K , Sheth J , Kalidasan V
Published: October 2021

Aim

Virtual consultation (VC) became the new norm for providing outpatient clinics during the COVID-19 pandemic. This is likely to be adopted in some form going forward. This study prospectively evaluated the effectiveness&safety of VC undertaken at a UK tertiary paediatric surgical centre during the pandemic.

Method

Data on paediatric surgery/urology outpatient video/telephone consultations between May-June 2020 was prospectively collected. VC episodes were given outcomes (1,2or3) depending how well surgeons were able to make definitive diagnoses/plans. 6months later, findings at later face-to-face visit were retrospectively compared with earlier VC to assess accuracy of decision-making using VC. Telephone survey of patient experience was done.

Results

186VC were evaluated. 95 (51%) were paediatric general surgical patients and 91 (49%) urology. 118 (63%) were follow-ups and 68 (37%) new. In 70% of cases, clinicians were able to make definitive diagnosis/plan using VC (outcome1) while 26% could be delayed till face-to-face consultation is safe (outcome2). 7 patients (4%) needed to be brought in urgently (outcome3). Clinicians were significantly more able to make definitive diagnosis/plan in urology and follow-up patients. Of those brought back for scheduled follow-up/surgery, there was 93% correlation between findings at physical consultation compared to the definitive plans made at VC. Patient survey showed 92% overall satisfaction rate. 75% felt VC is comparable to face-to-face/would use VC again.

Conclusions

This study provides evidence that VC is an effective&safe way to structure paediatric surgical outpatient care and it highlights the patient categories in which VC is most suitable.
67 Nutritional Assessment of Patients Admitted To “Adult Burns Unit” At Southmead Hospital from April To August 2017
Authors: Babar M , Katechia D , Sen S , Pleat J
Published: October 2021

Introduction

Nutritional support is an integral part of Burns management. Local guidelines for malnutrition screen are available at Southmead Hospital.

Aim

Audit was aimed at compliance of malnutrition screen for all admissions to “Adult Burns Unit” to the local guidelines.

Method

A retrospective data of baseline and weekly malnutrition screen was collected and analysed for 106 patients between April and August 2017. These findings were compared to the following local guidelines;

Results

Of 106 patients, most (n = 72) had <5% TBSA burn. 9 were resus burns (TBSA >15%). 50 patients stayed less than a week while 34 discharged within 24hrs. 20 stayed longer than seven days. Compliance of recording weight on admission was 46.2% while weekly assessment 10%. Height and BMI were measured for 24.5% of admissions. 81% of patients had admission bloods and 19 out 20 staying longer than a week had weekly bloods. All major burns were referred to dietician.

Conclusions

Assessment of %TBSA, admission and weekly bloods, and dietician referral were areas of good practice. However, compliance with recording weight and height on admission did not meet the Trust target of 85% We recommended a checkbox for weight and height on admission in Trust’s electronic handover system, monitor at weekly burns MDT and re-audit.
107 The Role of Tissue Engineering in Auricular Reconstruction: A Critical Review
Authors: Moura F , Varley R , Yao C
Published: October 2021

Aim

Despite several decades of research in tissue engineering, reconstructing a 3D human-sized ear that can stand the test of time has remained a challenge. Autologous cartilage reconstruction remains the main treatment choice despite the associated morbidity. Progress in the field has been made and several studies have used tissue-engineered implants in immunocompetent animals with promising results.

Method

This study critically reviews and assesses the characteristics that make auricular reconstruction so challenging and how far research has come in addressing the following: mechanical properties; vascularisation; immune response; cell sourcing; surgical attachments; allografts; and cost.

Results

The question is whether tissue engineering will realistically replace autologous cartilage reconstruction in the short-term, or will advances in other areas, outlined in this article, manage to provide suitable and aesthetically accurate scaffolds.

Conclusions

Advances in tissue engineering are slowly progressing and utilise advances in both biomaterial design and 3D bioprinting to try and address the challenges of auricular reconstruction. Tissue engineering is still a promising solution to auricular reconstruction but still requires further research before becoming a reality.
180 Improving Wall Access When Using Double Clamps for Microsurgical Anastomosis – A New Technique
Authors: Faderani R , Ali S , Masud D , Haywood R
Published: October 2021

Microvascular techniques and instrumentation have continually evolved since the advent of clinical microsurgery in the 1970’s. These refinements and improved patient selection have led to increased vessel patency and flap survival rates. However, a fundamental principle which has not changed over this time period is comfort and proper operating microscope set-up. Both these factors were described as a precondition of microsurgical success by the late pioneer of microsurgery himself, Robert Acland. Suboptimal comfort or set-up can negatively impact on access to the surgical field leading to improper technique and if significant enough, anastomotic thrombosis. We describe a new technique aimed at improving wall access when using double clamps for microsurgical anastomosis.
312 Retrospective Analysis of Long-Term Scarring Outcomes in Paediatric Burns Patients
Authors: Mistry R
Published: October 2021

Introduction

Paediatric burns are a common presentation to a plastic surgery unit. The long-term scar outcomes in paediatric burns patients are relatively unknown as most are discharged after 6 weeks follow up. We aimed to determine whether the long-term scarring outcomes are significantly different in those who had surgical treatment with Versajetâ debridement and Biobraneâ, versus those treated conservatively with non-adherent dressings, in a cohort of paediatric burns patients.

Method

The parents of all paediatric burns patients admitted to Stoke Mandeville Hospital from October 2014 to September 2017 were contacted by telephone to fill in the Brisbane Burn Scar Impact Profile (BBSIP), a patient reported outcome measure specifically aimed at children. The results from the questionnaires underwent statistical analysis to see if there was a significant difference in questionnaire scores between children treated surgically versus those treated conservatively.

Results

A total of 107 children were admitted in the timeframe, responses were received from 34 patients with 13 having been treated surgically and 21 having been treated conservatively. In all 58 questions that make up the BBSIP, there was no statistically significant difference observed in the scores of those treated surgically versus those treated conservatively. For 31 questions on the BBSIP, the lowest score indicating the best outcome was observed in all patients in both groups.

Conclusions

We found no statistically significant difference in the long-term scar outcomes as assessed by the BBSIP in paediatric burn patients treated with Versajetâ debridement and Biobraneâ, versus those treated conservatively with non-adherent dressings.
338 Management of Periprosthetic Breast Infection: A Systematic Review and Meta-Analysis
Authors: Arumugam V , Faderani R , Kanapathy M , Singh P , Haque S , Mosahebi A
Published: October 2021

Aim

This systematic review and meta-analysis aims to synthesize the current evidence and establish the efficacy of the various managements of infected breast implants.

Method

A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted for primary clinical studies reporting on the management of infected breast implants from 1946 to September 2019. The primary outcome measure was the proportion of patients with successful treatment.

Results

Nineteen articles involving 1044 patients were included. Mild infections seen in 29.00%(95%CI=11.51% to 50.58%) of the patients were treated exclusively with antibiotics, of which, 81.41%(95%CI=57.82% to 96.63%) were successfully treated without the need for surgical intervention. Overall, 39.01%(95%CI=21.41% to 58.23%) of the patients underwent surgical salvage of the infected breast implants, of which 84.56% (95%CI= 74.92% to 92.20%) successfully retained the salvaged implants without infection recurrence. Meanwhile, 35.01%(95%CI=27.01% to 43.57%) of the patients underwent explantation of the infected breast implant, of which, only 39.02%(95%CI=23.93% to 55.28%) had re-insertion of a new implant on a later date, and 4.99% (95%CI=1.66% to 9.99%) of these patients had recurrence of infection requiring removal of the infected implant. The commonest complication was capsular contracture, which was reported in 10.78%(95%CI=4.41% to 19.49%) of the patients. Changes in the quality of life and cost implications were not reported.

Conclusions

This study consolidates current available evidence on the management of infected breast implants, which could assist decision making and improve patient education, however current data is limited by the lack of level-1 evidence.
789 New Minor Surgical Set as A Way to Improve Surgical Efficiency During COVID-19 Pandemic
Authors: Eiben I , Eiben P , Bahadori D , Kazzazi D , Simon F
Published: October 2021

Introduction

Large number of paediatric plastic surgical procedures were identified in Evelina Hospital during COVID-19 pandemic as not requiring large conventional surgical operative sets that can contain at average 35 instruments. Large sets are more expensive, take longer preparation time due to instrument counting and as a consequence take more total operating time. Furthermore, more instruments need to be unnecessarily purchased, stored and cleaned post procedure. Simple paediatric plastic surgery procedures including nailbed repair or laceration repair require limited and largely replicating operative instrument set. We have therefore introduced Small Minor Plastic Surgical set (MS) containing only 10 instruments. We audited its effectiveness and introduced a revised version of the set as per feedback, permanently arranged into theatre operative set collection.

Method

MS set was introduced to Evelina Theatres and used at senior surgeons’ discursion for paediatric plastic surgical procedures. Feedback was gathered from the surgeon and scrub nurse via specially designed questionnaire at post operation and theatre team debrief. Suggested alterations were implemented and New Minor Surgical (NMS) set was introduced and re-audited using revised questionnaire.

Results

61% of surgeons and 89% of scrub personnel thought MS set contained everything that was needed for the case. Following revision 91% of surgeons and 95% of scrub nurses thought NMS set contained all necessary equipment for the operation.

Conclusions

NMS set introduced into daily surgical practice in Evelina Hospital theatres improved overall staff satisfaction when considering both surgeon and nursing staff. It provided cost- and time-effective operative set now vastly used across surgical specialities.
945 Elective Autologous Free Tissue Transfer for Breast Reconstruction During the Covid-19 Pandemic: A Comparative Analysis of Outcomes
Authors: Lafford G , Jeddi S , Masud D
Published: October 2021

Introduction

The demand placed on the National Health Service by Covid-19 has led to increased delays on elective surgery. Despite these challenges, our unit was the first centre in the UK to recommence elective breast reconstruction following the development of an evidence-based pathway to select low-risk patients. An enhanced recovery protocol was introduced to reduce length of stay. The aim of this study was to compare post-operative outcomes between our Pre-Covid group and our Covid-group of free tissue transfer breast reconstruction.

Method

We retrospectively reviewed autologous free tissue transfer breast reconstruction within our department between January 15th and September 27th 2020. Comparative data was split into two groups. A ‘pre-Covid group’ from 15th January to 12th March 2020 and a ‘Covid group’ from 3rd June to 27th September 2020. Both groups contained 15 patients. Operative notes and case notes were reviewed. Length of stay, haematoma-rate, flap failure, infection, fat necrosis, ischaemic time, re-do anastomosis and return-to-theatre were compared.

Results

Average length of stay was reduced from 4 to 3 days amongst our Covid group, haematoma rate was 7% pre-Covid and 13% during Covid. There was no evidence of flap failure, fat necrosis and donor site dehiscence in either group. Infection and flap dehiscence were 7% pre-Covid and 0% during Covid. Re-do anastomosis was 20% pre-Covid and 7% during Covid.

Conclusions

No statistically significant changes in outcomes were identified. This early review suggests that elective breast reconstructive surgery can still be achieved with comparable outcomes, despite the added challenges of Covid-19.
992 Infrared Thermal Imaging in The Diagnosis and Management of Upper Limb Trauma
Authors: Motiwala F , Liu C , Southern S , Jivan S
Published: October 2021

Aim

Trauma can affect perfusion and thereby the temperature of the injured area. Infrared thermal imaging (IRT) has been used as a non-invasive, non-ionising means of diagnosing and monitoring various pathologies. We aim to evaluate the role of IRT in upper limb trauma.

Method

A review of all literature from the Cochrane Database, PubMed, Medline and EMBASE was performed. All papers evaluating infrared thermal imaging in trauma of the upper limb were included. Exclusion criteria included animal or cadaveric studies, and studies not measuring outcomes related to thermal imaging.

Results

Six papers were included from a total of 149 papers. There were five observational studies (with limited population numbers) and one case report. Four studies (N = 217) identified significantly higher skin temperatures in fractured limbs compared to non-injured side (p ≤ 0.05). Two studies included follow-ups with skin temperature differences between injured and non-injured sides decreasing over time, consistent with fracture healing times (approximately 3-4 weeks for paediatrics and 6 weeks for adults). One study (N = 9) identified that the presence of activity-related chronic pain in the hand was consistent with higher mean skin temperatures, even at baseline (p = 0.00000795).

Conclusions

IRT has been successfully used as a means of diagnosis and monitoring fracture healing in the upper limb. It also shows potential for use in detecting fractures that may not be initially evident on x-ray in the acute setting e.g., scaphoid fractures. Further robust and higher quality studies with larger patient populations are required.
1112 The 100 Most Influential Papers in Nail Bed Injury: A Bibliometric Analysis
Authors: Banhidy N , Farhadi S
Published: October 2021

Aim

Nail bed injuries are the commonest paediatric hand injuries. Optimal management is essential to restoring form and function of the nail and fingertip, however high-level evidence of nail bed injury management is lacking, leading to large discrepancies in clinical practice. This paper evaluates the 100 most cited papers in nail bed injury and analyses their study characteristics to assess current research focus and evidence levels.

Method

A Web of Science search was carried out using the search term “nail bed injury”. All article types were included, and no language or publication date restrictions were applied. Results were ranked by overall citation number. All abstracts were screened for study relevance and the top 100 eligible studies were analysed for study type, main study theme, journal, and year of publication.

Result

The three most common study types included retrospective studies (n = 33), literature reviews (n = 25), case reports/series (n = 20). The three main study themes included evaluation of repair techniques (n = 72), aetiology and epidemiology of nail bed injuries (n = 12), and anatomical assessments (n = 7). The most frequently represented journals include Journal of Hand Surgery (n = 30), Plastic and Reconstructive Surgery (n = 7) and Hand Clinics (n = 4).

Conclusions

The most influential papers in nail bed injury are those describing repair techniques. There remains a lack of high level evidence with most papers presenting level 3-5 evidence. This paper demonstrates a continued need for more higher level robust evidence in the field of nail bed injuries.
1243 Sentinel Lymph Node Biopsy for Melanoma during the COVID-19 Pandemic
Authors: Stubley T , El-Khayat B
Published: October 2021

Aim

Sentinel lymph node biopsy (SLNB) is an established aspect of the staging process for primary melanoma, with the results dictating future treatment methods. Due to the COVID-19 pandemic no SLNBs were offered to patients with newly diagnosed melanoma at a hospital site in the West Midlands. The aim of this study was to identify the number of patients who missed out on this investigation in order to ascertain how many patients with a potential positive SLNB were missed.

Method

A patient list was provided from the dermatology and plastic surgery database, ensuring that all newly diagnosed melanoma patients throughout the period March-May 2020 were included. A retrospective study design was utilised, with all data collected from the computer system at a single hospital site.

Results

64 patients were provided via the patient list, of which 44 were appropriate for SLNB using the NICE criteria. After detailed reading of the patient notes, 80% (35/44) of patients were provided with a reason why they did not receive a SLNB, however the remaining 20% (9/44) did not have this clearly recorded.

Conclusions

A large cohort of patients did not receive a SLNB during the COVID-19 pandemic. Utilising the clinical literature, it can be predicted that around 9 of these patients would have had a SLNB that identified metastasis. These patients have potentially missed out on adjuvant treatment, and the cohort will therefore require follow up to be adapted to reflect this.
1312 Characteristics of Those Who Present with Self-Inflicted Burns: A Burns Unit Service Evaluation Which Challenges Stereotypes
Authors: Magness C , Kang M , Kennedy M , Alexander S , O'Boyle C , Hasham S , Shepherd L
Published: October 2021

Introduction

Self-harm rates in the UK are increasing. Healthcare professionals’ beliefs regarding repeat attendance; attention-seeking; and poor treatment compliance may contribute to patients’ stigma. Self-inflicted burns (SIB) constitute a minority of burns cases, but require disproportionate healthcare input, yet little is known about these patients. Our aim was to evaluate presentations, compliance and outcomes in this patient group.

Method

A retrospective audit of outpatients with SIBs attending a UK Burns Unit over four years (Jan 2016-Dec 2019).

Results

Over the study period, 58 patients presented with 94 burn wounds. Incidence doubled over one year (2018-2019). Most patients were female (85%) with a median age of 29 years (range 19-62). The most commonly associated psychiatric diagnosis was personality disorder. On presentation 22% (n = 21) were admitted under the Mental Health Act. For 83% (n = 48) it was their first presentation with a SIB, although 74% had previously presented with non-burn self-harm. Median burn size was 0.5% TBSA, the most common mechanism was contact (48%) and 77% were deep (n = 77). 92% were compliant with treatment and did not tamper with their wounds or dressings.

Conclusions

The majority, 70% (n = 41), of patients only presented once to the Burns Department during the study period. This challenges the commonly held stereotype that those who self-harm will also seek attention through repeat presentation. Ongoing education among health professionals may dispel some myths regarding these individuals. Further, larger investigations, may permit rigorous comparison of treatment outcomes with non-SIB patients.
1345 A Punch Above the Rest: A High Yield Modification of The Diagnostic Nailbed Biopsy
Authors: Park P D , Asher C , Chin K Y , Healy C
Published: October 2021

Aim

Diagnostic nailbed biopsy is indicated for pathology including malignancy, persistent and suspected mycomial infection and rheumatological disease. Operatively, the challenge resides in establishing an equilibrium between harvesting ample histological sample for diagnostic value without the creation of a functionally and aesthetically unacceptable nail due to significant disruption of the nailbed. We illustrate a simple and reproducible biopsy technique through one small forgiving defect without disruption of surrounding soft tissue.

Method

The procedure is carried out under normal sterile conditions with local anaesthetic and a ring tourniquet. A 5mm punch biopsy is taken of the nail, adjacent to the eponychium, followed by a 4mm punch biopsy of the underlying nailbed at a 45-degree angle. The subungual surface of the nail is tangentially transected generating a mycomial sample and the nailbed is sent for histology. The remaining nail is replaced if not required for histology, and cyanoacrylate glue applied followed by a finger dressing.

Results

Figures show an example of how the nail biopsy is carried out. Biopsy sample and the resulting defect in the nail is also displayed.

Conclusions

The double punch technique reliably harvests adequate diagnostic specimens through one wound, without the disruption of adjacent nail plate, nailbed and perionychium. This is even more a priority when histology identifies no pathology requiring further operative resection. Whilst the nail undergoes its normal growth cycle post-operatively, aesthetically, the fingertip does not draw undue patient dissatisfaction once the dressing is removed in comparison to alternative biopsy techniques.
1362 Early Experience on Flap Perfusion? Monitoring with Near-Infrared Spectroscopy Tissue Oximetry
Authors: Hagiga A , Ece Kumbasar D , Dawood O , Enrique Berner J , Blackburn A
Published: October 2021

Introduction

Free flap reconstruction is a routine procedure with more than 99% success rates. Yet, vascular complications may occur leading to flap failure. Thus, early detection of vascular compromise is crucial for flap salvage. Vascular complications may be detected early using Infrared Spectroscopy Tissue Oximetry (NIRS) parameter changes. This method can distinguish changes caused by arterial and venous thrombosis before surgical re-exploration. This study aims to assess the validity or feasibility of using NIRS Oximetry in free flap monitoring and compare it to standard clinical examination and Doppler .

Method

A prospective cohort observational study. Flap perfusion was measured using the INVOS™ 7100 system for 24-h continuous postoperative monitoring. The data were compared to findings of clinical assessment.

Results

Ten patients completed the measurements after breast flap reconstruction. Age ranged from 41 to 61 years. Patients underwent immediate d eep inferior epigastric perforators (DIEP) (n = 4), delayed DIEP (n = 4), transverse upper gracilis flap (n = 1), and latissimus dorsi flap with lipofilling (n = 1). All ten flaps are successfully monitored for 24hrs post-operatively. The overall flap survival was 100%. Clinical examination, Doppler studies and surgical outcome were consistent with NIRS (need numbers). There were no false negatives.

Conclusions

NIRS tissue oximetry could potentially monitor flaps non-invasively. Future adequately sampled cohort study is recommended.
1462 Sarcoma of the Distal Fibula; Presentation of an Anatomical Reconstruction and Literature Review
Authors: Wensley K , McCulloch R , Cosker T , Gibbons M , Giele H
Published: October 2021

Introduction

Musculoskeletal tumours affecting the lower limb, and the distal fibula in particular, are rare. Substantial variation exists in both reconstructive techniques employed in their management and reported results; a consequence of their low incidence and the specific challenges presented by the location. Advances in imaging and neo-adjuvant chemotherapy have sparked a paradigm shift in the management of these cases. Where amputation was once the mainstay, limb salvage surgery is now a viable option and multiple techniques exist, but outcomes are poorly studied.

Method

We performed a literature review and report a three-patient case series. All three patients underwent our novel reconstruction technique, utilising a vascularised ipsilateral fibula graft.

Results

102 patient cases of distal fibula resection were identified. 57 of these patients had malignant disease. Evidence that limb salvage surgery produces good functional outcomes for sarcoma patients is limited; 25% of patients with malignant disease were reported as having poor outcomes or disease progression. All three patients undergoing our novel reconstructive technique have had good functional and oncological outcomes.

Conclusions

This is the largest literature review of patients undergoing distal fibula resection. Reconstruction is complex and no single solution exists. We present the use of a vascular proximal ipsilateral fibula graft, which to the best of our knowledge, has not been previously reported. The reconstructive method we present appears to be a durable technique offering an excellent functional outcome and is an appealing alternative to arthrodesis or amputation in appropriate patients.
1479 Trench Foot: A Rare and Unusual Presentation of a World War I Disease
Authors: Dbeis R , Rymer B , Mills C
Published: October 2021

Introduction

'Trench foot' is a serious disorder of the lower limb, involving damage to the skin, nerves, and muscle, previously described in World War I soldiers during trench warfare. We present a rare and unusual case of ‘trench foot' sustained at home in a 20-year-old female.

Case Report

A 20-year-old woman presented to the Plastic Surgery department with pain and numbness affecting both feet, following failed trials of antibiotics. She managed her symptoms at home by immersing her feet in ice baths for 18-23 hours per day. She was tachycardic with raised inflammatory markers. Examination revealed breakdown of the skin bilaterally, with full thickness eschar. MRI showed extensive subcutaneous oedema and myositis. Initial surgical plan consisted of antibiotics and debridement of necrotic tissue with a view to grafting the skin later. Intra-operative findings included necrosis of the subcutaneous tissues and muscles. The patient deteriorated post-operatively with sepsis and underwent urgent Guillotine-style bilateral amputations. She was discharged home 18 days later.

Discussion

'Trench foot' can be mistaken for soft tissue infections or frostbite. It is attributed to vasoconstriction followed by neurovascular changes and repeated cycles of thawing and freezing, acquired above freezing temperatures, unlike frostbite which occurs below freezing temperatures. The patient was initially reviewed by non-specialist teams without a clear diagnosis and sustained more pervasive tissue destruction than was originally apparent on examination. Prevention remains the best cure for ‘trench foot'. It is therefore important to familiarise ourselves with this rare disease. Where prevention or early detection is not possible, amputation can reduce the morbidity and mortality of the ensuing sepsis.
1511 A Review of Non-Surgical Management of Hand Osteoarthritis
Authors: Shah J
Published: October 2021

Introduction

Hand osteoarthritis (OA) is a common musculoskeletal condition leading to pain and loss of function. Current treatment aims to target the symptoms of hand OA involving a combination of non-surgical and surgical interventions. During the COVID-19 pandemic, there has been a renewed interest in conservative management. The purpose of this article is to review non-surgical therapies in hand OA, their mechanism of action and efficacy.

Method

An online search of PubMed for articles between 1st January 2004- 1st February 2020 was performed according to specific terms and agreed inclusion criteria.

Results

The search produced 289 results of which 28 met the inclusion criteria comprising 13 RCTs, 8 systematic reviews, 5 clinical trials and 2 international guidelines.

Conclusions

Topical NSAIDs remain first-line pharmacological agents in the management of hand OA. Increasingly, oral NSAIDs have been recommended however their use must be balanced against their potential adverse effects. Supplementation with chondroitin sulfate may help to delay the structural damage in hand OA, which may reduce the need for oral NSAIDs. Intra-articular injections of hyaluronic acid and corticosteroids are effective treatments and provide longer symptomatic relief, additionally hyaluronic acid may improve function over a longer period of time. Targeted hand exercises are widely recommended however may only provide short-term improvements and vary according to the different subtypes of hand OA. In summary, there are multiple conservative management options for hand OA which should be considered prior to operative intervention given the current restrictions on surgical practice.
1576 Safeguarding Tools in Paediatric Burns
Authors: Dhillon D , Ibrahim Y , Vijaysurej K , Li Z , Malik M , Nijran A , Yarrow J , Drew P
Published: October 2021

Introduction

When assessing paediatric patients presenting with burns, non-accidental injury always has to be considered. In our department, local policy dictates that all patients aged 18 or below should have a child safeguarding tool completed on initial clerking.

Method

A retrospective audit of all paediatric burns seen over one month was performed. Primary outcome measures included completion of a safeguarding tool and documentation of referral outcome. These results were presented locally and implementing changes were carried out. This was then re-audited over a further monthly period.

Results

Initial data collection showed a safeguarding tool completion rate of 69% and referral outcome documentation rate of 50% (n = 16). Implement changes included dissemination of initial audit results to the department, changing the layout of our clerking proformas and introducing posters in the unit which provided more information on risk assessing paediatric patients. The re-audit results showed a safeguarding tool completion rate of 100% and a referral outcome documentation rate of 100% (n = 14).

Conclusions

There was a significant improvement in both the safeguarding tool completion and referral outcome documentation rates following our interventions. Simple measures just such education and strategic adjustments of clerking proformas have been shown to be effective measures for increasing documental compliance of child safeguarding tools.
305 Using Urology Specific Ward Round Sheets to Improve Clinical Documentation
Authors: Evans D
Published: October 2021

Aim

To improve the documentation of vital clinical information on the urology ward round. To prompt clinical staff to review antibiotics, venous thromboprophylaxis, patient observations, and formulate a plan in a structured format.

Method

A retrospective, cross-sectional analysis was performed on the urology ward to assess whether the following parameters were documented/accounted for during ward-round: date, time, NEWS score, antibiotics, venous thromboprophylaxis, and whether the entry was easily found in the medical notes. Following this, a urology-specific ward-round sheet was synthesised between the medical and nursing staff. This standardised sheet was easily identifiable in the notes and ensured all the above parameters were accounted for by prompting the note-taker to record them. Two months following introduction of this standardised ward-round sheet the same parameters were analysed on all the urology inpatients in the same retrospective, cross-sectional manner.

Results

Documentation of the NEWS score improved from 30% to 93% with the introduction of the ward-round sheet. Similarly, documentation of whether antibiotics were reviewed improved from 30% to 60%, and documentation of venous thromboprophylaxis improved from 20% to 53%. It was also noted that the ward-round entry was easier to find with the ward-round sheet.

Conclusions

Documentation of key clinical information is vital to ensure optimal patient care. Surgical ward-rounds can be quick paced and important considerations such as antibiotics and venous thromboprophylaxis may be missed. This simple intervention improved the documentation of the intended parameters. The next step is to alter and improve the ward-round sheet before re-auditing.