bluuebunny/crossref_metadata_2025_split huggingface dataset:
534 Use of Ultrasound by Breast Surgeons Reduces the Need for Wire-Guided Localisation Of Impalpable Breast Tumours By Radiologists
Authors: Patel B , Govindarajulu S , Sahu A 
Published: October 2021

Abstract

Aim
Ultrasound is increasingly being used by non-radiologists in clinical practice. Currently wire-guided localisation (WGL) of impalpable breast tumours requires the expertise of radiologists but can be uncomfortable and demands significant radiology resource. Furthermore, for logistical reasons at our institution during the COVID pandemic, wires were inserted the day before surgery, resulting in disruption to patients. At our institution, two of eight breast surgeons use ultrasound intraoperatively for localisation of breast lesions, thus obviating the need for a radiologist to localise the lesion for the surgeon. We hypothesise that ultrasound-localisation by surgeons is an effective way to improve patient experience.

Method
We undertook a retrospective review of all patients undergoing wire-guided localisation of impalpable breast tumours between 01/05/20-01/08/20. We retrospectively collected the following data: modality of image-guided insertion (ultrasound versus x-ray), operating surgeon and size of tumour.

Results
48 tumours were excised using WGL. 45 of these relied on ultrasound guidance for insertion. The median lesion size was 17mm, with 30 (62.5%) of lumps being ³10mm in size.

Conclusions
Most impalpable lumps were visualised using ultrasound. The majority of these lumps were &gt;10mm. Surgeons trained in ultrasound did not need localisation by radiologists. If breast surgeons were unanimously trained to use ultrasound for intra-operative localisation, a significant proportion of wires could be avoided, saving cost, radiology time, patient time and improving the patient experience. We argue that ultrasound should be a core part of breast trainees’ curriculum.
915 An Unusual Case of Breast Tuberculosis: A Case Report
Authors: Abdelqader B , Brodie A , Iqbal J , Shokuhi S 
Published: October 2021

Abstract

Background
Breast Tuberculosis (TB) is a rare form of extra-pulmonary tuberculosis. It can mimic the presentation of many breast diseases including malignancy. We present a case of breast tuberculosis that had negative cultures from breast tissue while positive on lymph node biopsy.

Case presentation
A 36-year-old Libyan British lady presented to the symptomatic breast clinic with a large left breast mass during the first trimester of her fifth pregnancy. She has received antibiotics to treat mastitis but with no improvement. On Examination she had large left upper quadrant mass with skin tethering as well as palpable left axillary lymph nodes. Ultrasound imaging suggested features suspicious for malignancy and hence core biopsies were obtained which showed chronic inflammatory changes only. Ziehl Neelson stain was negative at this stage. A week later she developed low grade fever as well as signs of infection at biopsy site, this was treated with flucloxacillin, pus aspirated from underlying mass and sent for culture and sensitivity. Unfortunately, this lady travelled to Tunisia after her review and was subsequently diagnosed with breast tuberculosis on cultures from lymph node biopsies. On her return to our clinic, she was on appropriate treatment for TB, she had good response to treatment and follow up ultrasound showed stable residual collection.

Conclusions
This case illustrates the challenges in the diagnosis of breast tuberculosis as it is a rare entity of a disease that remains less prevalent in European countries. In most cases full recovery can be expected with anti- tuberculous treatment.
1042 The Effect of Breast Reconstruction Type on Complication Rates and Patient Satisfaction in The Setting of Postmastectomy Radiotherapy (PMRT)
Authors: Sebastiao A 
Published: October 2021

Abstract

Introduction
The National Institute for Health and Care Excellence recommend offering post mastectomy radiotherapy (PMRT) to people with involved resection margins. With increasing evidence supporting the effectiveness of PMRT, it is important to optimise the outcomes of breast reconstruction in women receiving PMRT.

Method
A search was conducted in the PubMed database. The exclusion criteria were patients undergoing neoadjuvant radiotherapy and patients with metastases. The primary outcomes were patient satisfaction and complication rates.

Results
A meta-analysis (N = 380) found prosthetic reconstructions were 5 times more likely to develop complications than autologous reconstructions in the setting of PMRT (OR = 0.20, 95% CI = 0.1-0.4). A systematic review (N = 5437) had higher rates of total complications in prosthetic reconstructions compared to autologous reconstructions (41.3% vs 30.9%) with PMRT. Similarly, a retrospective study of PMRT patients (N = 622) had higher rates of complications with prosthetic reconstructions compared to autologous reconstructions (OR = 0.47, 95% CI = 0.27-0.82, P = 0.007). The adjusted mean satisfaction score (AMSS) of patients with autologous and prosthetic reconstructions receiving PMRT in a study (N = 54) was 4.4 and 2.8, respectively. Patient-reported satisfaction in a study (N = 622) was higher in patients with autologous (AMSS=63.5, 95% CI = 55.9-71.1) compared to prosthetic reconstructions (AMSS=47.7, 95% CI = 40.2-55.2) (all P = 0.002) with PMRT.

Conclusions
Existing data suggests that autologous tissue reconstructions tend to be more compatible with PMRT than prosthetic reconstructions in terms of patient satisfaction and complication rates. Although more research is needed to support these findings, current data can help patients and physicians make informed decisions regarding the type of breast reconstruction to use with PMRT.
1344 Assessment of Appropriateness of Red Flag Referrals to One Stop Breast Clinic in Antrim Area Hospital
Authors: Shaik Mohamed S A , Rychlik I , Christian L 
Published: October 2021

Abstract

Aim
To assess the appropriateness of red flag referrals to breast clinic.

Method
Retrospective study of patients attending breast clinic as red flag referrals within a few months period. 149 patients were identified. Their referrals and clinic notes were accessed through electronic care records. Out of the 149 patients used, 2 were routine referrals and the others were red flag. Various sources of referrals were seen such as from GP, Screening programme, SDA programme, and other departments.

Results
From the referrals, 95% are female (N = 142) and the remaining N = 7 (5%) were males. The youngest patient referred was 14 years old and the oldest 92. The average age for the referrals were 50 years old. From all the 125 referrals from GPs, 81.6% are in accordance with NI guideline and 78.4% are in accordance to NICE guidance. Of the 10 referrals made by other specialties, only 80% are in accordance with NICE and NI guidelines. The remaining 12 of the patients were from the SDA programme/ Breast screening programme. Interestingly of all the red flag referrals, only (9%, N = 13) are cancer.

Conclusions
Currently there is no triage system for red flag referrals in Antrim Area Hospital for breast clinic. We are currently seeing all the patients that are referred as red flag although some of them are inappropriate. A triage system needs to be placed.
329 Cardiothoracic Surgery: National Survey of Medical Students' Perspectives
Authors: Al-Nusair L 
Published: October 2021

Abstract

Aim
Cardiothoracic surgery (CTS) is a rapidly evolving specialty requiring the recruitment of talented graduates. This study aims to explore perceptions and exposure of medical students nationally, to CTS.

Method
Medical students currently in the clinical years of their study were invited to complete an online questionnaire exploring their perceptions of CTS. The questionnaire evaluated students’ personal speciality interest, interest in pursuing CTS as a career, exposure to CTS throughout medical school and using a 5-point likert-scale.

Results
A total of 917 students were surveyed across 30 different medical schools, of these 378 (41.2%) had exposure to CTS either through their medical school or via extra-curricular activities. 526 (57.3%) were considering CTS as a career choice, 76 (8.3%) were considering it as their top choice of which 9 (11.8%) were final years. Overall, 16.9% (76) of medical students in their penultimate and final years are considering a career in CTS, 39.5% of whom were undecided as to which subspeciality with cardiac surgery being the most popular choice after this. The length of training and the high competition for places were the most deterring factors for medical students while the skilful nature of the surgery and its impact on patients’ lives were attracting factors to CTS.

Conclusions
Despite many students recognizing CTS as a highly impactful and stimulating field this is not reflected by the number of students wanting to undertake a career pathway within CTS. Very few students have dedicated CTS placements which may be a factor in lack of interest.
157 Non-Surgical Management of an Acute Isolated Volar Dislocation of the Distal Radio-Ulnar Joint
Authors: Sreenivasan S , Nair R , Das D , Talawadekar G 
Published: October 2021

Abstract
Isolated distal radio-ulnar joint dislocations are rare and commonly missed on radiographs. A young male presented with severe pain and deformity of the left wrist, following a collision whilst playing rugby. This was easily diagnosed using plain radiographs, and the initial attempted reduction methods in the Emergency Department failed. The patient was subsequently anaesthetised in theatre, yet reduction by an accepted method of palmar to dorsal pressure over the interosseous membrane with simultaneous distraction of the wrist failed. A further attempt to manipulate the dislocated ulnar head was successful, with the same force applied whilst the wrist was maximally flexed and pronated – thereby avoiding an open reduction. The patient was asymptomatic at final follow-up, over one year later. This technique has not previously been described in the literature and may be used in similar injuries in the future.
248 Rectus flap for repair of Strangulated Obturator Hernia
Authors: Angamuthu N , Alagaratnam S , Varcada M , D'Souza R 
Published: October 2021

Abstract

Introduction
Obturator hernia (OH) is a rare abdominal wall hernia which commonly presents as small bowel obstruction. Surgical options include suture repair or use of autologous tissue or a mesh repair when primary suture repair is not feasible. We describe a case involving the use of the rectus abdominus muscle to repair a large OH.

Case report
An 81-year-old female presented with three days of abdominal distension and vomiting. A computerised tomography scan confirmed small bowel obstruction due to an obstructed left OH. At laparotomy, a short segment of non-viable distal ileum was reduced from the sac and resected with a primary anastomosis. The obturator defect was not amenable for suture approximation and due to concerns of possible mesh infection, the ipsilateral rectus muscle belly was mobilised from the anterior sheath, routed extra-peritoneally to plug the defect without tension. The muscle was anchored with prolene sutures to the cooper’s ligament, pectineus muscle and the fascia overlying the inner surface of inferior pubic ramus. Four months post-operatively, she has made an excellent recovery with no concerns currently.

Conclusions
In OH with a large defect precluding primary suture repair, a range of options have been described (use of autogenous peritoneal fold, pectineus muscle, round ligament, ovary, uterine fundus, omental and mesh plugs, and biological mesh). We believe, to plug and cover the defect, rectus muscle flap is a viable option giving a tension free robust repair, especially in patients with gangrenous bowel and local contamination.
296 Case Report: Pacemaker Lead-Induced Fibrosis Resulting in Right Atrial and Tricuspid Stenosis Managed with An Open Surgical Approach
Authors: Russell T , Lichtenstein K , Bashir J 
Published: October 2021

Abstract
Pacemaker leads can result in localised inflammation and, over time, fibrosis. Rarely, this can significantly alter the anatomy of the heart and impair cardiac function. In this case, a fifty-year-old female had undergone pacemaker placement in her teens having experienced symptomatic bradycardia. Due to pacemaker pocket erosion, she had undergone a lead extraction where lead fragments had been left in-situ. Years after a new generator and leads were placed, she presented with symptoms of proximal venous congestion and superior vena cava (SVC) syndrome. A venogram demonstrated completely occluded brachiocephalic and innominate veins with significant adjacent venous collateralization. Computed tomography showed partial obstruction of the SVC and tricuspid stenosis. Initially, a decision was made not to intervene.
After developing abdominal distension, she was diagnosed with hepatic congestion and cirrhosis secondary to elevated right sided pressures and right atrial congestion due to tricuspid stenosis. It was concluded that the patient’s symptoms were the result of occluded proximal veins, SVC syndrome, and functional tricuspid stenosis, all of which were likely the result of fibrotic tissue secondary to pacemaker lead-induced inflammation. Due to the severity of her symptoms, the patient accepted the risks associated with surgical management. Intra-operatively, electrocautery was used to debride the fibrotic tissue inhibiting the leaflets of the tricuspid valve. This worked to great effect and additional valve repair/replacement was not necessary. Whilst the patient has been left with SVC syndrome, her tricuspid stenosis symptoms are greatly improved. To our knowledge, such a case has not been previously described.
349 COVID Induced Acute Ischaemic Limb
Authors: Shah B , Kedrzycki M 
Published: October 2021

Abstract
The coronavirus pandemic has overwhelmed healthcare systems worldwide, with more than 40 million affected and 1 million deaths. In addition to the typical symptoms, less clinically obvious was the underlying hypercoagulable state, termed COVID-19 associated coagulopathy (CAC). The exact mechanism of CAC is unknown, but it is suspected to involve all three aspects of Virchow’s Triad: endothelial injury, stasis, and a hypercoagulable state. Here we report the case of a woman in her 60’s who was admitted with COVID-19 and developed CAC with subsequent complications. She presented with a 3-day history of fevers, severe shortness of breath, and cough. Past medical history was significant for hypertension, poorly controlled insulin dependant diabetes, and obesity. She was admitted with COVID induced type 2 respiratory failure (pO2 of 5.5 on 15L), DKA (ketones 2.1), AKI (Cr 163), and a hypercoagulable state (D-dimer &gt;20 000). She was intubated and commenced on an insulin sliding scale, therapeutic anticoagulation, and antibiotics. On day 2 she became anuric, with CT-angio demonstrating thrombus extending from renal arteries down to the right popliteal artery. She underwent an embolectomy and 4 compartment fasciotomy and was started on renal replacement therapy. Unfortunately, her leg was not deemed viable, and due to persistent hyperkalaemia required amputation 2 days later. She continued to deteriorate despite maximal multiple organ support and was palliated 15 days later. CAC can have life-threatening sequelae, and patients with COVID-19 infection should be commenced on anticoagulation upon diagnosis.
451 Metastatic Cervical Cancer to the Duodenum: A Learning Point
Authors: Ash J , Tsai A 
Published: October 2021

Abstract

Background
Carcinoma of the Cervix is the second most common gynaecological malignancy. It usually spreads in a predictable manner with most via direct extension to surrounding structures. When distant metastases present, they usually spread haematogenously and via the lymphatics to the liver, lung and bone marrow. Metastatic spread to the duodenum is rare with only 15 reported cases identifying spread to the bowel.

Case Presentation
An 81-year-old lady presented with signs and symptoms consistent with bowel obstruction with a background of renal cell carcinoma and cervical cancer. Investigations identified gastric outlet obstruction. Subsequent oesophago-gastroduodenoscopy showed structuring at D1/D2 and a enteric stent was inserted. Biopsies taken at the time showed lymphovascular permeation of the mucosa and submucosa by nests of tumour cells resembling squamous cells. The cells were P16 and P63 positive and FISH analysis detected Human papilloma virus 16. The tissue was identified as metastatic cervical cancer. The patient subsequently did not want further interventions and was referred to palliative care and subsequently passed away due to her illness.

Conclusions
Few reported cases of metastatic cervical cancer to the bowel have been reported. Of these, most commonly they have presented with obstructive bowel symptoms and metastasised to the duodenum such as in this case. The pathophysiology for this manner of transmission is poorly understood in literature. Obstructive bowel symptoms on the background of cervical cancer should raise the possibility of metastases in future practice.
595 Penetrating Pelvic Trauma from a Crossbow Bolt: An Unusual Choice of Weapon
Authors: Ting A , Barnetson C , Joegi A , Gibbs R 
Published: October 2021

Abstract

Introduction
The crossbow was a popular weapon in medieval times due to their relative ease of use and accuracy but was superseded by firearms around the 16th century. Today, it is legal for adults in the UK to own a crossbow without a licence.

Case Report
A young adult male victim was brought to a Major Trauma Centre with a single lower left quadrant penetrating wound caused a crossbow bolt that was self-removed immediately after the injury. A 2.5cm entry wound was present with no exit wound. The patient was haemodynamically unstable on arrival and was transferred to theatre without imaging within 16 minutes of arrival. The main operative findings were multiple small bowel serosal tears, a full thickness small bowel injury with no contamination and a left external iliac artery injury with active bleeding which were all repaired primarily. The post-operative recovery course included occlusive left cephalic and antecubital vein thrombi and an extensive non-occlusive left common femoral vein thrombus treated with anticoagulant therapy but was otherwise unremarkable. He was discharged 10 days later with no lasting sequelae at 6-week follow up.

Discussion
This case highlights a rare but important and likely underreported modality of penetrating injury. Crossbow bolts have low kinetic energy compared to bullets but high penetrative force, thus little energy is transferred to surrounding tissues. Hence the main injuries caused by crossbow bolts are due to direct damage to structures they come into contact with. Although rare, trauma surgeons should be aware of the pattern of injury caused by crossbows.
675 ICA Ligation and Malignant MCA Syndrome Secondary to A Gunshot Wound: A Case Presentation
Authors: Cairns G , Belshaw A 
Published: October 2021

Abstract
Penetrating carotid injuries occur infrequently in the UK. Without surgical intervention, mortality rates are close to 100%. Whilst vessel repair is the optimal surgical choice, zone III neck injuries or haemodynamic instability in particular often require vessel ligation, which carries higher mortality rates, increased risk of stroke and poorer outcomes overall.
We present a young patient who sustained a gunshot wound to the neck. Emergency exploration revealed a penetrating injury to zone III of the left side of the neck and a complete transection of the left internal carotid artery. Due to haemodynamic instability, damage control surgery was mandated, and the internal carotid artery was ligated. The patient was admitted to ITU but had a severe acute neurological deterioration post-operation. CT head imaging revealed a large left frontal-parietal infarct with rightward midline shift, in keeping with malignant MCA syndrome. He underwent an emergency decompressive craniectomy, with resolution of the midline shift seen on subsequent imaging. At 3 months, the patient walked independently out of hospital, with a reduction in his modified Rankin Scale score from 5 to 2 following intensive therapies input.
Whilst rare, the importance of timely recognition and intervention of an infrequent complication of carotid ligation is paramount. Decompressive craniectomy is the mainstay of treatment for malignant MCA syndrome, yet outcomes remain poor in all ages, highlighting the patient’s noteworthy recovery. Though emerging evidence suggests novel endovascular repair techniques may provide favourable outcomes and reduced complications in carotid injuries, open surgery remains the treatment of choice.
770 Mondor's Disease: A Rare Presentation of Inflammatory Bowel Disease
Authors: Armstrong L , Lockhart J , Mathers H 
Published: October 2021

Abstract

Introduction
Mondor's Disease (MD) is a rare condition characterised by thrombophlebitis of the superficial veins of the breast and anterior chest wall. Cases associated with inflammatory bowel disease are rare.

Case
A 54-year-old male presented to the symptomatic breast clinic with a 6-week history of a painful linear area on the anterolateral aspect of his left chest wall. There was no history of trauma or underlying coagulopathy. He also described increased stool frequency and crampy abdominal pain. On clinical examination, superficial thrombophlebitis with cording was noted along the outer upper quadrant of the chest wall. His past medical history included a previous diagnosis of ulcerative colitis, with no pharmacological treatment. He was subsequently referred to a gastroenterologist and all symptoms resolved following management of his underlying colitis.

Discussion
This gentleman’s thrombophlebitis followed the course of the thoracoepigastric vein. The occurrence of thromboembolic events has been documented in association with an exacerbation of ulcerative colitis; however, literature describing MD is scarce. The underlying aetiology is reportedly due to the hypercoagulable state identified in ulcerative colitis. There is a lack of consensus on the treatment of MD, however cases have responded well to the management of the precipitating colitis. Low molecular weight heparin can be used if chronicity ensues. Surgical management is not recommended.

Conclusions
MD is a rare presentation of ulcerative colitis. Clinicians should be aware of underlying aetiologies and a potential hypercoagulable state. Such cases in relation to UC require early diagnosis and treatment of underlying colitis.