bluuebunny/crossref_metadata_2025_split huggingface dataset:
1657 Systematic Review and Meta-Analysis of Mortality Risk Prediction Models in Adult Cardiac Surgery
Authors: Sinha S , Dimagli A , Dixon L , Gaudino M , Caputo M , Vohra H , Angelini G , Benedetto U 
Published: October 2021

Abstract

Background
The most used mortality risk prediction models in cardiac surgery are the European System for Cardiac Operative Risk Evaluation(EuroSCORE)(ES) and Society of Thoracic Surgeons(STS) score. There is no agreement on which score should be considered more accurate nor which score should be utilised in each population sub-group. We sought to provide a thorough quantitative assessment of these 2 models.

Method
We performed a systematic literature review and captured information on discrimination, as quantified by the area under the receiver operator curve(AUC), and calibration, as quantified by the ratio of observed-to-expected mortality(O:E). We performed random effects meta-analysis of the performance of the individual models as well as pairwise comparisons and sub-group analysis by procedure type, time and continent.

Results
The ES2(AUC 0.783[95%CI 0.765-0.800];O:E 1.102[95%CI 0.943-1.289]) and STS(AUC 0.757[95%CI 0.727-0.785];O:E 1.111[95%CI 0.853-1.447]) both showed good overall discrimination and calibration. There was no significant difference in the discrimination of the two models(Difference in AUC -0.016; 95%CI -0.034 to -0.002;p0.09). However, the calibration of ES2 showed significant geographical variations(p &lt; 0.001) and a trend towards miscalibration with time(p0.0057). This was not seen with STS.

Conclusions
ES2 and STS are both reliable predictors of short-term mortality following adult cardiac surgery in the populations from which they were derived. STS may have broader applications when comparing outcomes across continents and time periods as compared to ES2.
41 Low Flow Priapism as A Complication of Covid-19 Infection
Authors: Ahmed S , Alabai M , Datta S 
Published: October 2021

Abstract
On 12 March 2020 the World Health Organisation (WHO) declared a pandemic of SARS-COV-2(Covid 19). We report a case of a 58-year-old man who presented with dyspnoea, pyrexia and a dry cough. Upon admission he was noted to be in a severe Type 1 Respiratory Failure with Bi-lateral pulmonary infiltrates suggestive of Covid 19 infection. Rapid transfer to ITU ensued with Intubation, Ventilation and Inotropic support. Priapism was noted a day into admission which was subsequently aspirated by the Urology team, achieving detumescence. Priapism is a state of persistent penile erection that continues for 4 hours beyond sexual stimulation. We describe the role of thrombosis, dysregulation of the clotting cascade and acute disseminated intravascular coagulation (DIC) as shared pathologies in priapism and Covid 19 infection. We highlight the importance of vigilance for extra-pulmonary manifestations of Covid-19 and feel that the pro-thrombotic phenomena exhibited by Covid-19 infection affects distal vasculature in the same manner as Low Flow Priapism and hence explains why our patient suffered from this particular urological complication
154 Complete Inguinal Bladder Hernia Causing Acute Obstruction of Right Upper Urinary Tract
Authors: Madden-McKee C , Getty M , Thompson T 
Published: October 2021

Abstract

Case Summary
An 86-year-old male nursing home resident presented with increasing confusion and was initially treated for catheter-associated urinary tract infection. CT scan demonstrated acute acalculous cholecystitis and complete inguinal bladder hernia with compression of right vesico-ureteric junction leading to acute obstructive renal failure. Percutaneous cholecystostomy and percutaneous nephrostomy were attempted but were not possible due to patient non-compliance. Patient improved with conservative management.

Discussion
Bladder involvement in inguinal herniae is rare with most cases being identified at the time of hernia repair and there is a 17% risk of intra-operative bladder injury. Key risk factors include increasing age, male gender, lower urinary tract symptoms and previous hernia repair. Percutaneous nephrostomy followed by inguinal hernia repair is the treatment of choice for most patients. Clinicians should aim to make the diagnosis of inguinal bladder hernia pre-operatively to reduce risk of intra-operative bladder injury during hernia repair. Acute acalculous cholecystitis tends to occur in critically ill patients and is a marker of poor prognosis.
237 Massive Subcapsular Intra-hepatic Haematoma Post-laparoscopic Cholecystectomy: A Rare Complication of a Common Procedure
Authors: Saad E , O'Connell L 
Published: October 2021

Abstract

Abstract
Laparoscopic cholecystectomy (LC) is currently considered the gold standard for the management of symptomatic gallbladder stones disease. Specific complications remain challenging, particularly postoperative bleeding, bile leak, and bile duct injury. We report a rare case of a giant intrahepatic subcapsular haematoma (ISH) complicating LC.

Case Presentation
A 59-year-old female presented with symptomatic biliary colic. Her past medical history was noted for obesity (BMI &gt; 50). She underwent an elective LC with an uncomplicated intraoperative course; however, post-operatively she developed hypovolaemic shock with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. Emergency CT revealed a massive subcapsular haematoma measuring 21cm×3.1cm× 17cm at the right liver margin without evidence of ongoing bleeding. She was managed conservatively- as per a tertiary hepatobiliary surgery centre’s advice- with meticulous clinical observations, serial monitoring of haemoglobin, and repeat CT to assess for interval progressions. She progressed well with conservative management and did not require surgical or radiological intervention. A follow-up liver US performed eight weeks post-discharge confirmed a complete resolution.

Conclusions
Giant ISH is an exceedingly rare but life-threatening complication following LC which merits special attention. Our case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH in those who experience a refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post LC-ISH
302 Migratory Foreign Body in The Neck- How A Fishbone Morphed into A Piece of Glass In 18 Months
Authors: Horlick S , Sehgal S , Al-Dulaimy B , Anmolsingh R , Goswamy J 
Published: October 2021

Abstract

Background
Foreign body (FB) ingestion is a common presentation to ear, nose, and throat (ENT) surgeons. Usual culprits include fish or chicken bones, steak, or non-organic items. FBs can be categorised into batteries, hard objects, and soft boluses. Hard objects that have not passed beyond the post-cricoid region require removal to minimise perforation risk. In rare cases FBs are reported to migrate extra-luminally into surrounding tissues of the neck necessitating cross-sectional imaging ahead of neck exploration.

Case Report
A 70-year-old lady presented to A&E with a sensation of FBs in her throat. She was aphagic without dyspnoea. Home-cooked fish ingestion was the precursor. Panendoscopy was clear. The patient was discharged once tolerating fluids and soft diet. She presented 14 months later to the ENT clinic with a persistent FB sensation in her throat. A computed-tomography scan of neck showed a right sided, radio-opaque, 3 cm foreign body sitting just anterior to the carotid sheath, behind the right superior thyroid lobe. An elective external neck exploration revealed a 3 cm shard of glass which was successfully removed without complications.

Conclusions
Extra-luminal migration of FBs is extremely rare. They may present with life-threatening suppurative or vascular complications. A literature review revealed that migratory FBs tend to be sharp and long such as needles, wires, or fishbones. To allow prompt diagnosis and management, we propose a low threshold for CT imaging in instances with a clear history and persistent symptoms even when panendoscopy is negative.
356 An Unfortunate Case of Spinal Injury and Bladder Dysfunction During the Covid-19 Pandemic
Authors: Lane J , Johnston M , Davies M 
Published: October 2021

Abstract
There is no doubt that COVID-19 has had a profound impact on every medical and surgical speciality. In the height of the pandemic many non-emergency services were shut down, including dental services, with unexpected consequences. We present a case which highlights the unexpected and indirect consequences of a national lockdown on a Urology patient and discuss learning points.
A 54-year-old male, previously fit and well suffered with a small dental abscess, media outlets were reporting that dental surgeries were closed, and he therefore attempted to drain the abscess himself. The infection spread to his epidural space, causing compression via a collection at L2 and consequently spinal cord injury. This was managed with urgent lumbar decompression and antibiotics.
A specialist functional urology team were involved after his transfer to the tertiary spinal unit 3 months after his first presentation. He was catheterised but suffered with recurrent catheter blockages. Video urodynamics demonstrated a stable bladder with a low-pressure leak point, managed with urethral catheterisation. A repeat video urodynamics demonstrated a loss of compliance and stress incontinence. Unclear as to whether he would regain function rehabilitation techniques are currently being attempted prior for definitive operative management with an artificial sphincter.
This case highlights the indirect impact of COVID-19 on UK urology services, and this has not been widely reported.
412 Polytetrafluoroethylene(PTFE) Pledgets Masquerading As A Pseudo-Aneurysm Of Left Ventricle Apex. A Case Report
Authors: Moawad N , Asopa S , Lloyd C 
Published: October 2021

Abstract

Background
TransCatheter Aortic Valve Implantation (TAVI) is now established as an alternative for open aortic valve replacement in high-risk patients with severe calcified degenerative aortic stenosis.

Case presentation
Here we report a case of a 78 tears old female patient who presented six months following transapical TAVI with a pulsatile mass over the left anterior mini thoracotomy wound. Transthoracic echocardiography showed suspicion of a left ventricular apical aneurysm with no evidence of free pericardial fluid.Contrast enhanced CT reported a large pseudo-aneurysm arising from the apex of the left ventricle extending through the left anterior thoracic wall. She was scheduled for emergency surgical exploration via median sternotomy. Upon median sternotomy there were dense pericardial adhesions limiting the mobilization of the heart specially the apex, which necessitated establishment of cardiopulmonary bypass. The heart was arrested, and the dissection was completed. The cavity in connection with the ventricular apex had purulent contents and the site of the TAVI ventriculotomy was secure with the PTFE pledgets in place with no evidence of leakage. Samples of the cavity fluids had pus cells, but no organisms were grown. The patient made an uneventful recovery and was discharged home 6 days postoperatively.

Discussion
PTFE pledgets are frequently used in cardiac surgery to support surgical closure. These pledgets on a contrast enhanced CT scan can make it difficult to correctly diagnose and may mimic anastomotic leaks as both give similar hyper-dense appearance on contrast enhanced CT scan
455 A Case of An Unusual Penetrating Brain Injury
Authors: Augustin A , Joseph M , Abraham A , Nair R , Sudharsan P V , Yenukoti R 
Published: October 2021

Abstract

Introduction
Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident.

Case Presentation
45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring.

Discussion
It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).
479 Penetrating Chest Trauma Causing A Superior Mesenteric Artery-Inferior Vena Cava Fistula and Pancreatic Injury: A Case Report
Authors: Wagner K , Reimann S , Budge M , Claydon M , Musicki K , Ban E.-Jun 
Published: October 2021

Abstract
Penetrating traumatic injuries can present a challenging scenario due to the potential for multisystem involvement requiring swift collaboration between surgical specialities. We present the case of a 66-year-old female who was stabbed in the right posterior chest. CT revealed a diaphragmatic injury, liver laceration involving segments 6/7 with active bleeding, and a posterior superior mesenteric artery (SMA) to anterior inferior vena cava (IVC) fistula. Due to the proximity of the SMA injury to a replaced right hepatic artery origin, the fistulous connection with the suprarenal IVC, and suspected pancreatic and duodenal injuries, a hybrid rather than a purely endovascular approach was taken. A large compliant occlusion balloon was placed percutaneously in the hepatic IVC. Subsequent trauma laparotomy and right medial visceral rotation identified SMA and SMV injuries, which were repaired with temporary supracoeliac aortic clamping. Further kocherisation of the duodenum revealed a 10 cm longitudinal IVC laceration causing sudden large volume venous haemorrhage. This was repaired after control was gained with supracoeliac aortic clamping, infrarenal IVC vessel loop and balloon inflation. An abdominal VAC dressing was applied. Before transfer to ICU, however, 1L of blood was noted in the VAC cannister and a relook laparotomy demonstrated more than 1L of intrabdominal fresh blood. Bleeding vessels around the uncinate process were ligated. After 48 hours, a relook laparotomy revealed no significant bleeding, and the abdomen was closed. A post-operative MRCP demonstrated pancreatic divisum and likely laceration of the aberrant ventral duct. A subsequent peripancreatic collection was managed conservatively.
497 Delayed Gastropleural Fistula: A Rare Cause of a Persistent Pleural Effusion After Blunt Force Trauma
Authors: Chan K Y , Keogh S , Aucharaz N , Temperley H , O'Driscoll J , Ravi N , Tormey S 
Published: October 2021

Abstract

Background
A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. GPFs have been reported following traumatic diaphragmatic ruptures, perforated hiatal hernias and gastric fundal ulcers, and more recently, after bariatric surgery. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings.

Method
We describe a case of a 53-year-old gentleman who presented to our institution with acute respiratory distress and clinical findings of a pleural effusion. Uniquely he was discharged a week prior following an admission for a traumatic fall down a flight of stairs that resulted in a Grade-IV splenic injury, requiring an emergency splenectomy. A CT-proven massive haemothorax resulted in haemodynamic instability requiring resuscitation and chest drain insertion in the intensive care unit. On commencement of enteral diet, purulent exudate with evidence of food particulates was seen in his chest drain.

Results
Further diagnostic evaluation of drainage contents demonstrated gut flora and a subsequent positive dye test suggested an aero-digestive connection. Repeat CT revealed a fistula between the fundus of the stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm.

Conclusions
This is the first case in literature reporting a ‘gastropleural fistula’ presenting in such a fashion. Thorough assessment and decisive action led to a satisfactory outcome. Although rare, a persistent effusion with a history of blunt abdominal and thoracic trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.
505 Failed Femoral Nail with Significant Operative Technical Difficulty: A Practical Solution to Achieve Metalwork Extraction Using Conical Screw Remover
Authors: Paluch A , Clarke A , Smith S , Adams S 
Published: October 2021

Abstract

Introduction
There is a greater risk of delayed healing and revision surgery in atypical femoral fractures (AFFs). Although non-union in reamed intra-medullary (IM) nailing is relatively uncommon, it can lead to fracture of the nail and present a considerable challenge to the treating surgeon.

Case Report
We present a case of AFF treated with IM nail fixation. Metalwork failure of the nail prompted removal of distal locking screws and plating of the fracture site at 8 months. Failure of the plate-bone interface 3 months later led to further revision surgery to remove the broken metalwork. We focus on the significant operative difficulty encountered during removal of the failed IM metalwork and provide a novel practical solution to overcome this particular challenge - insertion of a conical cannulated screw remover under fluoroscopy guidance to create an interference fit with the distal segment of the broken nail.

Discussion
This case is an example of significant and unexpected intra-operative technical difficulty, requiring improvisation and teamwork to manage. We introduce an accessible and uncomplicated alternative to the existing techniques for removal of a broken femoral nail and in doing so hope to benefit peers and colleagues should they encounter similar difficulties in the future.
508 The Early Use of Intratympanic Steroid Injections in the Treatment of Labyrinthitis Obliterans – A Case Report
Authors: Thind R K , Ho G C , Yap D , Hunt A 
Published: October 2021

Abstract

Introduction
Labyrinthitis Obliterans is an inner ear condition characterised by pathological sclerosis and ossification of the membranous labyrinth as a response to inflammatory insult. It is associated with profound sensorineural hearing loss and occasionally dizziness and/or vertigo.In this case report, we describe the use of intratympanic steroid injections in a patient presenting with sudden sensorineural hearing loss (SSNHL) with a radiological diagnosis of Labyrinthitis Obliterans. Whilst many studies suggest the role of oral steroids in SSNHL, there is no current evidence regarding the role of intratympanic steroid injections specifically for the treatment of this condition.

Case Presentation
A 60-year-old gentleman was referred to ENT with a 3-day history of sudden right sided hearing loss. There was no improvement in his Pure Tone Audiometry (PTA) results after 7 days of oral Prednisolone. Subsequently, an MRI Internal Acoustic Meatus showed evidence of right sided Labyrinthitis Obliterans. The patient was initiated on a course of intratympanic Methylprednisolone injections 10 days after initial onset of symptoms. A significant improvement in his baseline hearing of over 60dB was demonstrated after 4 courses of injections over a 3-month period.

Discussion
Our findings reveal that despite a diagnosis of Labyrinthitis Obliterans, the early use of intratympanic steroid injections can significantly improve hearing threshold and quality of life of the patient. The biggest hurdle in the management of Labyrinthitis Obliterans is establishing the diagnosis early and ensuring timely treatment, therefore we would advocate the early use of MRI and early intervention with intratympanic steroid injections.
563 A Rare Case of Small Bowel Obstruction Secondary to Peritoneal Encapsulation, Congenital Adhesional Band and Gallstone Ileus
Authors: Gungadin P , Taib A , Ahmed M , Sultana A 
Published: October 2021

Abstract

Introduction
Small bowel obstruction can be caused by multiple factors. We describe an unusual case of small bowel obstruction secondary to three rare factors: gallstone ileus, peritoneal encapsulation and congenital adhesional band.

Case Presentation
A seventy-nine-year-old male presented with a four-day history of obstipation and abdominal pain. CT abdomen pelvis revealed small bowel obstruction secondary to gallstone ileus. The patient was managed by laparotomy. The intraoperative findings revealed the presence of a congenital peritoneal encapsulation with an adhesional band and gallstone proximal to the ileo-caecal valve. Although there was some dusky small bowel, this recovered following the release of the band.

Discussion
Peritoneal Encapsulation is a rare congenital pathology resulting in the formation of an accessory peritoneal membrane around the small bowel. This condition is asymptomatic and rarely presents as small bowel obstruction. The diagnosis is often made at laparotomy. There are less than 60 cases reported in literature. Gallstone ileus is another rare entity caused by an inflamed gallbladder adhering to part of the bowel resulting in a fistula.

Conclusions
The rarity of these conditions mean that they are poorly understood. A combination of this triad of gall stone ileus in the presence of peritoneal encapsulation and congenital band has not been reported before. Knowledge of this would raise awareness, facilitate diagnosis and management of patients.
571 Case of A Rare Presentation of Solitary Fibrous Tumour of the Pleura (SFTP)
Authors: Ishak L , Kostoulas N 
Published: October 2021

Abstract

Presentation
A 69-year-old male presented with rapidly worsening symptoms of breathlessness, productive cough, and weight loss. Examination revealed a deviated trachea, and no breath sounds on auscultation of the left side of the chest.

Investigations
Chest X-ray revealed a giant mass associated with a large pleural effusion, subtotal lung collapse and mediastinal shift. FEV1 was 39% predicted and DLCO 62% predicted.

Management
Due to the severity of presentation, urgent pleural inspection, drainage, and biopsy were carried out. Compression of the heart resulting in tamponade with increased heartrate and breathlessness was suspected

Further investigations and management
Pleural biopsies and pleural fluid cytology were negative for malignancy. PET-CT showed mild avidity. Definitive management was tumour mass resection via left double space open thoracotomy.

Macroscopy/Microscopy/Immunohistopathology
Intra-operatively, the tumour was giant, occupying three quarters of the chest cavity. It measured 21 × 14×8 cm. The whole lung was attached to the chest wall with adhesions. Microscopy revealed patternless architecture, high vascularity, hypercellularity, necrosis, elongated nuclei, pale cytoplasms and mitotic activity of 2-3 mitotic figures per 10-highpower-fields. Immunohistochemistry stained positive with CD34, BCL2, CD99, Ki-67 and STAT6. Diagnosis of SFT was suspected; malignant potential could not be predicted.
Follow-up was with repeat CT scans for five years. Recurrence risk was given as 20%.
Learning points