bluuebunny/crossref_metadata_2025_split huggingface dataset:
1115 The Role of Ultrasound and Computer Tomography Imaging in the Management of Suspected Acute Appendicitis at a District General Hospital: A Clinical Audit Evaluating Our Practice Against International Standards
Authors: Laouris P , Constantinou A , Haj Ali Z , Shafeik F , Adebisi A , McDonald-Nethercott M , Dai N 
Published: August 2024

Abstract

Aim
Definitive diagnosis of acute appendicitis (AA) continues to pose a clinical challenge. Computer tomography (CT) is the gold-standard imaging modality for diagnosis, but ultrasound (USS) remains first-line and recommended for paediatric and young patients given the absence of ionising radiation. We conducted an audit evaluating the use of imaging as a diagnostic adjunct in diagnosing AA and whether it reduced the negative appendicectomy rate in a large UK district general hospital. A high NAR has both a significant patient impact (complications, increased hospital length of stay) and healthcare resource burden.

Method
We performed a retrospective analysis of electronic health records for a pre-Covid cohort of 344 patients who underwent a coded diagnostic laparoscopy/laparoscopic appendicectomy between 1st January 2019 and 1st January 2020. Histological confirmation of appendicitis was utilised as the gold-standard.

Results
USS was performed in only 10% of patients, particularly young females (16-35), and had 44% sensitivity, 88% specificity, 57% positive predictive value (PPV) and 84% negative predictive value (NPV). CT was performed in 22% of patients with 99% sensitivity, 100% specificity, 100% PPV and 88% NVP. Use of imaging (versus DLA) was associated with greater length of stay and readmission rates.

Conclusions
Despite its widespread use, ultrasound’s low sensitivity and PPV render its clinical utility debatable, particularly in females. Additionally, by counting occasions whereby ultrasound fails to visualise the appendix as negative results, its specificity is inaccurately increased. Therefore, CT remains gold standard given its highest sensitivity and specificity for diagnosing AA and its association with a reduction in NAR.
1134 Audit on Timeliness of Imaging in Bicep Tendon Ruptures
Authors: Devashetty A 
Published: August 2024

Abstract

Aim
This audit aimed to assess the time interval between the date of injury and the acquisition of imaging for patients suspected of bicep tendon ruptures. The primary objective was to identify areas for improvement in reducing delays and optimizing the diagnostic timeline.

Method
A retrospective analysis was conducted on a cohort of 28 patients presenting with suspected bicep tendon ruptures between January 2022 and September 2023 at Basingstoke North Hampshire Hospital. Electronic medical records were systematically reviewed to extract data on the time elapsed from the reported date of injury to the date of imaging, encompassing modalities such as ultrasound and magnetic resonance imaging (MRI).

Results
The audit revealed considerable variability in the time taken to obtain imaging from date of presentation, with an average duration of 7.8 days. The average time from date of presentation to surgery performed was 23.2 days. Notably, delays were mainly due to patient unattendance and scheduling appointments for scans.

Conclusions
The findings underscore the importance of streamlining the diagnostic pathway for bicep tendon ruptures to reduce the time between injury and imaging/surgical procedure.
1167 A Closed Loop Audit to Benchmark Care for Emergency Department Attendances with Renal Colic
Authors: Dehbokri A , Mayer C P , Ariyanayagam D 
Published: August 2024

Abstract

Aim
Benchmark care against the NICE Standards for assessment and management of Renal Colic patients. Produce patient leaflet highlighting stone diet. Re-audit and assess care for renal colic patient, following he introduced changes in first cycle including patient leaflet & renal order-set. Highlight areas that may need improvement and improve the awareness clinicians.

Method
Using electronic system and notes, care for the most recent 150 patients attending St Heliers and Epsom A&E, coded on system as “Ureteric Stones”, was benchmarked against NICE guidance during two cycles (2022 & 2023) as bellow:CTKUB request, completion, and report timeTime between arrival, prescription, delivery & choice of analgesiaTime between arrival and Urological intervention.Proportion who had bone profile requested.Proportion that received stone diet advice as per documentation.

Results
100% CTKUB was reported within 24HRs (97.9% cycle 1). 71.9% of total patients received NSAIDS as analgesia in cycle 2 (54.5% cycle 1). 100% who required surgical intervention, had it within 48HRs in cycle 2 (70% cycle 1). 94.7% had calcium requested in cycle 2 (77.9% in cycle 1). In cycle 1, only 8.7% received dietary/fluid advice, this is improved to 39.4% in cycle 2.

Conclusions
Department currently successful in meeting the NICE quality standards for timing of CTKUB and Surgical management of ureteric stones. We have improved by 17.4% in prescribing appropriate analgesia and by16.8% improvement in serum calcium requests. Department improvement by 30.7% in giving patient advice regarding lifestyle and dietary changes for secondary prevention.
1227 Impact of Night Shift on Junior Doctor Driving : Two Third of Doctor Did Not Feel Safe to Drive Post Night
Authors: Islam M F , Noor M , Rahman N , Chakraborty M , Tanzum F , Islam M S 
Published: August 2024

Abstract

Aim
Over the last decade, the loss of three doctors' lives has highlighted the challenges faced by junior doctors commuting after night shifts. This audit explored how demanding schedules affect their driving performance, aiming to identify risks and enhance safety for both doctors and the public.

Method
A ten-question multiple-choice questionnaire was distributed to 120 junior doctors of all specialties.

Results
showed that 82.35% prefer driving, 14.29% use public transport, and 9.5% opt for alternative means like cycling or walking.
Two-thirds of doctors (64.2%) feel unsafe driving post-night shift, with varying frequencies: 30.56% often, 29.63% occasionally, 25.93% rarely, and 13.88% always.
Coping mechanisms include 62.91% consuming caffeinated drinks, 19.68% using public transport, and 15.38% napping. However, 30.95% struggle to find a nap spot. For those unable to find one, 46% nap in cars, 28.3% in On-Call rooms, 21.5% in doctors' offices, and 3% even ask colleagues to stay in their place after hospital.
Challenges after night shifts include 32.94% hitting the curb, 20% sleeping at the wheel, 18.8% getting honked, 16.4% swerving, 4.7% in the wrong lane, 4.81% receiving tickets, and 2.35% crashes.
Junior doctors attribute tiredness to consecutive nights (64.1%), excessive workload (60.68%), 12-hour shifts (63.25%), inability to rest (55.56%), and understaffing (41.9%).

Conclusions
Include adopting a 2-night pattern (62.71%), providing quiet rooms (50.85%), implementing 30-minute breaks every 6 hours (44.9%), improving staffing (43.2%), and considering an 8-hour shift. Future plans involve discussions with management, collaboration with the chief registrar, and contacting the local BMA representative to advocate for improved working conditions.
426 Nasopharyngeal Malignant Melanoma Masquerading in the Gallbladder: The Importance of Histological Assessment
Authors: Nagra R , Zaman S , Mohamedahmed A Y , Torrance A 
Published: August 2024

Abstract

Introduction
Metastatic malignant melanoma (MM) of the gallbladder (GB) is a rare entity which is often diagnosed late, leading to a poor prognosis. The disease may present insidiously as acute cholecystitis or remain asymptomatic. Optimal management remains unclear but surgical resection is considered the mainstay of treatment for this condition.

Method
A retrospective review of the electronic medical records of a 47-year-old patient who was diagnosed with metastatic MM of the GB was conducted. Data points included patient demographics, clinical features on presentation, radiological imaging, GB histology reports and outcomes was retrieved.

Results
This patient initially presented to our emergency department with a a protracted course of generalised abdominal. The patient was initially diagnosed with acute cholecystitis resulting in an emergency laparoscopic cholecystectomy. Following an emergency laparoscopic cholecystectomy, the histology incidentally revealed a melanoma with an unknown primary. Subsequently this was traced to the nasopharynx. Due to the presence of concurrent liver metastasis, systemic immunotherapy with palliative intent was commenced following a multi-disciplinary team discussion.

Conclusions
This case highlights the importance of sending all resected GB specimens following cholecystectomy for routine histological analysis. We argue against selectively choosing which specimens to send to histology based on radiological and/or intraoperative macroscopic inspection of resected tissue alone as this can delay or prevent the detection of sinister pathologies such as malignancy. We argue in favour of early detection in order to initiate early treatment to improve prognosis.
583 Use of LICAP Flap Reconstruction in a Breast Cancer Patient with Cosmetic Implants Undergoing Breast Conserving Surgery
Authors: Arisoy H , Sabaratnam R , Boland M 
Published: August 2024

Abstract

Introduction
The Lateral Intercostal Artery Perforator (LICAP) flap has emerged as an alternative to implant-based or free tissue transplantation techniques in breast reconstructive surgery. This technique uses a pedicled flap to replace lost volume. This reconstructive method provides acceptable recovery times, lower rates of flap size morbidity, and better aesthetic satisfaction of patients compared to other methods.
In this study we describe a case of LICAP flap surgery in a patient with a previous history of aesthetic breast implants.

Case Presentation
A 49-year-old patient with bilateral aesthetic breast implants presented to the emergency department with a six-week history of an anterior neck lump. Radiological and histological investigations of this lesion revealed a primary carcinoma of the parotid gland with lymph node metastasis.
A staging whole-body scan for this lesion showed additional areas of increased uptake in the right axilla and breast. Dedicated radiological imaging demonstrated a 1.5 cm mass and multiple abnormal axillary lymph nodes. Biopsies confirmed a concurrent Grade 2 Intraductal Carcinoma of the right breast with metastatic axillary lymph node involvement.
A two-stage LICAP reconstructive approach was taken with no postoperative complications. The patient also underwent parotidectomy and neck dissection. Six months post-operatively, the patient remains well, having successfully navigated additional chemotherapy and hormonal suppressive therapy.

Conclusions
This case contributes to the evolving landscape of LICAP flap utility in BCS, emphasising its role as a low-risk and viable option. It underscores successful oncological management and the achievement of favourable aesthetic outcomes, including in complex scenarios with need for preservation of existing implants.
616 A Rare Biliary Duct Anatomical Variant Encountered During a Routine Cholecystectomy
Authors: Liyanage D , Wilson P 
Published: August 2024

Abstract
Cholecystectomy, a common surgical procedure, faces complexities due to variations in biliary anatomy. Although bile duct injuries are uncommon, their potential for morbidity necessitates careful consideration. In this report, we present a case featuring a rare anatomical variant of the biliary duct, previously unreported in the literature.
A 53-year-old female, suffering from persistent biliary colic symptoms, underwent elective laparoscopic cholecystectomy. During the closure phase following gallbladder resection, the surgeon identified a small hole in one of the hepatic ducts, prompting intervention with a T-Tube. Subsequently, the patient was referred to a tertiary centre for in-depth evaluation and management.
Intraoperative cholangiography (IOC) conducted revealed a unique anatomical configuration, illustrating a right posterior sectoral duct draining into the left hepatic duct (Huang type III), connected to an accessory cystic duct, the Duct of Luschka. Despite unsuccessful attempts at intraductal stenting, the decision was made for biliary reconstruction via hepatico-jejunostomy, resulting in the patient's full recovery with no postoperative complications.
Currently, there are no clear guidelines regarding routine mapping of anatomical variations using imaging techniques such as IOC. The evidence in this area remains controversial due to the balance between the potential prevention of biliary duct injuries and the cost-effectiveness of such measures. More research is needed in this area, but at present, such considerations are made on a case-by-case basis.
This case underscores the challenges posed by unexpected anatomical variants during routine cholecystectomy and highlights the importance of adaptability in surgical management.
1033 A Rare Case of a Dog Bite Leading to Bilateral Lower Limb Amputation
Authors: Jones A , Moore P , Frewin R , Vardhan V , Kulkarni S 
Published: August 2024

Abstract

Introduction
Capnocytophaga canimorsus is a Gram- negative bacteria which is present in the normal gingival flora of both cats and dogs. C. canimorsus is a rare cause of bacteraemia in humans, occurring usually after animal bites, and can have devastating consequences for patients.

Report
This report describes the case of a 65-year-old female patient who presented acutely unwell six days after being bitten on the hand by a dog. Her blood culture flagged positive and further analysis by 16S rRNA PCR confirmed the organism as C. canimorsus. She suffered consequences of overwhelming sepsis, disseminated intravascular coagulation (DIC) and bilateral acute limb ischaemia requiring bilateral major lower limb amputations.

Discussion
A Dutch national surveillance study found the incidence of C. canimorsus to be 0.67 cases per million, however, with the incidence of dog bites doubling between 1998-2018; the incidence of C. canimorsus is likely to increase more than previously reported. A retrospective review of patients in a Helsinki ICU cohort between 2005 and 2014 found 65 patients with C. canimorsus; only three of these required lower limb amputation. Early prophylactic treatment with antibiotics after suffering a dog or cat bite could prevent serious complications associated with this bacterium.
1245 Management of Hypothermic Cardiac Arrest with Cardiopulmonary Bypass
Authors: Bowdren K , Downes A , Doddakula K 
Published: August 2024

Abstract

Aim
Hypothermic patients are at major risk of cardiac arrest. Accidental hypothermia is an unintentional drop in core temperature below 35 °C. Cardiopulmonary bypass may be used to rewarm patients in the surgical setting.

Method
A 48-year-old male was found after attempting suicide by carbon monoxide inhalation and Diazepam overdose. Recorded temperature on arrival of paramedics was 26 °C. He initially had a recordable blood pressure, but on transfer to the ambulance developed ventricular fibrillation secondary to rescue collapse, and CPR was commenced. One unsuccessful DC shock was delivered. The man was intubated, LUCAS machine was applied, and external warming measures were carried out. He arrived in resus over 2 hours after being found, with persistent ventricular fibrillation. Core temperature remained at 27-28 °C despite warming techniques. Cardiothoracic Surgery were contacted for consideration of a cardiopulmonary bypass to rewarm the patient. The patient was cannulated peripherally via the left femoral artery and vein, allowing the LUCAS machine to continue until institution of cardiopulmonary bypass. He was cardioverted from VF to NSR and rewarmed until temperature was 36.4 °C. He was weaned off bypass after 130 minutes and transferred to cardiac ICU.

Results
Extubated after 2 days with no neurological deficits. Self-ventilating and haemodynamically stable by day 3. Discharged from Cardiac Intensive Care Unit 7 days post-op with no neurological deficits to inpatient psychiatric unit.

Conclusions
Hypothermic arrests warrant continuous CPR as chances of survival and favourable neurological outcome are higher than for normothermic arrests.
1289 Rare Case of a Patient with Simultaneous Incarcerated Epigastric Hernia and De Garengeot Hernia: A Case Report
Authors: Lakshmipathy G R , Ball W 
Published: August 2024

Abstract

Case Presentation
66-year-old lady presents to surgical unit with main complaint of epigastric pain and swelling. She noticed lump in both groins. She had no previous abdominal surgery and has no past medical history.

Examination and bloods
Patient had irreducible tender swelling in epigastrium. Additionally, there was irreducible hot tender swelling in right groin. Left groin had soft reducible swelling. C-Reactive protein was 57 and white cell count was 7.9.

Imaging
CT Abdomen and Pelvis showed incarcerated epigastric hernia with omental fat and right inguinal hernia containing inflamed appendix.

Operative findings
Epigastric hernia had a 2cm defect containing pre-peritoneal fat. Right groin hernia constituted inflamed appendiceal tip within the femoral canal.

Management
Initial management included IV fluids and IV antibiotics. The first half of the operation involved mesh repair of epigastric hernia. The second half of the operation involved an incision for inguinal hernia repair and standard appendicectomy through dissection of lacunar ligament and desarda’s repair to the inguinal canal. Patient was discharged on the first post-operative day.

Conclusions
De Garengeot’s hernia is femoral hernia containing appendix with incidence of 0.15-5% of all femoral hernias. Systematic reviews demonstrate lack of clarity on whether inflamed appendix herniates or herniated appendix develops inflammation. In this case, appendicitis was confined to the tip raising possibility of the latter. Perhaps, strangulation at femoral canal prevented appendicitis to track up the rest of the appendix, which may explain the predominance of patient’s epigastric symptoms. Careful examination is necessary in patients with multiple hernias to guide appropriate operative management.
185 Examining the Efficiency of Diagnosing and Managing Necrotising Otitis Externa (NOE) Using a Departmental Management Algorithm
Authors: Hassan Haleem A 
Published: August 2024

Abstract

Aim
The audit aimed to evaluate a new NOE treatment algorithm's proficiency and the benefits of combining CT and Technetium Scan in comparison to CT alone for diagnosing and managing NOE.

Method
Patients admitted to Portsmouth Hospitals University NHS Trust between July 2021, and July 2023, with a possible or confirmed NOE diagnosis were examined. Among 37 identified patients, 33 were included, excluding those diagnosed with Squamous Cell Carcinoma. Patient records were analysed with the NOE algorithm to evaluate its effectiveness in diagnosing and managing NOE.

Results
Out of 33 patients (23 males, 10 females, mean age 77), 41% were diabetic. Ear swab results indicated 69.6% with pseudomonas, with 86.9% sensitive to Ceftazidime or Ciprofloxacin. NOE was confirmed in 60.6% (20/33) through CT. 7/13 patients with negative CT results underwent Technetium imaging, yielding a positive result in 4/7 of those cases. One patient was diagnosed with NOE via MRI. Technetium-negative patients received topical therapy and outpatient review. 25/33 radiologically diagnosed NOE patients and 3/33 with high clinical suspicion received 6 weeks of extended antibiotic therapy. 24/28 NOE-treated patients had an ENT follow-up in an average of 5.6 weeks. No recurrences or NOE-related mortalities were identified during follow-ups.

Conclusions
Technetium imaging influenced management in 30% of cases with a negative CT, making up 12% of the total study population. Without it, these patients might have overlooked extended antibiotic therapy, risking NOE complications. The algorithm was mostly adhered to, successfully identifying, and managing NOE patients with extended antibiotics, demonstrating no recurrence with no mortality since implementation.
1171 An Unusual Approach - Left Transorbital Approach to Repair of Lateral Sphenoid Wall CSF Leak Under Image Guidance
Authors: Ali D 
Published: August 2024

Abstract

Aim
To present a case where transorbital and endonasal approaches were taken simultaneously to repair a cerebrospinal fluid (CSF) leak.

Background
The initial management plan for a sinus CSF leak is conservative management, as leakage stops within 1 week for 70% of patients suffering from a traumatic leak.
However, in cases where the CSF leak does not heal spontaneously, surgical options must be explored as if left untreated patients run the risk of contracting meningitis.
The most common approach taken is the endonasal approach whereby a septal flap is used to seal the leak. In cases where the location of the leak is difficult or impossible to reach endonasally, another approach can be considered such as a transorbital approach. In this case a 60-year-old lady presented with a CSF leak preceded by a recent episode of meningitis. She had a previous left sided CSF repair endonasally 4 years prior.
Imaging revealed a meningo-encephalocoele from a left persistent sternbergs canal – After discussion in MDT a transorbital and endonasal approach was taken to repair the defect, with fat and fascia taken from her thigh.

Conclusions
A transorbital + endonasal approach is a safe, minimally invasive approach which can be used as an alternative to endonasal only approach in order to target and manipulate pathology within the skull base.
1257 Literature Review: Precision in Parathyroid Surgery: Unveiling New Frontiers with Robotic Assistance and Indocyanine Green Fluorescence Imaging
Authors: Al Maawali S S 
Published: August 2024

Abstract

Aim
This review delves into the effectiveness of indocyanine green (ICG) fluorescence for visually identifying hyperparathyroidism in robot-assisted parathyroidectomy, utilising FireflyTM technology. Concurrently, a comparative analysis between robot-assisted and open parathyroidectomy to discern clinical nuances between the two approaches.

Method
In a cohort of 37 primary hyperparathyroidism patients (open parathyroidectomy n=31, robot-assisted n=6), both groups used pre-op localization and IOPTH assays. ICG was selectively administered in robot-assisted. In another literature, BABA robotic parathyroidectomy (n=22, Dec 2013–Aug 2015), Firefly in da Vinci Si guided ICG for parathyroid identification. Post-op days 0, 1, 2, and 14 monitored parathyroid hormone levels. Propensity score matching formed a control group for age, gender, tumour size, and operation type, assessing parathyroid functionality.

Results
The robot group exhibited persistent fluorescence in pathologic parathyroids under near-infrared vision. Post-removal, IOPTH normalised in all robot group patients. Despite a superior cosmetic outcome, the robot group experienced longer hospital stays (3.0 ± 0.0 vs. 1.8 ± 1.2 days, p &lt; 0.001) and extended operation times (152.5 ± 23.6 vs. 91.1 ± 69.1 min, p = 0.001) compared to the open parathyroidectomy. After 6 months, both groups demonstrated normalised PTH, calcium, and ionised calcium levels. However, in BABA robotic thyroidectomy, ICG group had significantly less inadvertent parathyroidectomy than the control (0% vs. 15.9%, P = 0.048).

Conclusions
Robot-assisted parathyroidectomy with ICG facilitates precise identification of pathologic glands, offering a superior cosmetic outcome. However, clinical outcomes do not surpass those of conventional open parathyroidectomy. This review explains the nuanced approach to PHPT surgery, integrating robotics for enhanced precision and patient outcomes.