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Audit of compliance with AAGBI guidelines on coagulation screen requests for patients undergoing surgery for femoral fracturesConference abstract 67 of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Group of Anaesthetists in Training (GAT) Annual Scientific Meeting, 17–19 June 2015, Manchester, UK.
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Aseptic precautions for caudal anaesthesiaThis correspondence piece highlights the low rate at which anaesthetists seemed to have adopted new guidelines and recommendations.
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Fournier's gangrene secondary to an acutely inflamed appendix herniating into the deep inguinal ringFournier's gangrene (FG) requires prompt recognition and management. We report the case of a 68-year-old man who presented with extensive pain and purple discolouration from the right iliac fossa to perineum. Computed tomography demonstrated gas within the right hemiscrotum extending into the inguinal canal and right buttock, with a right pelvic fluid and air collection. At debridement necrotic fluid was arising from the superficial inguinal ring so laparotomy was performed, revealing a grossly inflamed appendix herniating into the inguinal canal; a right hemicolectomy was performed. Unfortunately, the patient went into cardiac arrest and passed away on the operating table. Histological analysis demonstrated acute-on-chronic inflammation involving the appendix. The condition where appendicitis is implicated in FG is usually due to retroperitoneal rupture and tracking into the perineal spaces. This is the first case reported of an inflamed appendix herniating into the inguinal canal and thus causing FG.
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Acquired isodisomy on chromosome 13 at diagnosis results in impaired overall survival in patients with FLT3-ITD mutant acute myeloid leukaemiaInternal tandem duplication (ITD) mutations in the FLT3 gene on chromosome 13 occur in 25% of patients with acute myeloid leukaemia (AML) and result in impaired overall survival (OS). Patients with a high allelic ratio (AR) of ITD mutant to wild-type FLT3 in genomic DNA have an even poorer prognosis. AR may be a predictor of response to FLT3 inhibitors and may also interact with other mutations in influencing disease risk. AR may be dependent on a number of factors including loss of the wild-type allele. Acquired isodisomy (AID) results in loss of the wild-type allele, through duplication of the mutant allele with segmental loss of the wild-type allele. Although studies have shown the importance of AID at chromosome 13 (AID13) at relapse, the impact of AID13 at diagnosis is unclear. The study reported in this Letter to the Editor aimed to identify the relationship between AID13 and FLT3-ITD AR and investigated the outcomes of patients with AID13.
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Human perception of visual stimuli modulated by direction of linear polarizationThis study explores both theoretically and experimentally the human perception of polarized light beyond that currently established. The radial analyser theory of Haidinger's phenomenon (HP) is used to predict the effect of observing visual stimuli comprising patterned zones characterized by orthogonal planes of linear polarization (linear polarization direction fields, LPD-fields). Any pattern can be represented as an LPD-field including optotypes and geometric forms. Simulated percepts differ from the original patterns although edges are mostly preserved. In edge-rich images a cross of attenuating contrast spanning the field of view is predicted. The mathematical model is verified experimentally using a liquid crystal display (LCD)-based polarization modulator imaged through a tangential (azimuthal) analyser with properties complementary to a radial analyser. The LCD device is then used in vivo to elicit perceptual responses in human subjects. Normal humans are found to readily detect spatially and temporally modulated isoluminant spatially-isochromatic, highly polarized LPD stimuli. Most subjects match the stimuli to corresponding images of theoretically predicted percepts. In particular edge perception and the presence of the contrast cross was confirmed. Unlike HP, static patterned LPD stimuli are perceived without difficulty. The simplest manifestation of human polarization perception is HP which is the fundamental element of an open set of stimulus-dependent percepts. This study demonstrates that humans have the ability to perceive and identify visual pattern stimuli defined solely by polarization state modulation. Keywords: Haidinger’s brushes; Human polarization perception; Macula; Optotype; Radial analyser model.
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One Step Nucleic Acid amplification testing for CK19 : single copy number >5,000 copies/μL vs Total Tumour Load of 15,000 copies/μLBackground: The diagnostic criteria for OSNA proposes cut-off values of >5000 copies/μL of CK 19 mRNA as macro-metastases. Practice in our centre is to perform axillary node clearance (ANC) on patients with a copy number of >5000 in any node. A recent study has suggested an alternative method using the total copy number of all sentinel nodes (Total Tumour Load) with a cut-off of 15,000 copies/μL.
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The use of SentiMag in identifying the sentinel lymph node : Warwick experienceIntroduction: SentiMag is a new system for the detection of the sentinel lymph node (SLN) in patients with breast cancer. The new technique uses 2 devices: a subcutaneous injection of a magnetic tracer into the breast and the use of a hand-held device (a magnetometer) to detect the SLN intra-operatively. We used SentiMag and compared it to the standard technique (radioisotope alone in our unit) used in breast cancer patients. We looked at the localisation rate of SLN detected with both the standard and the SentiMag technique.
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One-step nucleic acid amplification : CK 19 copy number as a predictor of further axillary involvementIntroduction: In 2013, the National Institute of Clinical Excellence (NICE) endorsed the use of One step nucleic acid amplification (OSNA) in clinical practice. Our study aims to seek a correlation between the OSNA results, indicated by CK 19 mRNA copy numbers and the likelihood of non-sentinel axillary involvement in patients with macro-metastases.
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Pulmonary oedemaA CPD article refreshed Abby Morrow-Barnes’s knowledge of acute pulmonary oedema and prompted her to reflect on her practice.
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Heel ultrasound scan in detecting osteoporosis in low trauma fracture patientsOsteoporosis is the most common metabolic disease with significant impact on the morbidity and mortality of affected patients. Osteoporosis has a significant impact on the economy worldwide. The aim of this study was to find out whether heel ultrasound is as good as central bone densitometry scanning in diagnosing osteoporosis in patients who are at high risk of osteoporosis. This was a prospective study of patients comparing heel ultrasound to central bone densitometry scanning (dual X-ray absorptiometry, DEXA) in patients. The recruited patients attended for a DEXA scan of the left hip and lumbar spine. All subjects had an ultrasound of the left heel using the quantitative heel ultrasound machine. The results of DEXA scan were blinded from the results of ultrasound and vice versa. There were 59 patients who took part in the study, 12 men and 47 women. The mean age was 66 years (SD 11.9) and mean weight was 62.5 kg (SD 10.7). The sensitivity and specificity of the ultrasound heel test to predict osteoporosis were 53% (95%CI: 29-77) and 86% (95%CI: 75-96) respectively. Specificity for predicting bone mineral density (BMD)-defined osteoporosis was high (86%), but sensitivity was low (53%). A heel ultrasound result in the osteoporotic range was highly predictive of BMD-defined osteoporosis. A positive ultrasound heel test in high risk patients is more useful in ruling in osteoporosis than a negative test to rule out osteoporosis. Keywords: Osteoporosis; bone mineral density; central bone density; quantitative ultrasound.
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Surgery for gallstone disease during pregnancy does not increase fetal or maternal mortality : a meta-analysisBackground: Pregnancy was traditionally considered a contraindication to cholecystectomy but is now becoming the favoured option for gallstone-related disease (GRD) during pregnancy. Methods: To assess if cholecystectomy during pregnancy increases the risk of preterm labour, fetal mortality and maternal mortality. PubMed and MEDLINE databases for the period from January 1966 through December 2013. Studies were both conservative and surgical intervention was utilised in the management of GRD were included. The results of the included studies were pooled using meta-analysis techniques. Results: Surgical intervention for GRD in pregnancy does not increase the risk of preterm labour, fetal mortality or maternal mortality. Conclusions: Cholecystectomy during pregnancy for GRD is associated with low complications for the fetus and mother and should be considered in all suitable patients. Keywords: Laparoscopic cholecystectomy; fetal mortality; gallstones; pregnancy; preterm labour.
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Patient anxiety on the use of one step nucleic acid amplification (OSNA) during breast cancer surgeryIntroduction: Assessment of the sentinel lymph node biopsy (SLNB) is used to stage the axilla in patients with breast cancer. There are a variety of methods to assess metastatic disease within the SLN. One-step nucleic acid amplification (OSNA) has a high sensitivity for detecting metastatic disease within the SLN and avoids the use of staged axillary surgery. However there remains a paucity of data within the literature on the psychological effects upon patients with the use of OSNA. Methods: All patients undergoing breast surgery (breast-conserving surgery or mastectomy) and assessment of the SLNB with OSNA from December 2011 to June 2012 were included in the study. A questionnaire was sent to patient within four weeks of surgery to assess their understanding and satisfaction with the OSNA procedure. Results: 60 patients responded to the questionnaire (83% response rate). All patients were female with a mean age of 63 years (range 38-71 years). 19 patients had positive SLNB as assessed by OSNA and all had ALND. 15 patients expressed pre-operative anxiety about having OSNA although 97% stated that they would be happy to undergo the same procedure again. Conclusion: Our study has identified the anxiety points that patients experience with OSNA based management and this will allow improved direct emotional support and provision of information. Keywords: Breast cancer; anexity; sentinel lymph node biopsy.
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Short and medium-term outcomes for general surgery in nonagenarian patients in a district general hospitalIntroduction Surgeons are increasingly performing surgery on older patients. There are currently no tools specifically for risk prediction in this group. The aim of this study was to review general surgical operations carried out on patients aged over 90 years and their outcome, before comparing these with predictors of morbidity and mortality. Methods A retrospective review was carried out at our district general hospital of all general surgery patients aged over 90 years who underwent a general surgical operation over a period of 14 years. Information collected included demographics, details of procedures, P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity), complications and outcomes. Results A total of 119 procedures were carried out, 72 involving entry into the peritoneal cavity. Overall, 14 patients (12%) died within 30 days and 34 (29%) died within one year. Postoperative complications included infection (56%), renal failure (24%), need for transfusion (17%) and readmission within 30 days (11%). Logistical regression analysis showed that the P-POSSUM correlated well with observed mortality and infection was a significant predictor of in-hospital mortality (p=0.003). Conclusions The P-POSSUM correlates significantly with outcome and should be used when planning major elective or emergency surgery in patients over 90 years of age. Infective complications appear to be a significant predictor of postoperative mortality. This study supports operative intervention as an option in this extreme age group but we emphasise the importance of appropriate patient selection and judicious clinical care. Keywords: Elderly; Morbidity; Mortality; Nonagenarian; P-POSSUM.
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Acute scrotal swelling following perforated rectal carcinoma with abscess formationA 59-year-old cachectic male was referred to the surgical outpatient department with intermittent haematochezia and a longstanding change in bowel habit with associated weight loss and anaemia. Following investigation, he was diagnosed with a large rectal tumour with multiple metastases. 7 days later, the patient presented again with fevers, bilious vomiting, abdominal pain and distension. On examination, he had a generally tender abdomen,= although no peritonism, but an enlarged, extremely tender hemiscrotum with no cough reflex. Imaging revealed a perforated rectum and subsequent abscess formation, which tracked via an unusual anatomical route to present as scrotal swelling.
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HOCUS POCUS : hands-on cloud uploading service for point-of-care ultrasoundConference abstract 0084 for E-Poster EPM.043 of the Intensive Care Society State of the Art 2016, 5–7 December 2016, London, UK. Corrigendum at doi.org/10.1177/1751143718790728
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The use of cricoid pressure during rapid sequence induction in trauma patients – UK and European practice comparedIntroduction There is ongoing debate and conflicting evidence surrounding the place of cricoid pressure (CP) as part of a rapid sequence induction (RSI) of anaesthesia. This study investigated the current use of CP during trauma RSI and compared reported practice in the UK with the rest of Europe. Methods An anonymised, web-based survey was sent to all clinicians registered as European Trauma Course instructors. Results CP use was reported by 83.1% of UK respondents and 39.4% from the rest of Europe, with an overall reported use of 49.8%. Anaesthetists use CP less commonly (35.6%) than clinicians from other specialties (63.6%). The most common reason given for not using CP (76.7%) was a perceived lack of evidence of effectiveness. Conclusion Generally the use of CP appears to be in decline with only half of all clinicians reporting to use it; however it remains much more commonly used in the UK than the rest of Europe.
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Steroid refractory autoimmune haemolytic anaemia secondary to sarcoidosis successfully treated with rituximab and mycophenolate mofetilAutoimmune haemolytic anaemia is not a well-recognised complication of sarcoidosis. We describe the case of a 30-year-old female who presented with acute warm haemolytic anaemia and widespread lymphadenopathy. Sarcoidosis was diagnosed on lymph node biopsy and further investigation. The haemolytic anaemia responded only to a high dose of steroids. Evidence regarding treatment of steroid refractory autoimmune haemolysis secondary to sarcoidosis is lacking. Based on the emergent evidence that both disorders share common immunopathogenic mechanisms involving Th1 and Th17 lymphocytes, our patient was given rituximab and mycophenolate mofetil to successfully suppress the haemolysis and sarcoid activity.
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Angiotensin receptor antagonist treatment, melanoma incidence and ethnicityA Letter to the Editor discussing angiotensin receptor antagonist treatment, melanoma incidence and ethnicity.
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Is there any relation between the value of CRP in the first post-operative day and the development of sepsis complications in elective colorectal resections?Poster abstract P326 of the 11th Scientific and Annual Meeting of the European Society of Coloproctology, 28–30 September 2016, Milan, Italy.
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Swollen and tender left nippleCase report of a 43‐year‐old man presenting with a 3‐week history of a swollen and tender left nipple.