Are we selecting appropriate admissions for intensive care following major abdominal surgery: A retrospective cohort study on outcomes of 1059 patients.

BACKGROUND: Like any other medical treatment, The intensive care unit (ICU) is a limited resource that needs to be utilized appropriately. This study aimed to identify the outcomes of patients admitted to the ICU based on patient demographic and severity score parameters. METHODS: An observational retrospective cohort study of 1059 patients undergoing laparotomy who were admitted to the ICU was performed. Cases were sub-classified by the mode of admission and risk prediction scores and analyzed outcomes of mortality, ICU length of stay (LOS), and hospital LOS. RESULTS: The mean age of patients who did not survive was older than those who survived, and higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Intensive Care National Audit and Research Centre Physiology Score (ICNARC) observed in patients who died. Emergency admission was also an indicator of increased mortality. Survivors APACHE II scores were the same if they were elective or emergency admissions, although Survivors ICNARC scores were higher in emergency than in elective admissions. Patients who did not survive had a longer ICU LOS stay than those who survived, whereas elective survivors had shorter ICU LOS than the emergency survivors. Regardless of this hospital LOS was the same for both elective and emergency survivors. CONCLUSION: The most unwell patients had the highest risk prediction scores, were more often admitted in the emergency setting, required longer stays in ICU, and had less favorable outcomes. However, ICU did appear to expedite the hospital discharges of emergency patients to match their elective counterparts. Decisions around when and to which patients ICU is an appropriate intervention remains a difficult decision and one that cannot be made without full consideration of all aspects of patient factors.

Can one stop nucleic acid sampling (OSNA) predict nodal positivity following neoadjuvant chemotherapy? A prospective cohort study of 293 patients.

Until recently, axillary node clearance had long been the standard of care in patients with axillary node-positive disease. One stop nucleic acid sampling (OSNA) has been used to guide intraoperative decision-making regarding suitability for axillary node clearance (ANC). The aim of this study is to evaluate the use of OSNA following neoadjuvant chemotherapy (NACT) and whether it can predict lymph node burden in ANC. A single center, prospective cohort study was performed on 297 patients having OSNA between 2016 and 2019. Patients were sub-classified according to node positivity at diagnosis and those treated with NACT and outcomes included copy number and lymph node harvest. Axillary complete pathological response was observed in 24/36 patients (67%) following NACT. 14/16 patients (87%) having axillary node clearance had axillary node disease limited to 4 nodes. OSNA copy numbers were significantly higher in patients showing disease progression following NACT. Overall, 73% of patients with lymph node positivity at diagnosis could be successfully treated with a combination of NACT and lymph node excision of four nodes. De-escalating axillary surgical treatment to resection of four nodes following NACT may be effective in balancing oncological resection and limiting treatment morbidity. ONSA can correctly identify patients experiencing disease progression who would benefit from traditional three-level ANC.

Sensitivity and missed cancer rate in the symptomatic breast clinic-A retrospective cohort study of 40 323 patients.

INTRODUCTION: Symptomatic presentations account for the majority of invasive breast cancer diagnoses. While the National Health Service Breast Screening Programme is subjected to strict quality control, no such system for performance monitoring exists in the symptomatic clinic. We assess the sensitivity of cancer detection and missed cancer rate for symptomatic breast patients to benchmark future outcome measures. METHODS: A retrospective cohort study of patients attending the symptomatic breast clinic between October 2013 and October 2018 was performed. Patients with new cancer diagnoses were identified and screened for those who had presented to the department within the 3 years prior to their diagnosis. From this, the sensitivity and missed cancer rate were calculated. RESULTS: About 40 323 patients were seen over the 5-year study period. About 2155 new cancers were diagnosed, with 2033 identified at their initial clinic attendance. A further 122 patients had cancer diagnosed on a subsequent appointment, of which 23 patients were considered to have had a delay in diagnosis. The sensitivity of the one-stop symptomatic breast clinic was therefore 99.0%, and the missed cancer rate was 0.06% over 5 years. CONCLUSION: The missed cancer rate reported in this study is favorable compared to the outcomes reported in the National Health Service Breast Screening Programme and superior to the only other study reporting outcomes on a much smaller cohort. The unit in question therefore is performing exceptionally against current standards and sets a benchmark against which future performance can be measured.

Is group and save still a necessary test in the preoperative workup for breast cancer surgery?

INTRODUCTION: Trust guidelines state that patients undergoing mastectomy have one group and save (G&S) sample preoperatively, or two for bilateral or complex mastectomy. Breast surgical patients rarely require blood transfusion, and G&S testing is costly and labour intensive. Our study assessed whether preoperative G&S testing is warranted for breast surgery patients. METHODS: Retrospective review of consecutive patients undergoing mastectomies from one centre, from June 2018 to June 2019 identified 190 women. Review of electronic records for G&S tests was performed and transfusions prescribed. Discussion with laboratory personnel regarding costs of processing G&S tests. RESULTS: Forty-six (32%) patients who underwent simple mastectomies had one G&S, eight (6%) patients had two. Twenty (45%) patients who underwent bilateral/complex mastectomy/reconstruction had one G&S and four (9%) had two. No patients required peri or postoperative blood transfusions. Seventy-eight G&S tests performed cost the trust £1,082. CONCLUSION: Simple mastectomies rarely require blood transfusions. G&S tests cost £13.83 and are time consuming for the patient and laboratory. We propose that G&S tests are unnecessary for patients undergoing simple mastectomies and preoperative protocols require adjustment. Trust policy is to have 'routine G&S'; however, 124 patients did not have any G&S testing. Had the guideline been followed, this would have cost the Trust a further £1,715.

Symptomatic Breast Cancers and Why Breast Pain May not Always Need Clinical Review.

OBJECTIVE: Breast pain contributes a heavy burden to the symptomatic breast clinic, accounting for a large number of referrals due to patient/clinician subjective anxiety and unclear aetiology. We assess the link between breast pain and cancer with a view to easing the demand on breast services. MATERIALS AND METHODS: All new breast cancer diagnoses were identified from the multidisciplinary team outcomes for the 12 months between October 2017 and October 2018. Presenting symptoms were identified from the General Practice referrals and consultant letters. Examination findings were checked with details on imaging requests. RESULTS: 436 new symptomatic cancer diagnoses were made in patients with a median age of 68 (range 25-97). 334 patients were referred by General Practice as two-week waits who formed the cohort selected for analysis (77%). New lumps accounted for 294 ipsilateral cancer diagnoses (88%), nipple symptoms for 28 (8%) and pain with normal examination for 12 (4%, all screening aged patients). All 12 cancers in the patients presenting with pain were correctly identified on mammography, including 4 cancers in the symptomatic breast and 8 Incidental cancers in the contralateral, non-symptomatic breast. CONCLUSION: Pain does not appear to be frequent symptom of breast cancer presentation. It was more common for patients to have incidental, contralateral asymptomatic cancer than it was for patients with pain alone to have underlying ipsilateral cancer. In such cases, new cancers were identified accurately on mammography. Patients presenting with pain as an isolated symptom, having been carefully assessed in Primary Care, may yield little benefit in repeat clinical examination by a Breast Specialist. Direct to test with mammography could be safe, effective and efficient alternative practice.

Dilutional local anaesthetic techniques in oncoplastic breast surgery and potential benefits during the COVID-19 pandemic and beyond.

INTRODUCTION: COVID-19 has changed the approach to operating on breast cancer for the benefit of patients, staff and the general population. One approach involves the switch from operating under general to local anaesthetic. We assess whether diluational local anaesthetic is as effective as the current standard approach. METHODS: Postoperative pain was recorded in prospective, consecutive patients undergoing wide local excision under dilutional local anaesthetic (concentration < 1mg/ml). Pain scores were documented at 0, 30 and 60 minutes and compared to a control group consisting of combined general with local anaesthetic. RESULTS: Pain significantly increased in the control group during the postoperative recovery. This was not seen in the dilutional local anaesthetic group that was non-inferior to the standard approach at 0, 30 and 60 minutes. CONCLUSION: Dilutional local anaesthetic provides a safe and effective alternative approach to operating on breast cancer patients whilst avoiding risky general anaesthetic in a COVID-19 pandemic environment.

Neo-Adjuvant chemotherapy and its affects to the axilla-Can we safely downgrade axillary surgery to mirror the approach in the breast.

The use of neo-adjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast-conserving surgery is well-established. In certain patients, the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice. Patients undergoing neo-adjuvant chemotherapy were identified over a seven-year period between 2010 and 2017. Surgical plans were compared with pre- and post-chemotherapy. Histological information at the time of diagnosis was compared to surgical excision specimens. 349 patients were included for analysis, and 264 had axillary status documented at diagnosis. The average patient age was 51 years, and Grade 3, ER-positive, and Her2-negative cancers made the biggest histological subgroups. Complete pathological response (CPR) was seen in the breast in 27% of cases. 19% of patients requiring mastectomy had their surgery downgraded. Following NACT, axillary CPR was seen in 42% of patients and residual axillary nodal burden was limited to four nodes in 73% of patients. Axillary conserving surgery may be a safe alternative surgical approach in the downstaged axilla following neo-adjuvant chemotherapy. Advances in perioperative identification of suspicious nodes may be needed to facilitate progress.

eAppendicitis: Diagnostic uncertainty in appendicitis and the role of ehealth - does IT help?

The availability of medical information on the World Wide Web has grown as information technology has become more accessible. Patients seeking online information may be able to selfselect conditions having been adequately informed. This study evaluates the effect of eHealth information on those presenting to hospital with a suspected appendicitis and its effect on their management and clinical outcome. Patients who had performed online reading were more likely to go to theatre but were less likely to have a confirmed histological diagnosis of appendicitis.

Cost awareness of disposable surgical equipment and strategies for improvement: cross sectional survey and literature review.

A significant healthcare funding gap has been predicted over the coming years. NHS England has made transparency and cost efficiency a key priority. Healthcare technology accounts for a large portion of healthcare expenditure. The aim of the study was to establish the cost awareness of theatre staff for disposable surgical equipment and to review the current evidence around improving cost awareness. A cross sectional survey was performed. A questionnaire was distributed to consultants, registrars, core surgical trainees and theatre scrub practitioners within an NHS foundation trust and analysed using Microsoft excel 2010. Following the results, which indicated poor cost awareness amongst theatre staff, a literature review was performed to identify strategies to improving cost awareness in healthcare. The results showed that only 22% of all participants (n = 48) were able to estimate cost correctly. There was no significant difference in cost accuracy between surgeons or scrub practitioners. Strategies for improvement in cost awareness were identified. A lack of cost awareness was identified amongst theatre healthcare professionals for common disposable surgical equipment. This is an area which must improve through the use of proven strategies such as national programs, education, visible pricing and price feedback, as highlighted in this paper.

Oxygen reduces tourniquet-associated pain: a double-blind, randomized, controlled trial for application in hand surgery.

BACKGROUND: Why do limb tourniquets cause pain? If ischemia is the mechanism, can supplemental oxygen reduce pain? The Reducing Tourniquet Associated Pain study investigated whether this simple treatment could extend tourniquet tolerance time to facilitate hand surgery under local or regional anesthesia. METHODS: The Reducing Tourniquet Associated Pain study was a double-blind, randomized, controlled trial of healthy volunteers. Participants received either 50% inhaled oxygen or air placebo via a face mask for 3 minutes before and up to 30 minutes after upper arm tourniquet inflation to 250 mmHg. Pain scores were recorded at 2-minute intervals using a validated 100-mm visual analogue scale. The primary outcomes were (1) difference in visual analogue scale score and (2) difference in time taken to reach visual analogue score of 40 mm or more in oxygen and air groups. RESULTS: Fifty participants enrolled and, after exclusion criteria were applied, 46 were analyzed (oxygen, n = 23; air, n = 23). Oxygen supplementation was associated with a 29 percent mean reduction in pain on visual analogue scoring compared with air placebo over the entire period of inhalation (p = 0.027). Oxygen also extended the time to visual analogue scale score of 40 mm or more by a mean of 6½ minutes compared with air placebo (p = 0.008). CONCLUSIONS: Oxygen is a readily available, low-risk, low-cost treatment that significantly reduced tourniquet-associated pain in this study and significantly increased the time taken to reach visual analogue scale score of 40 or more. The authors recommend oxygen to facilitate hand surgery under a tourniquet and when a regional block fails to control tourniquet pain.

Spontaneous surgical emphysema of the larynx following hyperextension of the neck.

Surgical emphysema of the larynx is rare in the absence of trauma and there are a paucity of case reports that describe such conditions. We present what we believe to be an unusual, atraumatic mechanism for mucosal breech of the larynx with subsequent surgical emphysema. Nasendoscopy revealed oedema of the arytenoid cartilage and computed tomography revealed moderate subcutaneous emphysema of the larynx. No fracture was seen. After conservative management the patient made a complete recovery.

Exploring the impact of expertise, clinical history, and visual search on electrocardiogram interpretation.

BACKGROUND: The primary aim of this study is to understand more about the perceptual-cognitive mechanisms underpinning the expert advantage in electrocardiogram (ECG) interpretation. While research has examined visual search processes in other aspects of medical decision making (e.g., radiology), this is the first study to apply the paradigm to ECG interpretation. The secondary aim is to explore the role that clinical history plays in influencing visual search behavior and diagnostic decision making. While clinical history may aid diagnostic decision making, it may also bias the visual search process. METHODS: Ten final-year medical students and 10 consultant emergency medics were presented with 16 ECG traces (8 with clinical history that was not manipulated independently of case) while wearing eye tracking equipment. The ECGs represented common abnormalities encountered in emergency departments and were among those taught to final-year medical students. Participants were asked to make a diagnosis on each presented trace and report their level of diagnostic confidence. RESULTS: Experts made significantly faster, more accurate, and more confident diagnoses, and this advantage was underpinned by differences in visual search behavior. Specifically, experts were significantly quicker at locating the leads of critical importance. Contrary to our hypothesis, clinical history had no significant effect on the readers' ability to detect the abnormality or make an accurate diagnosis. CONCLUSIONS: Accurate ECG interpretation appears dependent on the perceptual skill of pattern recognition and specifically the time to fixate the critical lead(s). Therefore, there is potential clinical utility in developing perceptual training programs to train novices to detect abnormalities more effectively.