ABSTRACT
INTRODUCTION: This case report is the first in the Australian literature of a patient, without prior diagnosis, presenting with a bowel obstruction secondary to lobular breast cancer. This highlights a relatively rare cause of bowel obstruction, but also the importance of breast self-examination as a compliment to the current BreastScreen Australia program. PRESENTATION OF CASE: A 67-year-old female presented to the Emergency Department with a 48-h history of sharp, constant epigastric pain, vomiting and constipation. The patient proceeded to emergency laparotomy for presumed large bowel obstruction, which revealed a stricture in the distal terminal ileum causing a distal small bowel obstruction. A right hemicolectomy was performed. Histopathology revealed the terminal ileum stricture to be metastatic lobular breast carcinoma. Clinical examination of the patient's right breast revealed a lesion suggestive of the primary malignancy despite a normal ultrasound and mammogram in 2014. After failing to progress, a CT scan was performed which revealed progressive small and large bowel distension. A repeat laparotomy was performed revealing dilated large bowel without obstructing pathology and an intact anastomosis. A loop ileostomy was performed. Following a further febrile episode, the patient decided to withdraw care and the patient passed away three weeks into her admission from suspected intra-abdominal sepsis. DISCUSSION: Breast cancer is becoming the third most common cancer amongst Australian women with a significant burden of disease and mortality. CONCLUSION: Despite the rare presentation, this case reminds the medical community and general population of the importance of breast self-examination and the BreastScreen Australia program.
ABSTRACT
BACKGROUND: Giant cell arteritis (GCA) has the potential to cause irreversible blindness and stroke in affected patients [1-4]. Temporal artery biopsy (TAB) remains the gold standard test for GCA [6-8]. Recent literature suggests that TAB does not change management of patients with suspected GCA and that ultrasound scan (USS) may be sufficient enough alone to confirm the diagnosis [9-11,13]. The aim of this study is to therefore determine the impact of TAB on current surgical practice and emergency theatre services. MATERIALS AND METHODS: A retrospective clinical study was performed of patients who had undergone TAB at the Caboolture Hospital from January 2010 to September 2015. Demographic and clinical data was collected from patient's medical records in regards to GCA. RESULTS: A total of 55 TAB were performed on 50 patients. Only two TAB were positive for GCA. Thirty-eight (76%) patients had a pre-TAB ACR criteria score of ≥3. Pre-operative corticosteroids were administered in forty-five (90%) patients, on average 4 ± 10 days pre-TAB. Mean time to TAB was 1.6 ± 1.6 days following their booking. Ninety-one percent of TAB were performed by surgical registrars. All TAB were performed using local anaesthesia alone. CONCLUSIONS: TAB is an expensive procedure with a low positive yield. Recent evidence suggests promising results with USS in diagnosing GCA. With the exceedingly low positive TAB results found in this study, patients with suspected GCA should be investigated in accordance with the above algorithm. The routine use of USS will reduce the number of negative TAB performed.
ABSTRACT
BACKGROUND: The non-operative time during the process of patient change-over between operating theatre cases is a significant source of delay and overall theatre inefficiency. The aim of this study was to integrate and trial a working strategy to improve this change-over time. METHOD: This was a single-blinded, randomised controlled intervention study comparing a surgeon-led, team-based model of strategies versus routine patient change-over. This model was trialled by a single surgeon, and the primary outcome was the difference in change-over times compared with 4 other surgeons who were blinded and served as controls. Secondary outcome measures included overall differences in complications between the groups, and the number and differences in operative case cancellations due to inadequate theatre time. RESULTS: 1265 patients were randomised into 5 general surgical lists, and included all major and minor cases. Median number of operative cases were 214 per surgeon, with an overall median change over time of 17.9 ± 3.7 min. Surgeon A in the intervention group had a median change-over time of 12.1 ± 5.4 min (p < 0.001), with a median difference of 8.5 min ± 21.4 min (p < 0.0001), translating to a 58% reduction in median change-over time between the intervention and control groups. There were no differences in complication rates amongst the groups. The intervention group had no cancellations due to lack of time, compared with 37 cancellations in the control group. CONCLUSION: This study demonstrates a statistically significant improvement in median change-over times using this model. This re-design can be implemented without incurring extra costs, staff, or operating theatres.
