The application of human reliability analysis to carpal tunnel decompression.

INTRODUCTION: Many surgical procedures are prone to human error, particularly in the learning phase of skills acquisition. Task standardisation has been suggested as an approach to reducing errors, but it fails to account for the human factors associated with learning. Human reliability analysis (HRA) is a structured approach to assess human error during surgery. This study used HRA methodologies to examine skills acquisition associated with carpal tunnel decompression. METHODS: The individual steps or subtasks required to complete a carpal tunnel decompression were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was carried out by consensus of subject matter experts. This identified the potential human errors at each subgoal, the level of risk associated with each task and how these potential errors could be prevented. RESULTS: Carpal tunnel decompression was broken down into 46 subtasks, of which 21 (45%) were medium risk and 25 (55%) were low risk. Of the 46 subtasks, 4 (9%) were assigned high probability and 18 (39%) were assigned medium probability. High probability errors (>1/50 cases) included selecting incorrect tourniquet size, failure to infiltrate local anaesthetic in a proximal-to-distal direction and completion of the World Health Organization (WHO) surgical sign-out. Three (6%) of the subtasks were assigned high criticality, which included failure to aspirate before anaesthetic injection, whereas 21 (45%) were assigned medium criticality. Remedial strategies for each potential error were devised. CONCLUSIONS: The use of HRA techniques provides surgeons with a platform to identify critical steps that are prone to error. This approach may improve surgical training and enhance patient safety.

Head and Neck Merkel Cell Carcinoma: A 12-Year Single Institutional Experience.

Background: Merkel cell carcinoma (MCC) is an aggressive malignancy of presumed neuroendocrine origin. Most case series of MCC are limited by low case numbers and are not specific to head and neck tumours. The purpose of this study was to provide a focused review of head and neck MCC diagnosis and management in a single Irish institution. Methods: Patient's demographics, tumour characteristics, pathological diagnosis, surgical treatment, adjuvant treatment, subsequent management and clinical course were collected. Estimates of progression-free MCC survival rates were calculated by the Kaplan-Meier statistical model. A Pearson product-moment correlation coefficient examined the association between surgical margins and disease-free follow-up. Results: In total, 11 patients were treated for head and neck MCC with a mean age of 79.6 years (range = 69-91 years). The mean average follow-up duration of patients was 18.3 months. Of the cohort, 18% (n=2) had a sentinel node biopsy (SLNB). A selective neck dissection was subsequently performed in 18% (n=2). In total, 72% (n=8) of patients received adjuvant radiotherapy. Median disease-specific survival was 15 months for the SLNB group and 17 months for the non-SLNB group, not statistically significant (p=0.23). There was no significant association between surgical margins and disease-free follow (p=0.65). Conclusions: Our case series adds to a limited body of evidence of head and neck MCC. Surgery remains the treatment priority in localized disease, with an increasing role of SLNB for accurate prognostication and staging. Early management of stage I disease results in moderate long-term disease-free survivability.

Acellular dermal substitute use in the reconstruction of axillary hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic recurrent debilitating condition that affects the skin near to the follicular glands. The disease manifests with the formation of abscesses that can be complicated by rupture, sinus tracts, and scarring leading to pain, chronic discharge, malodor, and scar contractures. The management of HS is multidisciplinary, involving general lifestyle modification, medical treatment, and surgery. A wide range of surgical interventions has been described for HS disease control and management. However, surgical management strategies are highly variable. We describe the case of a 33-year-old female with refractory HS which was reconstructed with Matriderm® and an immediate split-thickness skin graft. Acellular dermal skin substitutes may be an alternative to conventional means of HS reconstruction, producing subtle, pliable, and durable skin.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention.

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.1 This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.

Analysis of sentinel node positivity in primary cutaneous melanoma: an 8-year single institution experience.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a standard method for determining the pathologic status of the regional lymph nodes. AIMS: The aim of our study was to determine the incidence and clinicopathologic factors predictive of SLN positivity, and to evaluate the prognostic importance of SLNB in patients with cutaneous melanoma. METHODS: We performed a retrospective analysis of a prospectively maintained database of all patients who underwent SLNB for primary melanoma at our institution from 2005 to 2012. Statistical analysis was performed using χ 2 and Fischer exact test. RESULTS: In total, 318 patients underwent SLNB, of which 65 were for thin melanoma (≤1 mm). There were 36 positive SLNB, 278 negative SLNB and in four cases the SLN was not located. The incidence rate for SLNB was 11.3% overall and 1.5% in thin melanomas alone. Statistical analysis identified Breslow thickness >1 mm (P = 0.006), Clark level ≥ IV (P = 0.004) and age <75 years (P = 0.035) as the strongest predictors of SLN positivity. Our overall false negativity rate was 20% (9/45) with one case of false-negative SLNB in thin melanomas. CONCLUSION: Breslow thickness of the primary tumour remains the strongest predictor of SLN positivity. Our findings point to a possible limited role for SLNB in thin melanoma due to its low positivity rate, associated false-negative rate and related morbidity.

Trends in breast reconstruction practices in a specialized breast tertiary referral centre.

BACKGROUND: Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population. METHODS: Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy. RESULTS: Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy. CONCLUSION: Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

The Irish contribution to the plastic surgery literature: 21 years of publications.

INTRODUCTION: The Republic of Ireland has always had an influence on medicine and has produced many renowned doctors who have helped shape its history. Furthermore, many clinical articles that have originated from Ireland have changed clinical practice throughout the world. The Irish have also had an impact on the plastic surgery literature yet it has never specifically been analyzed before. The purpose of this study was to identify and analyze all papers that have originated from the plastic surgery units in the Republic of Ireland in the medical literature over the past 21 years. METHODOLOGY: Twenty-four well-known plastic surgery, hand surgery and burns journals were selected for this study. By utilizing Scopus, the largest abstract and citation database of peer-reviewed literature, we analyzed each of our chosen 24 journals looking for Irish publications. Each paper was examined for article type, authorship, year of publication, institution of origin and level of evidence. RESULTS: Papers from the Republic of Ireland were published in 20 of the 24 journals over the past 21 years. A total of 245 articles from Ireland were published in the plastic surgery, hand surgery and burns literature over the 21-year period. Of these, 111 were original articles and 73 were case reports. The institution that published the most papers over the past 21 years was University Hospital Galway (66 publications) followed by Cork University Hospital with 54 papers. The journal with the most Irish articles was the Journal of Plastic, Reconstructive and Aesthetic Surgery with 56 papers. 2014 was the year with the most publications (28 papers). Authorship numbers also increased over time as the average number of authors in 1994 was 3.5, whereas it was 5.54 in 2014. DISCUSSION: The number of publications per year continues to increase along with authorship numbers. This mirrors the trend in other specialties. Publications are now no longer required for selection on to a higher surgical training scheme. There is now a fear that the academic output of trainees will decrease as a consequence. To prevent this, each unit must actively support and encourage research activity with their trainees.

A review of sentinel lymph node biopsy for thin melanoma.

INTRODUCTION: Although there is a lack of established survival benefit of sentinel lymph node biopsy (SLNB), this technique has been increasingly applied in the staging of patients with thin (≤1.00 mm) melanoma (T1Nx), without clear supportive evidence. METHODS: We review the guidelines and available literature on the indications and rationale for performing SLNB in thin melanoma. RESULTS: As a consequence of the paucity of evidence of SLNB in thin melanoma, there is considerable variability in the guidelines. It is difficult to define clinicopathologic factors that reliably predict the presence of nodal metastasis. SLNB does not yet inform management in thin melanoma to improve survival outcome. CONCLUSION: Based on available evidence, high risk patients with melanomas between 0.75 and 1.00 mm may be appropriate candidates to be considered for SLN biopsy after discussing the likelihood of finding evidence of nodal progression, the risks of sentinel node biopsy, and the lack of proven survival benefit from any form of surgical nodal staging.

Do gastrointestinal taste receptors contribute to associative learning and foraging behavior?

Foraging behavior is an expression of learning, context, and experience arising from integration of sensory information obtained during feeding with postingestive consequences of food ingestion. Although it has been well established that gustatory and olfactory systems of the mouth and nose provide sensory information to the consumer (in the form of flavor), sweet and bitter taste receptors have recently been identified in the intestinal tract of humans and rodents. It remains possible that sensory information generated in the gut could contribute to the learning process. Thus, a series of experiments was conducted to determine if classical associative learning occurs when the conditional stimulus circumvents oronasal presentation via direct delivery to the gut or peritoneal cavity. Mice receiving an intragastric infusion of 5 mM sodium saccharin immediately followed by LiCl administration demonstrated a significant decrease in preference for 5 mM saccharin in 4 consecutive 23 h, 2-bottle preference tests versus water (P = 0.0053). Saccharin was highly preferred in mice receiving intragastric (IG) saccharin only or interperitoneal (i.p.) injection of LiCl only. This reduced preference indicated that mice "tasted" saccharin infused into the gut. However, efforts to replicate with a reduced infusion volume failed to result in decreased preference. To understand if there were alternative pathways for oral detection of infused saccharin, mice received intragastric infusions (5.4 mM) and i.p. injections (10.8 mM) of sodium fluorescein. Fluorescence was observed from the tongues and esophagi of mice infused with volumes of 0.5 mL or more or injected with volumes of 0.25 mL or greater. Interperitoneal injections of 5 mM saccharin in mice resulted in reduced preference for 5 mM saccharin presented orally in 2-bottle preference tests (P = 0.0287). Oral delivery of a 500-fold less concentration of saccharin (0.01 mM) during conditioning resulted in a similar preference expression as shown in the initial IG experiment. These results demonstrate that although compounds may be tasted in the mouth absent of oral contact, associative learning is attenuated. Therefore, intestinal taste receptors are unlikely to participate directly in learning and recognition of foods during foraging events.

Microsurgical replantation of an ear with no venous repair.

Replantation of an avulsed ear was completely successful with only arterial repair (to the superficial temporal artery) and the use of medicinal leeches.

Pancreatic islet transplantation using vascularised chambers containing nerve growth factor ameliorates hyperglycaemia in diabetic mice.

Intraportal islet transplantation has shown initial promise for the treatment of type 1 diabetes. However, the portal vein site is associated with complications such as thrombosis and hepatic steatosis, leading to transplant failure. The aims of this study were to (1) test the feasibility of an alternative islet transplantation method that utilises a FDA-approved gelatin sponge as a novel islet carrier and (2) assess if exogenous addition of nerve growth factor (NGF) has any additional beneficial effects on graft performance in diabetic mice. Mice were rendered diabetic by a single intraperitoneal injection of streptozotocin. Five hundred syngeneic islets were seeded onto a Gelitaspon((R)) disc in the presence or absence of NGF, and placed into a silicone chamber surrounding the femoral neurovascular pedicle. Islet function was assessed by weekly monitoring of blood glucose levels and an intraperitoneal glucose tolerance test performed at the end of the study. Chambers were harvested for further histological analysis. Four of five mice transplanted with islets seeded onto Gelitaspon with NGF showed a significant reduction in blood glucose levels by 4 weeks after transplantation, and demonstrated a response similar to non-diabetic mice when tested with an intraperitoneal glucose tolerance test. Chamber tissue from this group contained islets with insulin-producing beta cells adjacent to the vascular pedicle. Islets seeded onto Gelitaspon with NGF and sited on femoral vessels using a tissue-engineering chamber offer an alternative method for islet transplantation in diabetic mice. This may have potential as a method for clinical islet transplantation.

An assessment of skin preparation in upper limb surgery.

Postoperative wound infections remain a major source of upper limb morbidity. The effectiveness of peri-operative human upper limb preparation was determined using a clear fluid antiseptic and an iodine-based solution over 60 and 90 seconds. Less area was missed using iodine over both times and increasing clear solution preparation time from 60 to 90 seconds improved coverage. Surgical experience had little outcome relevance and a 90-second preparation time with either solution was insufficient, with fingers being the sites most commonly missed.

An anatomical study of the gracilis muscle and its application in groin wounds.

The management of groin wounds is a common and challenging problem encountered in surgical practice. The purpose of this study is to examine the anatomic basis of the gracilis muscle with relation to this problem. Twelve cadaveric lower limbs were studied to examine both the extramuscular and intramuscular vasculature of the gracilis muscle. These underwent dissection and in 3 cases radiologic examination. The mean entry point of the dominant arterial pedicle was 9.4 cm, with mean length and width of the muscle recorded as 38.4 cm and 6.2 cm, respectively. Each gracilis muscle was then mobilized between the adductor longus and adductor magnus muscles on its dominant pedicle and transposed into the femoral triangle. In each case, the gracilis muscle mobilized easily on its dominant pedicle to adequately cover the groin. The gracilis muscle is a reliable muscle flap with a consistent blood supply, which can be transposed easily into the groin, based on its dominant pedicle, and offers adequate coverage of the femoral vessels.

Parsonage-Turner syndrome-case report and literature review.

Parsonage-Turner syndrome is the term used to describe a neuritis involving the brachial plexus. It may present with symptoms of an isolated peripheral nerve lesion, although the pathology is thought to lie more proximally. A case describing an isolated anterior interosseus nerve palsy due to an acute brachial neuritis is presented where the electromyographic findings confirmed the diagnosis, but also demonstrated the coexistence of a dual pathology in the form of a cervical radiculopathy. The literature is reviewed regarding etiology, treatment, and prognosis.

Patient and hospital delays in acute ischaemic stroke in a Dublin teaching hospital.

A limiting factor for thrombolysis in ischaemic stroke is delayed presentation to hospital. Prolonged A&E stay and delayed rehabilitation affects care. We evaluated the delay in presentation, A&E stay and rehabilitation delivery in 117 consecutive stroke patients. The mean presentation delay was 16.0 +/- 23.7 hours. A prior history of TIA or stroke, a reduced Glascow Coma Scale and larger strokes were associated with shorter delays to presentation. Longer delays occurred in patients living alone. The mean time spent in A&E was 11 hours, those with larger strokes spent shorter time. There were significant delays in referral to, and assessment by certain rehabilitation disciplines. Delayed presentation in stroke is a barrier to thrombolysis. Increasing public awareness may reduce this delay. In addition, prolonged A&E stay and delayed rehabilitation may adversely affect management, outcome and duration of hospital stay. Further study is required to investigate the reasons and possible solutions for such deficiencies.