Renal failure parathyroidectomy - Is pre-operative imaging worthwhile?

BACKGROUND: Tertiary hyperparathyroidism is a significant issue in renal failure patients and some require surgery to control their serum calcium. A number of imaging techniques are used to localise the position of the parathyroid glands prior to surgery. Currently, a combination of ultrasound and isotope preoperative localisation imaging is accepted as useful in parathyroid surgery for primary disease. However, the use of pre-operative imaging in parathyroid surgery in renal failure patients is uncertain. The role of pre-operative imaging of the parathyroid glands in patients with renal failure hyperparathyroidism was assessed with imaging outcomes compared to operative and pathological findings in two cohorts of patients undergoing parathyroid surgery - primary and tertiary. METHODS: All data were collected prospectively over a 10-year period (2003-2013) from the practice of a single surgeon. Patients were grouped into either primary hyperparathyroidism (49 patients) or tertiary hyperparathyroidism (41 patients). The majority, 63 of 90 (70%) patients, underwent both ultrasound (US) and isotope (MIBI) pre-operative imaging. Pre-operative imaging was correlated with operative and pathological findings. FINDINGS: Comparison of the results of the two groups using ordinal regression analysis confirmed these imaging techniques are significantly more accurate in primary than tertiary parathyroid surgery (p = 0.022). CONCLUSIONS: While accepted practice of pre-operative combined USS and MIBI imaging is essential in unilateral imaged-focused neck exploration for primary disease, these imaging techniques have a more limited use pre-operatively in renal failure parathyroidectomy.

Assistantship improves medical students' perception of their preparedness for starting work.

BACKGROUND: The GMC has recommended introducing student assistantships during which final year students, under supervision, undertake most of the responsibilities of a FY1 doctor. The Medical School at Queen's University Belfast in 2011/12 introduced an assistantship programme. We have evaluated the impact of the assistantship on students' perception of their preparedness for starting work. METHODS: Students were asked to complete a questionnaire at the beginning of the assistantship. It assessed the students' perception of their preparedness in five areas: clinical and practical skills, communications skills, teaching and learning, understanding the work environment and team working. After the assistantship they again completed the questionnaire. Comparison of the results allowed an assessment of the impact of the assistantship. RESULTS: There was a statistically significant improvement in the students' perception of their preparation for 49 of 56 tasks contained within the questionnaire. After the assistantship 81.2% of students felt well prepared for starting work compared with 38.9% before the assistantship. 93.9% agreed that the assistantship had improved their preparedness for starting work. CONCLUSIONS: The assistantship at Queen's University improves medical students' perception of their preparedness for starting work. The majority of medical students feel well prepared for starting work after completing the assistantship.

Surgeon and haematologist: a review of comprehensive care for patients with inherited bleeding disorders in Northern Ireland.

BACKGROUND: Management of patients with inherited bleeding disorders has improved since the introduction of Comprehensive Care Centres (CCC) in the United Kingdom (UK). In the event such patients need surgery, the aim of the multidisciplinary team is to facilitate outcomes as good as what would be expected in a non-bleeding disorder patient. A review of such comprehensive care was carried out in patients with inherited bleeding disorders when they needed surgery at Northern Ireland CCC. Aims of the study were to evaluate surgical morbidity and mortality in these patients. METHODS: All patients with inherited bleeding disorders who underwent non-orthopaedic surgery between 2008 and 2012 were identified from the CCC records within the Belfast Health and Social Care Trust (BHSCT) in Northern Ireland (NI) and their case records reviewed. RESULTS: 28 patients received elective and emergency surgery during this period. There was minimum morbidity and no mortality in this cohort. CONCLUSIONS: Surgery in patients with inherited bleeding disorders has become safe with the advent of multidisciplinary CCCs. Close communication between surgeon and haematologist is key in the successful management of these complex patients.

Doxycycline inhibition of abdominal aortic aneurysm growth: a systematic review of the literature.

Abdominal aortic aneurysm (AAA) is a common disease and a major cause of death through rupture, the risk of which increases with aneurysm size. There is approximately a 5 year interval from when aneurysmal dilatation develops until it reaches a size where surgery is indicated. Slowing, or arresting, aneurysm growth during this period would be beneficial. Aneurysmal aortic wall degeneration is a multifactorial, chronic inflammatory process resulting via activation of matrix metalloproteinases (MMPs), in destruction of mural connective tissue. Doxycycline, a tetracycline antibiotic, is a known inhibitor of MMPs. Animal studies of doxcycline for AAA provide significant evidence of a beneficial effect. However, the human studies, comprising 6 controlled trials and 2 cohort studies, provide conflicting evidence. They are generally of poor methodological quality with small numbers (just 255 subjects analyzed), lack of adjustment for confounding variables, short term doxycycline exposure and a lack of long term follow up. Standardization of dose (per unit weight) and confirmation of compliance remain other systemic failings. The safety of long-term doxycycline use is yet to be proved. The evidence for any beneficial effect of doxycycline as a treatment for AAA, therefore, remains weak. Further studies are required and will ideally be multicentre, involve large subject numbers and be of high quality randomization and blinding with longer periods of doxycycline exposure, confirmation of compliance, standardization of confounding variables and prolonged follow up.

Primary osteosarcoma of breast.

Primary osteosarcoma of breast is rare. The authors present a case of a 51-year-old female who was admitted with a large necrotising tumour involving the right breast. CT scan confirmed chest wall invasion along with a solitary lung metastasis. She underwent a primary mastectomy with chest wall reconstruction. Unfortunately 3 months later she developed local recurrence.

Familial multiple lipomatosis with clear autosomal dominant inheritance and onset in early adolescence.

Familial multiple lipomatosis is rare. Several modes of inheritance have been proposed but no conclusive evidence shown, although some families have suggested autosomal dominant inheritance. The authors describe a family with multiple lipomatosis showing clear autosomal dominant inheritance, and no mutations within the NF1, SPRED1 or Cowden disease (PTEN) genes. Familial autosomal dominant lipomatosis is a rare but distinct entity.

Open carpal tunnel release--still a safe and effective operation.

BACKGROUND: Carpal tunnel syndrome is a common cause of neurological symptomatology. Surgical decompression remains the treatment of choice in patients not responding to conservative therapies. The aim of this study was to assess the effectiveness of standard open decompression by analysis of symptomatic and functional improvement and to assess whether a general surgeon can still perform this operation safely. PATIENTS AND METHODS: Patients undergoing standard open carpal tunnel release by a single general surgeon were recruited. A self-administered Boston questionnaire was used to assess symptom severity and functional status pre- and post-surgical intervention. RESULTS: Forty-seven patients (51 hands) underwent carpal tunnel release and 32 patients completed the questionnaire. 88% had a significant reduction in the symptom severity score, while improvement in function status score was achieved in 79% of patients. Mean symptom severity score improved from 3.41 points preoperatively to 1.85 (p < 0.0001) points at the last follow up examination, while the mean function status score improved from 2.73 to 1.99 points (p < 0.0001). Outcome was poor in six patients with slight worsening of either symptom or function status score. Three patients were treated conservatively for minor wound infection without long-term sequelae. DISCUSSION: Standard open carpal tunnel release still provides efficacious symptomatic relief with a low risk of associated complications when performed by a general surgeon.

Carpal tunnel syndrome.

Carpal tunnel syndrome is one of the most common peripheral neuropathies. It affects mainly middle aged women. In the majority of patients the exact cause and pathogenesis of CTS is unclear. Although several occupations have been linked to increased incidence and prevalence of CTS the evidence is not clear. Occupational CTS is uncommon and it is essential to exclude all other causes particularly the intrinsic factors such as obesity before attributing it to occupation. The risk of CTS is high in occupations involving exposure to high pressure, high force, repetitive work, and vibrating tools. The classic symptoms of CTS include nocturnal pain associated with tingling and numbness in the distribution of median nerve in the hand. There are several physical examination tests that will help in the diagnosis of CTS but none of these tests are diagnostic on their own. The gold standard test is nerve conduction studies. However, they are also associated with false positive and false negative results. The diagnosis of CTS should be based on history, physical examination and results of electrophysiological studies. The patient with mild symptoms of CTS can be managed with conservative treatment, particularly local injection of steroids. However, in moderate to severe cases, surgery is the only treatment that provides cure. The basic principle of surgery is to increase the volume of the carpal tunnel by dividing transverse carpal ligament to release the pressure on the median nerve. Apart from early recovery and return to work there is no significant difference in terms of early and late complications and long-term pain relief between endoscopic and open carpal tunnel surgery.

Chronic pain after hernia surgery--an informed consent issue.

Chronic severe pain following inguinal hernia repair is a significant post-operative problem. Its exact cause and lack of evidence-based treatment path present problems in the effective management of this surgical complication. We retrospectively reviewed the records of patients diagnosed with chronic pain following open inguinal hernia repair between November 1995 and November 2000, who were under the care of the senior author. Over the five-year period, 146 patients underwent inguinal hernia repair. 88 (60%) had suture repair (darn & modified Bassini's) and 58 (40%) underwent a Lichtenstein mesh repair. Thirteen patients (9%), (3 in suture vs. 10 in mesh group, p = 0.004) developed chronic severe pain. Examination revealed maximal tenderness over the genitofemoral nerve (GF) distribution (n = 5), over the medial end of the scar (n = 3), over the pubic tubercle (n = 1) and in the ilioinguinal nerve distribution (n = 1) No abnormality was detected on clinical examination in the cases of three patients. Treatment involved GF nerve block (n = 5), local injection of Chirocaine and Methylprednisolone acetate into the medial end of the scar (n = 3), Chirocaine and Methylprednisolone acetate into the pubic tubercle (n = 1), ilioinguinal nerve block (n = 1), re-exploration with re-suturing of the mesh (n = 1), and Amitriptyline (n = 2). At a median follow up of 45 months (range: 24-87), 10 (77%) are completely pain free; two (15.4%) had mild pain and one patient still has significant persistent pain. To conclude, chronic severe pain occurred in nine percent of patients following primary open inguinal hernia repair. The majority of patients were successfully treated by therapeutic injection into the point of maximal tenderness.