A case series of successfully managing exomphalos major with awake graduated compression dressing and early enteral feeding.

INTRODUCTION: Exomphalos anomaly is defined as the herniation of abdominal viscera into the base of the umbilical cord, with only a membranous sac covering these contents. It has an incidence of approximately 1 in 4000-6000 births. Management of exomphalos major (EM) remains controversial and limited, with very few studies to guide decision-making. METHOD: This is a case series of four neonates with EM treated at a tertiary paediatric referral centre between 2018 and 2021 with a gradual compression dressing technique. RESULTS: Four neonates were diagnosed with EM. The average gestational age was 38 + 5 (range 38 + 2 - 39 + 2), and the average birth weight was 3.1 kg (range 2.56 - 3.49 kg). The defect size ranged between 5 and 7 cm. All patients were commenced on gradual compression dressing between days 1 and 3 of life. Dressings were applied at the bedside in the general neonatal ward. The average time taken to reach full feeds was 1 week; only one patient required parenteral nutrition. Three underwent surgical repair at two and 16 weeks of age; one had delayed repair at the age of 1 year because of the COVID-19 pandemic. None required patch repair. None required prolonged ventilation after repair. CONCLUSION: This case series describes a successful compression dressing technique that reduces sac content without the need for general anaesthetic or respiratory compromise, whereby simultaneous enteral feeding is tolerated.

Grit personality trait of doctors and medical students in level 4 acute hospital.

INTRODUCTION: GRIT, defined as passion and perseverance for long-term goals, is a personality trait that is key to academic success and career achievement. Doctors face significant challenges and exposure to stressful situations throughout their career and require high levels of grit and perseverance to achieve success and avoid burn-out. This study aimed to measure overall levels of grit among hospital doctors and medical students and to compare levels of Grit across specialties and career grades. METHOD: ology: A cross-sectional survey was used to measure GRIT levels using the validated Short Grit Scale (GRIT-S). Hospital doctors and medical students at University Hospital Galway were asked to complete the questionnaire. Gender, age, grade, education, and speciality were recorded. Analysis was conducted using STATA V12.1™ and SPSS 25™. RESULTS: 378 questionnaires were completed with a participation rate of 75.6% eligible for analysis. The female: male ratio was 1.2:1, with a mean age of 29.6 ± 8.3 years. The mean Grit score of participants was 3.56 ± 0.55. Grit trait was independent of gender and increased with age and grade. Consultants had significantly higher mean Grit score (3.86 ± 0.59, p = 0.004). There was no difference between medical specialities, nor between graduate-entry and undergraduate medical students. CONCLUSION: our results show that medical students and NCHDs alike have high levels of Grit compared to the general population, and the levels increase with career advancement, with the highest scores observed in consultants. This suggests that Grit might be of benefit as an adjunct in the selection process of applicants for training schemes and jobs that require high levels of resilience, as well as an adjunct to monitoring progress in training from a personality and mental health perspective.

Microwave Imaging in Breast Cancer - Results from the First-In-Human Clinical Investigation of the Wavelia System.

RATIONALE AND OBJECTIVES: Microwave Breast Imaging (MBI) is an emerging non-ionising technology with the potential to detect breast pathology. The investigational device considered in this article is a low-power electromagnetic wave MBI prototype that demonstrated the ability to detect dielectric contrast between tumour phantoms and synthetic fibroglandular tissue in preclinical studies. Herein, we evaluate the MBI system in the clinical setting. The capacity of the MBI system to detect and localise breast tumours in addition to benign breast pathology is assessed. Secondly, the safety profile and patient experience of this device is established. MATERIALS AND METHODS: Female patients were recruited from the symptomatic unit to 1 of 3 groups: Biopsy-proven breast cancers (Group-1), unaspirated cysts (Group-2) and biopsy-proven benign breast lesions (Group-3). Breast Density was determined by Volpara VDM (Volumetric Density Measurement) Software. MBI, radiological, pathological and histological findings were reviewed. Subjects were surveyed to assess patient experience. RESULTS: A total of 25 patients underwent MBI. 24 of these were included in final data analysis (11 Group-1, 8 Group-2 and 5 Group-3). The MBI system detected and localised 12 of 13 benign breast lesions, and 9 out of the 11 breast cancers. This included 1 case of a radiographically occult invasive lobular cancer. No device related adverse events were recorded. 92% (n = 23) of women reported that they would recommend MBI imaging to other women. CONCLUSION: The MBI system detected and localized the majority of breast lesions. This modality may have the potential to offer a non-invasive, non-ionizing and painless adjunct to breast cancer diagnosis. Further larger studies are required to validate the findings of this study.

Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

BACKGROUND: In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period. METHODS: All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison. RESULTS: There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) - a 0% negative appendicectomy rate (NAR). DISCUSSION: The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

Clinicopathological correlates, oncological impact, and validation of Oncotype DX™ in a European Tertiary Referral Centre.

Oncotype DX™ (ODX) score estimates prognosis and predicts breast cancer recurrence. It also individualizes patient adjuvant chemotherapy prescription in breast cancer. This assay relies on genetic and molecular markers; the clinicopathological phenotype of which are tested routinely. The aim of this study was determine whether clinicopathological and immunohistochemical information predicts ODX recurrence score (RS). Secondly, to assess the impact on adjuvant chemotherapy (AC) and oncological outcome of ODX testing in patients in a European tertiary referral center. Estrogen receptor positive (ER+), human epidermal growth factor receptor-2 negative (HER2-), lymph node negative (LN-), and female breast cancer patients with ODX testing performed between 2007 and 2015 were categorized into low- (<11), intermediate- (11-25), and high-risk (>25) groups. Clinicopathological and immunohistochemical correlates of RS were determined. Predictors of RS were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan-Meier and Cox regression analyses. ODX was performed in 400 consecutive ER+LN- patients. Median follow-up was 74.1 months (3.0-144.4). Low grade (odds ratio [OR]:2.39; 95% confidence interval [CI]:1.04-5.51, p = 0.041) independently predicted low ODX, while high grade (OR:2.04; 95% CI: 1.19-3.49, p = 0.009) and reduced progesterone receptor (PgR) expression (OR: 2.57, 95% CI: 1.42-4.65, p = 0.002) independently predicted high ODX. Omission of AC in intermediate- (p = 0.159) and high-risk (p = 0.702) groups did not negatively impact survival. In conclusion, tumor grade independently predicts low and high RS, while PgR negativity predicts high RS. ODX reduced AC prescription without compromising oncological outcome.

Neoadjuvant chemotherapy for luminal a breast cancer: Factors predictive of histopathologic response and oncologic outcome.

BACKGROUND: The benefit of chemotherapy (NAC) for patients with ER/PR positive, HER2 negative breast cancer is unclear. Our aim was to determine factors associated with histopathologic response and oncologic outcome following NAC in this group. METHODS: Consecutive female patients undergoing neoadjuvant therapy and surgery for locally advanced Luminal A breast cancer between 2010 and 2015 were studied. Multivariable linear, logistic, and Cox regression analysis was undertaken. RESULTS: 114 patients were studied. Pathological complete response (pCR) was achieved in 7.9% of patients, ypN0 in 25.5%, and downstaging in 33.6%. However, 43.9% exhibited a Sataloff C-D response. Tumor grade independently predicted pCR (P = 0.039), while PR score predicted ypN0 (P = 0.017) and downstaging (P=0.029). 5-year invasive disease-free (iDFS) and overall survival (OS) were 68.5 ± 4.7% and 77.7 ± 4.3%, respectively. CONCLUSION: After NAC for Luminal A breast cancer, pCR rates are low. Patients with high grade tumors with weak PR expression exhibit the most promising response rates.

Defining clinicopathological and radiological features of breast cancer in women under the age of 35: an epidemiological study.

INTRODUCTION: Breast cancer is the most commonly diagnosed female cancer. Diagnosis in younger women (under 35 years) is different to their older counterparts, and mammography is not considered as sensitive in this cohort. Consequentially, younger patients may present later with more advanced disease. METHODS: This is a retrospective analysis of a prospectively updated database containing consecutive patients who presented to the symptomatic breast unit of Galway University Hospital between 2009 and 2015. Patient clinicopathologic factors, clinical examination features, diagnostic radiological modalities and Bi-RADS score were all assessed. Data was analysed using Statistical Package for the Social Sciences version 25. RESULTS: One thousand eight hundred thirty-six patients were diagnosed with breast cancer, and of these, 51 (2.8%) patients were < 35 years. Invasive ductal carcinoma made up 90% of diagnosis, and 42% had an associated ductal carcinoma in situ. Fifty-four percent were high-grade tumours and 52% presented with stage III disease or greater. The main radiological tool used was ultrasound, which had a sensitivity of 87.50% (95% confidence interval [CI] 74.75 to 95.27%). Mammogram sensitivity was 86.84% (95% CI 71.91 to 95.59%). Magnetic resonance imaging was used in 29% of cases, with a sensitivity of 100.00% (95% CI 78.20 to 100.00%). CONCLUSION: Females under 35 tend to be diagnosed with aggressive, advanced stage tumours. Ultrasound remains the radiological test of choice, although diagnosis using mammography demonstrated a relatively high sensitivity compared with previous reports. This study emphasises the varying epidemiology of breast cancer in younger patients and the potential role of mammography in making radiological diagnosis in those who are symptomatic.

Breast Cancer Detection-A Synopsis of Conventional Modalities and the Potential Role of Microwave Imaging.

Global statistics have demonstrated that breast cancer is the most frequently diagnosed invasive cancer and the leading cause of cancer death among female patients. Survival following a diagnosis of breast cancer is grossly determined by the stage of the disease at the time of initial diagnosis, highlighting the importance of early detection. Improving early diagnosis will require a multi-faceted approach to optimizing the use of currently available imaging modalities and investigating new methods of detection. The application of microwave technologies in medical diagnostics is an emerging field of research, with breast cancer detection seeing the most significant progress in the last twenty years. In this review, the application of current conventional imaging modalities is discussed, and recurrent shortcomings highlighted. Microwave imaging is rapid and inexpensive. If the preliminary results of its diagnostic capacity are substantiated, microwave technology may offer a non-ionizing, non-invasive, and painless adjunct or stand-alone modality that could possibly be implemented in routine diagnostic breast care.

Spinal cord herniation after resection of cervical spinal neurofibroma with a unique presentation.

BACKGROUND CONTEXT: Spinal cord herniation (SCH) is a very rare condition. It was first reported in the lumbar spine in 1974. Thereafter, cases were reported in the thoracic and cervical spine occurring either spontaneously or after vertebral fracture, nerve root avulsion, and trauma surgery. PURPOSE: There is only one recorded case of SCH after tumor surgery. In this article, we reported the second case. STUDY DESIGN: We described the original surgical procedure, the clinical presentation, the operative repair, and the postoperative course. METHODS: No funding was required for this case report. RESULTS: The patient was a 56-years-old man, who presented with SCH 5 years after subtotal excision of a cervical neurofibroma. He presented with right upper monoparesis. CONCLUSIONS: To our knowledge, this presentation has not been reported previously in literature.

What about doctors? The impact of medical errors.

Medical error is a distressing event to the patient and the health care providers. The impact of such events has been well studied on patients but poorly on health professionals. These events are still considered as a taboo in the medical culture and hence missed as great learning opportunities. They have negative impact on doctors' emotional wellbeing, general quality of life, and their professional practice and conduct. Medical errors and adverse events also affect the quality and cost of the health service. Health service administrations should provide healthcare professionals involved in such events with professional support and counselling services, and should consider and treat them as second victims.

Somatoform abdominal pain in surgery: is SD worthy of surgical attention? Case reports and literature review.

Somatoform disorders (SD) or medically unexplained physical symptoms (MUPS) are a group of disorders that represent a group of symptoms that cannot be explained by an organic or physical pathology. These disorders are widely prevalent, and, if unrecognised, SD may lead medical professionals to embark on tests or procedures which may inflict unnecessary iatrogenic complications. Despite the high prevalence, they are only poorly included in medical training curricula, at both undergraduate and postgraduate levels. In this article, we review the literature and present two cases. The first one presented with a recurrent acute abdomen had an unnecessary CT abdomen. The second case had laparoscopy for acute right-sided abdominal pain which turned out to be normal, and was readmitted again after a short period with acute urine retention which resolved spontaneously following discussion with the patient and family. Both cases were referred for psychiatric assessment and their family doctors were informed.