RESUMO
Introduction Animal or human hand bites are a common presentation to the emergency department. If hand bites are not treated adequately, they can give rise to significant local and systemic complications, potentially leading to functional deficits that impact patients' lives. Traditionally, hand bites require hospital admission for the administration of intravenous antibiotics and, in some cases, surgical intervention. A combination of the increasing incidence, hospital admission rates, and in-patient bed pressures prompted a change in our bite management protocol and a move toward ambulatory management of bite injuries. We found this new protocol to be safe, efficient, and cost-effective with a scope for wider implementation. Aim The primary outcome is to assess the feasibility of safely managing hand bites on an outpatient basis, by reviewing the local data before and after the change in practice. The secondary outcome is to compare the financial implications of treating hand bites with an outpatient approach. Material and methods All first-presentation adult consultations referred to Trauma and Orthopaedics from the emergency department over a three-month snapshot period were reviewed in 2017. This was repeated after the implementation of the updated handbite guidelines in 2023. Initial admission documentation as well as operation notes and clinic follow-up letters were each reviewed retrospectively. Results In 2017, 36 patients were identified over three months. The average time to surgery was 1.19 days with an average inpatient stay of 2.36 days. There were two re-operations and follow-up of two cases of osteomyelitis. In 2023, 63 patients were identified over three months. The average time to surgery was 1.03 days with an average inpatient stay of 0.56 days. Thirty-seven surgeries were performed for 33 patients with 32% (20/63) of patients admitted directly from the emergency department. There were no documented cases of osteomyelitis on follow-up. The cost per patient episode decreased by 40% from 2017 to 2023, without accounting for inflation. Conclusions With the implementation of the new departmental guidelines, there has been a reduced average inpatient stay and reduced time to surgery without an increase in documented osteomyelitis. There is also a significant decrease in the average patient cost. This data suggests that without compromising patient safety it is possible to cost-effectively manage hand bites without the need for long inpatient stays. However, it is imperative that there is close patient follow-up as well as prompt time to surgery to ensure patient safety. Our findings suggest a need for further research to strengthen the evidence supporting our conclusions.
RESUMO
Background: Systematic reviews and meta-analyses allow a transparent, rigorous, and replicable analysis to summarize the results of multiple related studies and are considered top of the evidence-based medicine study hierarchy. The COVID-19 pandemic has shed light on the unmet educational needs of students worldwide, notably those from underprivileged backgrounds. This cross-sectional study aimed to ascertain students' and junior doctors' attitudes on their current knowledge, confidence and preparedness of appraising and conducting systematic reviews and meta-analysis internationally. Methods: A free online webinar was held in May 2021 by the senior author and a pre-event questionnaire was distributed. Responses collected were used for analysis anonymously to ascertain students' knowledge, experience, and confidence in preparing a systematic review and meta-analysis using a 1-5 Likert scale using IBM SPSS 26.0. Associations were examined using Chi-square and crosstabs analysis. Results: Out of 2004 responses from 104 countries included in the analysis, the majority of delegates were from lower middle-income countries and were not familiar with the PRISMA checklist (59.2% and 81.1% respectively of the total number of participants). The majority had never attended any formal training (83%) and felt their medical institute gave them minimal advice (72.5%) in preparing systematic reviews. Among those who had attended formal training, the proportion was significantly higher in those belonging to high and upper middle-income countries combined (20.3%) than lower and lower-middle-income countries combined (15%). Conclusion: This study highlights gaps that need addressing to enhance the knowledge of medical students and junior doctors performing systematic reviews and meta-analyses. Clear disparities are found in country income and the level of education. Future large-scale studies are needed to understand the rationale of working on online research projects and the opportunities available to medical students and junior doctors that may lead to medical curriculum changes.
RESUMO
Retroperitoneal liposarcomas (RPL) are rare mesenchymal tumours with an annual incidence of 2.7 cases per million. Well-differentiated liposarcomas (WDLs) and dedifferentiated liposarcomas (DDLs) are the most common subtype. WDLs are widely known to be low-grade tumours that are less likely to metastasise and easily resected. In contrast, DDLs are high-grade aggressive metastatic tumours with mortality rates between 50% and 70%. We present an unusual case of a 47-year-old male with a background of hypertension presenting with cardiac-sounding chest pain. Initially managed as an acute coronary syndrome (ACS), he eventually underwent a CT scan which revealed a 20x18x17cm retroperitoneal complex mass with possible infiltrates to the posterior wall of the greater curvature of the stomach. Ultrasound-guided biopsy and subsequent histopathology analysis revealed DDL consistent with MDM2 amplification. This case highlights how RPL can present with diagnostic difficulties. Multidisciplinary input from haematology, surgery and specialist teams is vital to optimise patient management.
