Developing Bespoke High Volume Low Complexity (HVLC) Theatre Lists With a Focus on Training to Address the Impact of COVID-19: A Pilot Study.

Introduction The COVID-19 pandemic has had an unprecedented impact on both healthcare delivery and surgical training. There have been significant efforts to manage the growing elective waiting list backlog whilst addressing the training deficit. We outline a successful pilot high volume low complexity (HVLC) program held at the Croydon Elective Centre between 2021-2022 which aimed to amalgamate training and elective recovery. Methods Two pilot HVLC training lists were carried out in June 2021 and March 2022. Three parallel theatre lists on each date were supervised by a single consultant floor trainer. All lists followed a standard pre-defined HVLC protocol. Trainees and trainers were invited to participate and encouraged to utilize these lists to sign off relevant work-based assessments. HVLC cases included hernia repairs and simple lesion excisions. Patient, theatre staff, and trainee experiences were collated via questionnaires. Results A total of one consultant supervisor, six trainers, and eight trainees participated in the pilot with a total of 34 elective procedures performed on 29 patients. The mean patient age was 52.4 years with 8 out of 29 patients being female. Of these patients 41.4% were American Society of Anaesthesiologists (ASA) Classification one, 51.72% were ASA two and 6.9% were ASA three. No patients to date were readmitted to the hospital post-operatively or presented with post-operative complications. One hundred percent of trainees felt satisfied with the training and would recommend it to a colleague. Conclusion The training deficit that developed during the first COVID-19 pandemic wave has been compounded by the second and third waves, and trainees are concerned that further waves are anticipated. Returning to operating is vital and our approach has been shown to improve training, whilst maintaining patient safety and accelerating elective waiting list recovery.

Oncoplastic breast-conserving surgery for women with primary breast cancer.

BACKGROUND: Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques. OBJECTIVES: Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer. DATA COLLECTION AND ANALYSIS: Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures. MAIN RESULTS: We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation. AUTHORS' CONCLUSIONS: The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

Efficacy of surgical masks or cloth masks in the prevention of viral transmission: Systematic review, meta-analysis, and proposal for future trial.

OBJECTIVE: Recommendations for widespread use of face mask, including suggested type, should reflect the current published evidence and concurrently be studied. This review evaluates the preclinical and clinical evidence on use of cloth and surgical face masks in SARS-CoV-2 transmission and proposes a trial to gather further evidence. METHODS: PubMed, EMbase, and the Cochrane Library were searched. Studies of SARS-CoV-2 and face masks and randomized controlled trials (RCTs) of n ≥ 50 for other respiratory illnesses were included. RESULTS: Fourteen studies were included in this study. One preclinical and 1 observational cohort clinical study found significant benefit of masks in limiting SARS-CoV-2 transmission. Eleven RCTs in a meta-analysis studying other respiratory illnesses found no significant benefit of masks (±hand hygiene) for influenza-like-illness symptoms nor laboratory confirmed viruses. One RCT found a significant benefit of surgical masks compared with cloth masks. CONCLUSION: There is limited available preclinical and clinical evidence for face mask benefit in SARS-CoV-2. RCT evidence for other respiratory viral illnesses shows no significant benefit of masks in limiting transmission but is of poor quality and not SARS-CoV-2 specific. There is an urgent need for evidence from randomized controlled trials to investigate the efficacy of surgical and cloth masks on transmission of SARS-CoV-2 and user reported outcomes such as comfort and compliance.

The elbow plica: a systematic review of terminology and characteristics.

BACKGROUND: There has been a lack of evidence regarding the structure of the elbow plica, or synovial fold. Inconsistency remains regarding the correct terminology, prevalence, and investigation used to understand this anatomic structure. METHODS: For this systematic review, we searched the PubMed, Ovid-MEDLINE, Cochrane, Google Scholar, and Embase databases using keywords as well as medical subject headings for English-language studies. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: We included 27 articles in this review. "Plica" was the most commonly used terminology (33%). The prevalence of plicae in asymptomatic and symptomatic patients was 77% and 97%, respectively. Provocative factors were sporting activities (57%), including those performed by professional athletes, and heavy labor (43%). Lateral elbow pain represented the most common symptom (49%). Magnetic resonance imaging was the most commonly used diagnostic modality (64%). On the magnetic resonance imaging scans of symptomatic patients, the most common location of the plica was the posterolateral region (54%) and its thickness was a minimum of 3 mm. In 2 studies that included symptomatic patients, the plica was found to cover more than one-third of the radial head. CONCLUSION: Plicae are prevalent in both asymptomatic and symptomatic patients. Consideration of the pathologies associated with an elbow plica helped identify the following: (1) its thickness is >3 mm and (2) its location is in the posterolateral aspect and/or it covers more than one-third of the radial head quadrant.

Systematic Review of the Surgical Outcomes of Elbow Plicae.

BACKGROUND: Surgical resection is usually required for symptomatic elbow plicae that have failed nonoperative therapy. However, evidence of surgical outcomes has not been presented. PURPOSE: To review the surgical outcomes for the treatment of synovial plicae in the radiocapitellar joint. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, and Embase databases using keywords as well as Medical Subject Headings terms and Emtree ([(elbow OR humeroradial joint OR radiohumeral joint) AND (meniscus OR plica)] OR snapping elbow OR snapping triceps OR synovial fold syndrome OR synovial fringe) for English-language studies. We conducted a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: A total of 14 articles comprising four level 5 and ten level 4 studies were identified, including 279 patients (284 elbows). The triggering factors reported for 58 patients were heavy labor (29 patients; 50.0%), sporting activities (17 patients; 29.3%), and nonspecific trauma (12 patients; 20.7%). Overall, 92 patients (33.0%) were administered a steroid injection before surgery. Arthroscopic plica resection was performed in 266 patients (95.3%). Intraoperatively, plicae were mostly found in the posterior (44.0%) and posterolateral (28.6%) sites, and chondromalacia of the radial head was observed in 25 patients (9.2%). Of the reported surgical outcomes, 67.7% showed a resolution of symptoms. However, 9.3% of patients had residual symptoms, which were likely associated with pre-existing radial head chondromalacia. The complication rate was reported as 1.8%. CONCLUSION: Symptomatic elbow plicae were mostly treated arthroscopically, with most of the results being favorable. Pre-existing chondromalacia and the underestimation of concomitant intra-articular abnormalities may yield an inferior outcome.

Humeral Diaphyseal Fracture Nonunion: An Audit of the Outcome from Intramedullary Nailing and DCP Plating.

PURPOSE: This study aims to compare the functional outcomes of nonunion humeral diaphyseal fractures following conservative treatment when managed surgically with either a plate or intramedullary (IM) nail fixation. METHODS: This was a retrospective study of 56 patients with nonunion humeral fractures following conservative treatment who underwent plate or IM nail fixation between 2007 and 2014. Comparison was made for short term profile (intraoperative blood loss, duration of surgery, and length of hospitalization) and long term clinical outcome with functional score (Constant-Murley score (CMS)) and Disabilities of the Arm, Shoulder and Hand (DASH) score). The union and complication rate were also compared. RESULTS: There were 36 and 20 patients included in plate and IM nail fixation group with the average of 36.14 ± 7.54-month follow-up time. The intraoperative blood loss, duration of surgery, and length of hospitalization were superior in IM nail group compared to plate group (p < 0.001, p < 0.001, and p < 0.001, respectively). The mean CMS and DASH score were superior in the plate group compared to the IM nail group (82.40 ± 16.84 versus 77.58 ± 12.96; 17.46 ± 11.05 versus 20.86 ± 11.63, respectively; with p = 0.246, p = 0.299, respectively). Plate fixation group showed higher union rate and complication rate compared to IM nail group (100% versus 90%, 13.8% versus 10%, respectively). CONCLUSIONS: IM nail and plate fixation demonstrated comparable clinical outcome. IM nail fixation showed superior short term result with lower complication rate which benefits the elderly group patients with significant comorbidities.