A Case Report on a Hybrid Approach to Managing Acute Large Bowel Obstruction Secondary to Spigelian Hernia.

Spigelian hernias are an uncommon type of primary ventral hernia and are defined as a defect in the Spigelian aponeurosis (fascia). Herein, we present an uncommon case of Spigelian hernia to highlight the potential complications of these hernias and the need for surgical management. This is a case report of an 86-year-old gentleman presenting post-fall with an acute rib fracture and an incidental Spigelian hernia seen on a CT trauma pan scan. The Spigelian hernia surgical treatment was planned for elective management due to the anesthetic risks associated with an elderly patient and acute rib fractures. Ultimately, the patient developed a large bowel obstruction secondary to the Spigelian hernia and required emergency operative management to relieve the obstruction. The patient had an uncomplicated recovery following his emergency surgery. This case report highlights the importance of assessing anesthetic risks versus surgical risks when it comes to surgical planning. Clinicians should recognize occult hernias and continue ongoing clinical reviews with a high index of suspicion, as symptoms of Spigelian hernia obstruction might be non-specific.

Therapeutic duplication on the general surgical wards.

Therapeutic duplication is the practice of prescribing multiple medications for the same indication or purpose without a clear distinction of when one agent should be administered over another. This is a problem that occurs frequently, especially on electronic prescribing records (EPR) as the medication chart is not always reviewed before prescribing. The aim of this Quality Improvement Project (QIP) was to reduce therapeutic duplication to 0% through educating the general surgical team. Prescriptions of all general surgical patients in the surgical wards were reviewed daily for a month. EPR was used to check if there were any duplications or identical class of drug prescribed. Patient documentation was thoroughly checked to rule out if the duplication was intentional. Following this, if duplication was still unclear, the relevant teams would be contacted for clarification. Any unintentional error was removed, and data was collected. The QIP results were presented to the local general surgical meeting and our fellow colleagues were educated on the importance of safe prescribing and on how to prevent prescribing errors. The baseline of therapeutic duplications on the general surgical wards was 9% prior to our first cycle. Following the presentation of data and educating the surgical team at the surgical meeting, the number of errors seemingly reduced, however, there was a jump to 22% of therapeutic duplication on a particular Friday which brought the average of therapeutic duplication to 8.77%. The team was reminded again about the importance of correct prescribing and after the second cycle, the number of errors reduced to 5.29%. For the third audit cycle, the team was presented with the reaudited data and following this, the number of errors dropped down to 3.12%. Therapeutic duplication should never occur as this could cause a risk to patient harm. Through educating the surgical team and reminding our team regularly, the average number of errors reduced by more than half of the original number. In our hospital, the main source of safety net is through pharmacists and nurses, however as shown, this is not enough to prevent all therapeutic errors. A more sustainable intervention such as an alert on EPR prior to prescribing may be required to maintain a low therapeutic duplication average and prevent patient harm.

Is it Possible to Predict Non Sentinel Node Positivity on the Basis of mRNA Copy Numbers of CK19 Receptor in Breast Cancer?

AIMS: To determine if there is any correlation between the number of positive non-sentinel lymph nodes (NSLN) and the mRNA copy numbers of cytokeratin 19 receptor on one step nucleic acid amplification (OSNA) in the sentinel lymph node (SLN). METHODS: An 8-year retrospective study of consecutive patients who had primary surgery and sentinel node biopsy for breast cancer from January 2011 to December 2018 was carried out. All these patients had intra-operative analysis of sentinel lymph nodes by OSNA. Patients who had neoadjuvant chemotherapy or neoadjuvant endocrine therapy were excluded. RESULTS: There were 1159 patients with an age range of 24 to 90 years and a mean age of 63 years in this study. A total of 1324 SLNs were analyzed by OSNA. Macrometastasis was found in 120 patients and they underwent axillary lymph node dissection (ALND). A total of 2405 NSLNs were analyzed. Of the patients who had ALND, 51 (43%) patients had negative NSLNs and 69 (57%) had positive NSLNs. The mean mRNA copy numbers respectively for the 2 groups were 853,665 and 609,855. The difference between the means is not statistically significant (P = 0.82). Also the Receiver Operating Characteristic (ROC) Curve of the total CK-19 mRNA copy number for both groups-negative and positive NSLN were almost identical (Figure 3) indicating mRNA copy numbers cannot be used to discriminate between positive and negative non-sentinel lymph nodes. CONCLUSION: It is clear from our study that in patients who have ALND due to macromets on OSNA, there is no correlation between the total tumor load as represented by mRNA copy numbers and the likelihood of positive non-sentinel lymph nodes. We therefore cannot rely solely on the mRNA copy numbers to decide on ALND.

Laryngohyoid and cervical vertebra lesions after a fall from a low height.

The aim of this study was to determine the frequency and nature of cervical trauma in the case of low-height falls (up to 2.50 m). A retrospective study was carried out on 114 autopsy cases that died after low-height falls. For each case, age, sex, manner and cause of death, estimated height of fall, ground type, type of primary impact, type of laryngeal and hyoid bone trauma, presence of associated local trauma in the neck and cephalic region, and toxicological data were reported. Fractures of the hyoid bone and/or of the laryngeal cartilages were present in 2.5% of the cases (n = 3). Cervical soft tissue bruising was found in 13% of the cases (n = 15). About 6% of the cases (n = 7) showed blunt cervical vertebral column trauma, including 3 cases with ruptured intervertebral disk. Interpretation and mechanisms of these lesions are discussed.

Between stigmatisation and regulation: prostitution in colonial Northern Vietnam.

Colonisation was a masculine adventure which took place in a distorted world full of 'welcoming' native women. The colonial encounter therefore was both racial and gendered: boundaries between European men and Vietnamese women were obvious. On the other hand the intimacy that resulted from this encounter blurred the racial boundaries that were the foundation of the colonial order. These boundaries had to be redrawn or sharpened. Focusing on French colonial northern Vietnam (Tonkin) this paper examines how the whole colonial encounter was embodied in the sexual encounter between European men and native women and how prostitution was an integral part of the colonial order. This analysis of the regulation of prostitution and its ambivalence reveals that the definition of prostitution and its treatment by the French colonial authorities was political, racial and therefore connected to a specific period. The political definition of prostitution in today's Vietnam is different from the colonial one. This shift reveals that prostitution is a pertinent vantage point from which one can study how a society apprehends itself and its own future.