The impact of changes in work practice and service delivery on surgical infection rates in a general surgical unit.

Ring-fencing of elective orthopaedic beds has been shown to significantly reduce surgical site infection (SSI) rates. There are fewer studies in general surgical practice. Comparison of overall surgical workload in 2007 and 2011 was performed. Data pertaining to SSI were collected and analysis of this prospectively maintained database was performed on all SSI diagnosed in 2007 and 2011. There was a significant reduction in the crude SSI rate from 117 cases in 2007 (8%) to 42 cases in 2011 (3.5%). A statistically significant reduction in SSI rate for elective surgery was observed, 7.6% vs. 2.5% (p<0.001 Chi-square test). Apart from the introduction of ring fencing, all other contributory variables remained unchanged. Ring-fencing of inpatient general surgical beds has been associated with a significant reduction in SSI rates. These data provide timely supportive evidence that ring-fencing of inpatient beds is an appropriate patient-orientated strategy.

The influence of breast cancer subtype on bone metastases development and survival in women with metastatic breast cancer.

BACKGROUND: Tumour metastatic disease reflects a complex interplay between tumour characteristics and local host factors. This complex relationship may have an influence on the development of metastatic disease and patient survival. Multiple factors of the primary tumour influence the development of metastases and survival in patients. Breast cancer subtype has been shown to influence patient prognosis and response to therapy. AIM: The aim of our study was to correlate breast cancer subtype with bony metastatic disease and patient survival. METHODS: All women undergoing breast cancer surgery in a single institution in Ireland between January 1990 and July 2012 were included in the study. A prospectively maintained database was reviewed and expanded retrospectively. Univariate and multivariate analysis was carried out. RESULTS: Database interrogation identified 238 patients for inclusion. Patient demographics, tumour characteristics and survival data were analyzed. Average follow-up of patients was 57.6 months (range 1-272 months). Multivariate analysis identified oestrogen receptor positivity and presence of metastatic disease elsewhere as significant factors influencing the development of bone metastases. Breast cancer subtype did not influence the bone metastases development (p = 0.99). Breast cancer subtype influenced patients' overall survival (p < 0.001), bone disease-free survival (p < 0.001) and survival with bone disease (p < 0.001). Subtype did not influence distant disease-free survival. CONCLUSION: Breast cancer subtype influences patients' overall survival, with luminal A and B subtypes associated with the best outcome. Bone metastases remain the most common form of breast cancer metastases but are not influenced by breast cancer subtype.

Analysis of sentinel node positivity in primary cutaneous melanoma: an 8-year single institution experience.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a standard method for determining the pathologic status of the regional lymph nodes. AIMS: The aim of our study was to determine the incidence and clinicopathologic factors predictive of SLN positivity, and to evaluate the prognostic importance of SLNB in patients with cutaneous melanoma. METHODS: We performed a retrospective analysis of a prospectively maintained database of all patients who underwent SLNB for primary melanoma at our institution from 2005 to 2012. Statistical analysis was performed using χ 2 and Fischer exact test. RESULTS: In total, 318 patients underwent SLNB, of which 65 were for thin melanoma (≤1 mm). There were 36 positive SLNB, 278 negative SLNB and in four cases the SLN was not located. The incidence rate for SLNB was 11.3% overall and 1.5% in thin melanomas alone. Statistical analysis identified Breslow thickness >1 mm (P = 0.006), Clark level ≥ IV (P = 0.004) and age <75 years (P = 0.035) as the strongest predictors of SLN positivity. Our overall false negativity rate was 20% (9/45) with one case of false-negative SLNB in thin melanomas. CONCLUSION: Breslow thickness of the primary tumour remains the strongest predictor of SLN positivity. Our findings point to a possible limited role for SLNB in thin melanoma due to its low positivity rate, associated false-negative rate and related morbidity.

Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery?

BACKGROUND: Pelvic and acetabular fractures are rare, complex injuries associated with significant morbidity. Fixation of these injuries requires major orthopaedic surgery which in itself is associated with substantial blood loss owing to the extensile operative approach and prolonged operating time required to address the complex fracture anatomy. In order to reduce morbidity, a multifactor approach to blood conservation must be adopted. CURRENT ROLE OF ANTIFIBRINOLYTICS IN ORTHOPAEDIC SURGERY: The use of antifibrinolytics to reduce operative blood loss is well documented in many surgical specialties, including orthopaedic surgery. Elective spinal surgery and joint arthroplasty have benefited from the introduction of antifibrinolytics; however, their role in trauma and fracture surgery is not fully defined. Pelvic and acetabular fracture surgery would benefit from further investigation on the benefit and safety of these agents. CONCLUSION: Routine use cannot be recommended at this time but agents may be considered on a case-specific basis.

A SPION-eicosane protective coating for water soluble capsules: Evidence for on-demand drug release triggered by magnetic hyperthermia.

An orally-administered system for targeted, on-demand drug delivery to the gastrointestinal (GI) tract is highly desirable due to the high instances of diseases of that organ system and harsh mechanical and physical conditions any such system has to endure. To that end, we present an iron oxide nanoparticle/wax composite capsule coating using magnetic hyperthermia as a release trigger. The coating is synthesised using a simple dip-coating process from pharmaceutically approved materials using a gelatin drug capsule as a template. We show that the coating is impervious to chemical conditions within the GI tract and is completely melted within two minutes when exposed to an RF magnetic field under biologically-relevant conditions. The overall simplicity of action, durability and non-toxic and inexpensive nature of our system demonstrated herein are key for successful drug delivery systems.

On-demand, magnetic hyperthermia-triggered drug delivery: optimisation for the GI tract.

An orally-administered vehicle for targeted, on-demand drug delivery to the gastrointestinal (GI) tract is highly desirable due to the high incidence of diseases of that organ system and harsh mechanical and physical conditions any such drug delivery vehicle has to endure. To that end, we present an iron oxide nanoparticle/wax composite capsule coating that protects the capsule contents from the highly variable chemical conditions of the GI tract. It can be triggered using magnetic hyperthermia initiated from an external AC magnetic field. The coating is produced from pharmaceutically approved materials and is applied using a simple dip-coating process using a gelatin drug capsule as a template. We show that the coating is impervious to chemical conditions found within the GI tract, but is completely melted within two minutes of magnetically-induced heating under biologically-relevant conditions of temperature, pH, buffer and external field strength, allowing the delivery and dispersal of the capsule contents. The overall simplicity of action, durability and non-toxic and inexpensive nature of our drug delivery vehicle demonstrated herein are key for successful drug delivery systems for the kinds of focal therapy being sought for modern precision medicine.

Unusual osseous metastases from rectal adenocarcinoma: a case report and review of the literature.

INTRODUCTION: Rectal adenocarcinoma typically metastasizes to the liver. When osseous spread occurs, it is most commonly detected in the vertebrae and pelvis. Distal osseous spread is unusual and may be the first presentation of the carcinoma. We present a review of the current literature on unusual osseous rectal adenocarcinoma metastases and highlight a case of a scapular lesion as the first presentation of rectal carcinoma from our institution. MATERIALS AND METHODS: A Pubmed search using keywords 'rectal carcinoma metastases,' 'colorectal cancer metastases' and 'skeletal metastases' was performed. RESULTS: Twenty-four cases were identified (54 % male, mean age at diagnosis 61 ± 16 years). The most common site was the mandible, followed by the foot. In four cases, the metastasis was the first presentation of the carcinoma. Mean time from resection of the primary tumour to osseous metastases diagnosis of skeletal metastases was 26 ± 17 (SD) months. Mean time from diagnosis of skeletal metastases to death was 3.2 (±2.8) months. CONCLUSION: Rectal adenocarcinoma osseous metastases located distal to the pelvis and/or vertebrae are rare and associated with a poor prognosis. Unusual bony lesions should raise an index of suspicion for distal carcinoma, including rectal carcinoma.

The trap door flap: a reliable, reproducible method of anterior pinna reconstruction.

INTRODUCTION: Resection of skin cancers of the conchal fossa and anti-helical rim presents a challenging reconstructive problem. A full thickness skin graft is often used following excision of the cartilage underlying the lesion. Colour mismatch, a contour defect and a donor site scar are potential drawbacks to this method of reconstruction. The postauricular trap door flap offers a superior option for these defects. AIMS: This study aims to assess the reliability and outcomes of the trap door flap for defects of the anterior surface of the pinna. METHODS: A retrospective review of all trap door flaps carried out in Galway University Hospital was carried out. Charts were reviewed in order to examine operative notes and assess for any complications and length of follow up. RESULTS: 45 Patients were operated on by a single surgeon. The age range was 61-93 years. The majority of lesions excised were from the conchal area with 6 defects predominantly involving the scapha. No partial or complete flap loss occurred. 2 patients required further excision due to an incomplete margin and a local recurrence respectively. Follow up ranged from 3 months to 4 years with excellent cosmetic results were achieved in all cases with no scar issues at the flap or donor sites. CONCLUSION: The trap door flap is an excellent method of conchal reconstruction. It is reliable and reproducible with no flap loss demonstrated in our series of 45 patients. Large defects can be reconstructed with this flap and the cosmetic result in terms of colour and contour, as well as a hidden donor site scar, make this a superior option to a full thickness skin graft.

Water-clear cell adenoma: A rare form of hyperparathyroidism.

INTRODUCTION: Primary hyperparathyroidism is a common endocrine disorder, with an incidence of 21.6 per 100,000 person-years. Asymptomatic elevated serum calcium levels on routine biochemical investigations accounts for 80% of newly diagnosed primary hyperparathyroidism. Solitary adenoma is the commonest cause of primary hyperparathyroidism and can be treated by excision of a single gland. PRESENTATION OF CASE: We present a case of primary hyperparathyroidism in a 74-year-old female was referred to our surgery endocrine outpatients for assessment of a persistently elevated calcium level, lower abdominal pain and constipation. Biochemical analysis revealed corrected serum calcium of 3.13mmol/L (reference range 2.17-2.51mmol/L) and an intact parathyroid hormone level (iPTH) of 488.9ng/L (reference range 15-65ng/L). Sestamibi scan localised a persistent increased area of activity inferior to the lower pole of the left lobe of thyroid gland. DISCUSSION: The patient underwent a minimally invasive parathyroidectomy using a 3cm incision with intra-op radionucliotide localisation. At surgery a single large parathyroid gland measuring 5.5cm was excised without complication. Grossly the parathyroid gland was an encapsulated tan mass measuring 5.5cm×2.5cm×2cm and weight 13g and histological assessment revealed a water-clear cell (WCC) adenoma. She made an uneventful post op recovery with normalisation of her serum calcium. CONCLUSION: WCC adenomas have a "low endocrinological activity" in which serum calcium levels do not elevate until the adenoma has reached considerable size. Our case supports this hypothesis and aids to the understanding of these rare tumours.

Immediate care of burns.

The assessment, first aid treatment and immediate care of severely burned patients in the Accident and Emergency Department have been reviewed and the factors which influence the decision to transfer a case to a specialist Burns Unit have been discussed.

Cloning in Bacillus subtilis of an extremely thermostable alpha amylase: comparison with other cloned heatstable alpha amylases.

A heatstable alpha amylase gene was shotgun cloned from Bacillus licheniformis RPO1 into Bacillus subtilis. Restriction endonuclease analysis of the recombinant plasmid revealed a map which was identical to a previously cloned alpha amylase from B. licheniformis FDO2 and very similar to the restriction map of a high temperature amylase from Bacillus coagulans. The thermostability and temperature optimum of the cloned alpha amylase was measureably different from those of the previously reported cloned alpha amylases.