Prevalence and risk factors for nerve injury following shoulder dislocation.

BACKGROUND: The glenohumeral joint dislocation can be associated with major nerve injury. The reported prevalence and risk factors for major nerve injury are variable and this injury can have a severe and life-long impact on the patient. The objectives of this study were to analyse the prevalence of major nerve injury following shoulder dislocation and examine risk factors. Management and outcomes of nerve injury were explored. METHODS: A 1 year retrospective cohort study of 243 consecutive adults who presented with a shoulder dislocation was performed. Data were collected on patient demographics, timings of investigations, treatment, follow-up, and nerve injury prevalence and management. The primary outcome measure was prevalence of nerve injury. Risk factors for this were analysed using appropriate tests with Stata SE15.1. RESULTS: Of 243 patients with shoulder dislocation, 14 (6%) had neurological deficit. Primary dislocation (p = 0.004) and older age (p = 0.02) were significantly associated with major nerve injury. Sex, time to successful reduction and force of injury were not associated with major nerve injury in this cohort. Patients with nerve injury made functional recovery to varying degrees. Recurrent shoulder dislocation was common accounting for 133/243 (55%) attendances. CONCLUSIONS: Shoulder dislocation requires careful assessment and timely management in the ED. A 6% rate of nerve injury following shoulder dislocation was at the lower border of reported rates (5-55%), and primary dislocation and older age were identified as risk factors for nerve injury. We emphasise the importance of referring patients with suspected major nerve injury to specialist services.

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta-analysis.

BACKGROUND: Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates. OBJECTIVES: We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies. METHODS: A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000-27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs). RESULTS: Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7-12·4] and for SCC 9·4% (95% CI 7·6-11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0-7·3) and SCCs (RR 4·8, 95% CI 1·0-22·8). Studies were heterogeneous (I2  = 98%) and at high risk of bias. CONCLUSIONS: The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Tenosynovial giant cell tumours of the hand: A multicentre case-control study.

Many factors have been proposed to contribute to the risk of recurrent tenosynovial giant cell tumours (TSGCT); however, we remain unable to predict those at risk, which formed the rationale for this multicentre retrospective case-control study of 28 patients with recurrence. We included cases of recurrence in a 1:1 ratio matched for age and sex with controls over 10 years. Using Cox regression, we present hazard ratios (HRs) for recurrence with 95% confidence intervals (CIs). Out of 285 cases, 28 individuals developed recurrence after a median of 2.4 years. Recurrent TSGCT had a higher mitotic count/mm2 in the primary tumour (median increase of 3 [IQR 1, 7]). Mitotic count in the primary tumour was associated with the risk of recurrence (adjusted HR 1.1 [95% CI 1.1, 1.2]) meaning that for every additional mitosis, the risk of recurrence increased by 10% per annum. We recommend a prospective cohort study to validate our findings.

Systematic review of fibrin glue in burn wound reconstruction.

BACKGROUND: In the reconstruction of burns using split-skin grafts (SSGs), fibrin glue can be used to improve graft take and reduce haematoma formation, although the efficacy and cost-effectiveness are unknown. This systematic review evaluated outcomes of fibrin glue compared with conventional SSG attachment techniques. Outcomes of interest included SSG take, haematoma formation, patient satisfaction and cost-effectiveness. METHODS: This PROSPERO-registered review was performed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA statement. Embase, PubMed, Cochrane and ClinicalTrial.gov databases were searched systematically. Observational and experimental studies comparing fibrin glue with other methods of SSG attachment in burn wounds were included. Risk of bias was assessed using the Cochrane risk-of-bias and Risk of Bias In Non-Randomized Studies - of Intervention tools. The quality of the evidence was assessed using the GRADE tool. RESULTS: Two RCTs and four observational studies were included. Graft take at day 5 was not significantly different between groups (3 studies, 183 individuals). Fibrin glue significantly reduced the risk of postoperative haematoma in two studies and reduced patient-reported pain in two studies, with suggested cost savings in four studies. All studies were at risk of methodological bias and the quality of the evidence was universally very low. CONCLUSION: As the evidence is sparse, the quality very low and the risk of bias significant both within and across studies, it is not possible to make any recommendations regarding the use of fibrin glue in burn wounds.

Cytokines in the systemic inflammatory response syndrome: a review.

INTRODUCTION: Patients subject to major surgery, suffering sepsis, major trauma, or following cardiopulmonary bypass exhibit a systemic inflammatory response. This inflammatory response involves a complex array of inflammatory polypeptide molecules known as cytokines. It is well accepted that the loss of local control of the release of these cytokines leads to systemic inflammation and potentially deleterious consequences including the Systemic Inflammatory Response Syndrome, Multi-Organ Dysfunction Syndrome, shock and death. METHODS: The Medline database was searched for literature on mechanisms involved in the development of SIRS and potential targets for modifying the inflammatory response. We focus on the novel therapy of cytokine adsorption as a promising removal technology. RESULTS: Accumulating data from human studies and experimental animal models suggests that both pro- and anti- inflammatory cytokines are released following a variety of initiating stimuli including endotoxin release, complement activation, ischaemia reperfusion injury and others. DISCUSSION: Pro-and anti-inflammatory cytokines interact in a complex and unpredictable manner to influence the immune system and eventually cause multiple end organ effects. Cytokine adsorption therapy provides a potential solution to improving outcomes following Systemic Inflammatory Response Syndrome.