D3 Lymphadenectomy for Right Colon Cancer: Feasibility, Safety, and Early Outcomes from a District General Hospital in London.

BACKGROUND AND OBJECTIVES: Observational studies suggest a link between D3 lymphadenectomy and improved disease-free survival in some colon cancer patients. However, high-quality randomized controlled trials are needed to confirm its advantage over D2 lymphadenectomy. Concerns about potential complications with D3 have limited its use outside of Japan. This study examines short-term outcomes following D3 lymphadenectomy for right-sided colon cancer compared to the established D2 procedure. Materials and Methods: This retrospective cohort single center study analyzed data on patients with right-sided colon cancer who underwent curative surgery within our healthcare trust between January 2019 and November 2022. Only patients treated by surgeons who routinely perform D3 lymphadenectomy were included for a homogenous study population. The decision to perform D3 was at the discretion of the operating surgeon. Data were collected from both paper charts and electronic medical records. Non-parametric statistical tests were used for data analysis. Results: A total of 214 patients met the criteria, with 170 undergoing D2 lymphadenectomy and 44 undergoing D3 lymphadenectomy. There were no significant differences between the groups in terms of surgery duration, blood loss, postoperative hemoglobin levels, or transfusion needs. Interestingly, the D3 group had a lower complication rate (25%) compared to the D2 group (41.2%). However, the D3 group also had a higher rate of lymph node spread (45.5% vs. 30.6% for D2) and more lymph nodes removed (19 [16, 25] vs. 23 [18, 28]). Importantly, both groups achieved similar complete tumour removal rates. Conclusions: This study suggests D3 lymphadenectomy for right-sided colon cancer might be safe with potential benefits, especially for younger patients with suspected lymph node involvement. However, the limited sample size necessitates larger, randomized trials to confirm these findings and potentially establish D3 lymphadenectomy as standard care.

A clinical evaluation of variation in paediatric intracranial pressure waveforms.

Introduction: Intracranial pressure (ICP) monitoring is commonly used in investigating the aetiology of chronic paediatric neurological conditions. A series of high-amplitude spikes has been observed in overnight ICP recordings of some children, many of whom have hydrocephalus or craniosynostosis. Research question: This clinical evaluation aimed to define the spike pattern, describe the patient group in which it is most likely to occur, and conduct high-resolution waveform analysis. Material and methods: ICP waveforms from 40 patients aged 0-5 years (inclusive), recorded between 2017 and 2021 at the Royal Hospital for Children Glasgow, were retrospectively analysed. The pattern was defined through visual inspection of regions of interest by two reviewers. Patients were stratified using demographic and clinical data. R software was used to perform regression and high-resolution waveform analyses. Results: The spike pattern was defined as the presence of 2 consecutive spikes with an amplitude of at least 8 mmHg, with a gap of at least 30 min between spikes. In the adjusted Poisson regression, age was significantly associated with the number of spikes (IRR 0.8, 95% CI 0.70 to 0.92, p-value 0.001). Discussion and conclusion: Younger age was significantly associated with an increased number of spikes in this cohort. Investigation of clinical consequences of the spikes is warranted.

Exploring the implementation of an educational film within antenatal care to reduce the risk of cytomegalovirus infection in pregnancy: A qualitative study.

BACKGROUND: Congenital cytomegalovirus (CMV) infection is a leading cause of sensorineural hearing loss and neuro-disability in childhood. In the absence of a licensed vaccine, adoption of hygiene-based measures may reduce the risk of CMV infection in pregnancy, however these measures are not routinely discussed with pregnant women as part of National Health Service (NHS) antenatal care in the United Kingdom (UK). METHODS: An exploratory qualitative study was conducted, underpinned by Normalization Process Theory (NPT), to investigate how an educational intervention comprising of a short film about CMV may best be implemented, sustained, and enhanced in real-world routine antenatal care settings. Video, semi-structured interviews were conducted with participants who were recruited using a purposive sample that comprised of midwives providing antenatal care from three NHS hospitals (n = 15) and participants from professional colleges and from organisations or charities providing, or with an interest in, antenatal education or health information in the UK (n = 15). FINDINGS: Midwives were reluctant to include CMV as part of early pregnancy discussions about reducing the risk of other infections due to lack of time, knowledge and absence of guidance or policies relating to CMV in antenatal education. However, the educational intervention was perceived to be a useful tool to encourage conversations and empower women to manage risk by all stakeholders, which would overcome some identified barriers. Macro-level challenges such as screening policies and lack of official guidelines to legitimise dissemination were identified. DISCUSSION: Successful implementation of education about CMV as part of routine NHS care in the UK will require an increase in awareness and knowledge about CMV amongst midwives. NPT revealed that 'coherence' and 'cognitive participation' between service members are vital to imbed CMV education in routine practice. 'Collective action' and 'reflexive monitoring' is required to sustain service changes.

Exploration of the relationship between partial pressure of brain tissue oxygen and intracranial pressure.

Introduction: Partial pressure of brain tissue oxygen (PbtO2) has been shown to be a safe an effective monitoring modality to compliment intracranial pressure (ICP) monitoring. It is related to metabolic activity, disease severity and mortality. Research question: Understanding the complex relationship between PbtO2 and ICP for patients with traumatic brain injury will enable better clinical decision making beyond simple threshold treatment strategies. Material and methods: Patients with PbtO2 monitoring were identified from the BrainIT database, a multi-centre dataset, containing minute by minute PbtO2 and ICP readings. Missing data was imputed and a multi-level log-normal regression model with a compound symmetry correlation structure was built. This accounted for any increased correlation due to the repeated measurements. The model was adjusted for mean arterial pressure and the partial pressure of carbon dioxide. Non-linearity was assessed using analysis of deviance and trends using expected marginal means. Results: 11 subjects with over 82,000 readings were included. They had a median age of 38 (IQR: 37-47), 73% were male, a median length of stay of 11.8 (IQR: 6.6-19.7) days and a median extended Glasgow outcome scale of 7.00 (IQR: 5-8).There is a statistically significant (p < 0.001) non-linear effect of ICP on PbtO2. With an overall increase in PbtO2 of 5.2% (95% CI 4%-6.4%, p < 0.001) for a 10 mmHg increase in ICP below 22 mmHg and a decrease of 5.5% (95% CI 2.7%-8.3%, p=<0.001) in PbtO2 for a 10 mmHg increase in ICP above 22 mmHg. As well as a decrease of 40.9% (95% CI 2.3%-64.3%, p = 0.040) in PbtO2 per day in the intensive care unit. Discussion and conclusion: This model demonstrates that there is a significant non-linear relationship between ICP and PbtO2, however, this is a small heterogeneous cohort and further validation will be required.

Outcomes Post Beyond Total Mesorectal Excision Plane Resections Following Setting up Complex Colorectal Cancer Service in a District General Hospital.

Background: This study aims to validate the feasibility of a hub-and-spoke model for pelvic exenteration (PE) surgery while upholding favorable patient outcomes. Methods: A retrospective analysis of patients undergoing PE at our trust October 2017 and December 2023 was conducted. Descriptive statistics and Kaplan-Meier survival analysis were employed. Results: Sixty-seven patients underwent PE during the study period, mainly for locally advanced colorectal cancer (n=61, 91.04%). Minimally invasive surgery was performed in 16 cases (Robotic 3, 4.47% / Laparoscopic 13, 19.40) while the rest of patients 51 had open surgery (75.11%). Median hospital stay was 12 days (range:8-20). While 24 patients (35.82%) developed major complications (CD III-IV) post-surgery, there were no mortalities associated with pelvic exenteration in this study. Of the 67 patients undergoing surgery with curative intent, negative margins (R0 resection) were achieved in 57 patients (85.12%). This is comparable to outcomes reported by the PelvEx collaborative (85.07% versus 79.8%). At a median follow-up of 22 months, 15 patient (22.38%) recurred with 10.44% local recurrence rate. The 2 years overall and disease-free survival were 85.31% and 77.0.36%, respectively. Conclusion: Our study suggests that a nascent PE service, supported by specialist expertise and resources, can achieve good surgical outcomes within a district general hospital.

Can transcutaneous bilirubinometry safely be used to monitor rebound hyperbilirubinaemia after phototherapy in neonates ≥35 weeks' gestation? A prospective, comparative study.

INTRODUCTION: There is insufficient evidence to determine if non-invasive transcutaneous bilirubin (TcB) measurement can replace serum bilirubin (SBR) in assessing rebound hyperbilirubinaemia after phototherapy. OBJECTIVE: To investigate if TcB can safely guide management of neonates after phototherapy. SUBJECTS: 100 well neonates ≥35 weeks' gestation who had received inpatient phototherapy. METHOD: Measurement of both helix (manufacturer's recommendation) and earlobe TcB coincidentally with routine SBR 12 hours after cessation of phototherapy. All mothers gave written informed consent. RESULTS: Gestation ranged from 35+0 to 41+5 (median 37+6) weeks; birth weight 2018-4566 (median 3230) g; age 55-222 (median 109) hours at testing. 86% neonates were Caucasian. Outcomes determined by SBR included restarting phototherapy (n=0), repeat SBR next day (n=29), no further routine follow-up (n=71).TcB and SBR measurements were unpredictably inconsistent. Helix TcB tended to underestimate SBR (mean difference 50.1 (95% CI 113.9 to -13.7) µmols/L); for earlobe TcB mean difference was -13.4 (95% CI 46.3 to -73.2) µmols/L (overestimate), but bias was greater over the range of mean differences. No demographic factor predicted consistency between TcB and SBR. TcB was 25% (helix) and 76% (earlobe) sensitive in predicting repeat phototherapy and/or repeat SBR; specificities were 92% and 58%, respectively. Adding a safety margin of 120 µmols/L to helix TcB value could have safely avoided invasive SBR measurement in 50/98 (51%) babies. CONCLUSIONS: Consistency between TcB and rebound SBR is unpredictable in well neonates >35 weeks' gestation but adopting a wide safety margin has potential to reduce blood sampling. Recommencement of phototherapy is uncommon in this population.

Comparison of early surgical outcomes of robotic and laparoscopic colorectal cancer resection reported by a busy district general hospital in England.

Robotic platforms provide a stable tool with high-definition views and improved ergonomics compared to laparoscopic approaches. The aim of this retrospective study was to compare the intra- and short-term postoperative results of oncological resections performed robotically (RCR) and laparoscopically (LCR) at a single centre. Between February 2020 and October 2022, retrospective data on RCR were compared to LCR undertaken during the same period. Parameters compared include total operative time, length of stay (LOS), re-admission rates, 30-day morbidity. 100 RCR and 112 LCR satisfied inclusion criteria. There was no difference between the two group's demographic and tumour characteristics. Overall, median operative time was shorter in LCR group [200 vs. 247.5 min, p < 0.005], but this advantage was not observed with pelvic and muti-quadrant resections. There was no difference in the rate of conversion [5(5%) vs. 5(4.5%), p > 0.95]. With respect to perioperative outcomes, there was no difference in the overall morbidity, or mortality between RCR and LCR, in particular requirement for blood transfusion [3(3%) vs. 5(4.5%), p 0.72], prolonged ileus [9(9%) vs. 15(13.2%), p 0.38], surgical site infections [5(4%) vs. 5(4.4%), p > 0.95], anastomotic leak [7(7%) vs. 5(4.4%), p 0.55], and re-operation rate [9(9%) vs. 7(6.3%), p 0.6]. RCR had shorter LOS by one night, but this did not reach statistical significance. No difference was observed in completeness of resection but there was a statically significant increase in lymph node harvest in the robotic series. Robotic approach to oncological colorectal resections is safe, with comparable intra- and peri-operative morbidity and mortality to laparoscopic surgery.

Laparoscopic right hemicolectomy with complete mesocolic excision and D3 lymphadenectomy using the open book approach: a video vignette.

According to the concept of total mesorectal excision for rectal cancer, Hohenberger translated this concept to colonic cancer by introducing complete mesocolic excision (CME). The concept of this surgical technique was further elucidated by Benz et al. in the form of an open book approach. This article presents and demonstrates in a video a case of laparoscopic right hemicolectomy with CME and D3 lymphadenectomy using open book approach in the treatment of a T3N1M0 distal ascending colonic adenocarcinoma. The final pathology report confirmed moderately differentiated adenocarcinoma with a maximum tumor size of 55 mm and 0/60 lymph nodes. The mesocolic fascia was intact and R0 was achieved. The final staging was pT3pN0pM0. However, D3 lymphadenectomy is not universally adopted due to concerns of higher morbidity we believe that with adequate training and supervision CME with D3 LDN is feasible and safe to be offered to all right-sided colorectal cancers with curative intent treatment.

Peer coaching, implementation support and organisational power.

This article looks at the effects of power (conceived as complex and multi-directional) on the collaborative, interprofessional relationships of peer coaches when delivering implementation support. The study conducted ethnographic observations, semi-structured interviews and documentary analysis to evaluate the dynamics of peer coaching during the implementation of an evidence-based programme, Patient and Family Centred Care (PFCC), to improve 24 end-of-life care services. The article draws on perspectives from critical management studies to offer insights on the effect of organisational power on collaborations during the administration of peer coaching. This article details the difficulties that organisational power structures posed to interprofessional peer-coaching collaborations. Many of the peer coaches found it difficult to place their advice in the existing ethos of organisations, existing organisational hierarchies, or collaborate in the midst of staff turnover and general time management outside of their control. These considerations meant that successful peer-coaching collaborations and the success of the implementation programme were often divergent.

Radiofrequency thermocoagulation of haemorrhoids: learning curve of a novel approach.

Haemorrhoidal disease (HD) is a common condition that often requires surgical treatment. In comparison with other traditional techniques, radiofrequency thermocoagulation (RFTC) has multiple advantages to traditional repairs and can be a good alternative in surgical management of HD. We retrospectively analysed 20 patients with Grades 2 (n = 6, 30%) and 3 (n = 12, 70%) haemorrhoids undergoing RFTC from 1 September 2019 to 31 December 2021. Outcomes including post-operative (PO) pain, immediate/late PO complications, recurrence and patient satisfaction were assessed. Twenty cases were included in this case series. All pathological symptoms showed significant improvement in PO period. Eight complications were noted, including minor bleeding (n = 2), bleeding that required admissions (n = 3), pain (n = 2) and recurrence (n = 1). The mean time off work is 7 days and all patients were satisfied or very satisfied PO as per telephone questionnaire. RFTC is a safe and effective solution in the management of HD and is a good alternative to conventional procedures.

Defining, conceptualizing and evaluating pragmatic qualities of quantitative instruments measuring implementation determinants and outcomes: a scoping and critical review of the literature and recommendations for future research.

The pragmatic (i.e., practical) quality of quantitative implementation measures has received increased attention in the implementation science literature in recent years. Implementation measures that are judged to be pragmatic by implementation stakeholders are thought to be more likely to be applied in research and practice. Despite the need for pragmatic implementation measures, ambiguity and uncertainty regarding what constitutes a pragmatic measure remains. This study sought to identify and critically appraise the published literature to understand (i) how pragmatism is defined as a measurement construct/quality of implementation determinants and outcome instruments; (ii) how pragmatic qualities of instruments are evaluated; (iii) identify key gaps and limitations of the current evidence-base and (iv) identify recommendations for future research. We conducted a scoping review of the literature also employing methods of critical review. PubMed and PsycINFO databases, using the OVID interface, were searched for relevant articles published between January 2010 and September 2020. Articles that contained a definition and/or described characteristics of "pragmatism" as a measurement construct of quantitative implementation outcomes (as defined by Proctor's Implementation Outcomes taxonomy) and/or implementation determinants were eligible for inclusion. Nine articles met inclusion criteria. A degree of overlap in definitions and terms used to describe the pragmatic qualities of quantitative implementation determinant and outcome instruments were found. The most frequently cited descriptors of pragmatism were "not burdensome", "brief", "reliable", "valid" and "sensitive to change". 3 of the 9 included articles involved international implementation stakeholders in defining and conceptualizing pragmatism and employed specific methods to do so, including a systematic literature review, stakeholder interviews, concept mapping, and a Delphi process. All other articles defined pragmatism, with or without citing relevant literature. One article objectively assessed the pragmatic qualities, above and beyond the psychometric qualities, of implementation measures, using the Psychometric and Pragmatic Evidence Rating Scale (PAPERS). The evidence base within the implementation instrumentation literature on what pragmatism is and how it might be assessed is limited. Some of the research identified in the review provides a strong foundation to build upon, by testing its applicability in other settings (including healthcare areas and countries) and among a more diverse group of stakeholders. We discuss directions for further development of the concept of pragmatism relating to the measurement of implementation determinants and outcomes.

The need for pragmatic (i.e., practical) measures to evaluate implementation efforts has been repeatedly called for in the implementation science literature. This literature review focuses on understanding how pragmatism, as a measurement construct and quality of implementation measures, is defined, conceptualized and evaluated. We identified few articles (n = 9) that contribute to our understanding of how pragmatism is defined and evaluated. We found that the most frequently used terms to describe pragmatic qualities of implementation measures include "not burdensome", "brief", "reliable", "valid" and "sensitive to change". We identified one scale, the Psychometric and Pragmatic Evidence Rating Scale (PAPERS), developed to measure the pragmatic quality, as well as psychometric quality, of implementation measures. We identified several gaps and limitations of the current evidence-base and offer directions to further develop the concept and appraisal of pragmatism. Specifically, we recommend that future research focus on engaging and involving a wider diversity of implementation stakeholders in defining and conceptualizing pragmatism as well as subjecting existing pragmatic assessment measures to more rigorous and extensive evaluation.

Torture-survivors' experiences of healthcare services for pain: a qualitative study.

BACKGROUND: Increasing numbers of torture-survivors are presenting to UK healthcare services with persistent pain. However, there is a paucity of evidence surrounding the management of persistent pain among torture-survivors and their experience of healthcare services for pain is currently unknown. This qualitative study explores their experiences of services for managing pain, to inform clinical practice and service provision. METHODS: Thirteen participants were recruited from a specialist pain clinic for torture-survivors in the United Kingdom. Utilising an ethnographic approach, data were collected via clinic appointment observations, interviews and medical records and analysed using inductive thematic analysis. RESULTS: Three themes emerged in relation to torture-survivors' experiences of healthcare services for pain: the patient-clinician relationship; multiplicity of diagnoses and treatments; lack of service integration. Participants described limited engagement in decision-making processes regarding their care. Lack of recognition of torture experience when diagnosing and treating pain, alongside multiple unsuccessful treatments, led to confusion, frustration and hopelessness. These issues were exacerbated by the disconnect between physical and mental health services. CONCLUSION: This study provides new insight into the challenges faced by torture-survivors when accessing healthcare services for pain. Our findings suggest current service provision is not meeting their complex needs. Clinical implications include the need for integrated care systems and better recognition of the influence of torture experience on persistent pain. Strategies to engage and empower torture-survivors in the management of their pain are suggested.

Telemetric Intracranial Pressure: A Snapshot Does not Give the Full Story.

Telemetric intracranial pressure (ICP) monitors are useful tools in the management of complex hydrocephalus and idiopathic intracranial hypertension (IIH). Clinicians may use them as a "snapshot" screening tool to assess shunt function or ICP. We compared "snapshot" telemetric ICP recordings with extended, in-patient periods of monitoring to determine whether this practice is safe and useful for clinical decision making.

The Cultural Politics of 'Implementation Science'.

Despite the growing profile of 'implementation science', its status as a field of study remains ambiguous. Implementation science originates in the evidence-based movement and attempts to broaden the scope of evidence-based medicine to improve 'clinical effectiveness' and close the 'implementation gap'. To achieve this agenda, implementation science draws on methodologies from the social sciences to emphasise coherence between qualitative and quantitative approaches. In so doing, we ask if this is at the expense of ignoring the dominating tendencies of the evidence-based movement and consider if some of the methodologies being drawn on should be considered irreconcilable with evidence-based methodologies.

The emotional labour of quality improvement work in end of life care: a qualitative study of Patient and Family Centred Care (PFCC) in England.

BACKGROUND: There is a growing emphasis on understanding patient experience in order to inform efforts to support improvement. This paper reports findings from an implementation study of an evidence-based intervention called Patient and Family Centred Care (PFCC) designed to tap into patient experiences as a basis for improvement. In this study the PFCC intervention was spread to a new service area (end of life care) and delivered at scale in England. The findings presented here focus specifically on one key aspect of the intervention: staff shadowing of patients, and the experiences of staff carrying out shadowing for the purposes of service improvements. METHODS: The study methods were ethnographic observations of key events, semi-structured interviews with members of participating teams and the programme implementation support team and managers, and a review of the documents used in the set up and running of the programme. RESULTS: One of the key strengths of the PFCC approach is to encourage staff through shadowing to engage with patient experience of services. Many staff described the process of shadowing as a transformative experience that alerted them to immediate areas where their services could be improved. However, engaging with patient experience of end of life care services also had unintended consequences for some staff in the form of emotional labour. Furthermore, we observed difficulties encountered by staff that are not accounted for in the existing PFCC literature relating to how care service structures may unevenly distribute the amount of 'emotional labour' that staff members need to invest in implementing the programme. CONCLUSIONS: Connecting with patient experience is a crucial aspect of a number of quality improvement interventions that aim to help staff to engage with the lived experience of their services and reconnect their motivations for working in the health care system. However, there may be unintended consequences for health care service staff, particularly in sensitive areas of service delivery such as end of life care. The 'emotional labour' for staff of engaging in quality improvement work informed by patient experience should be considered in planning and supporting patient experience led quality improvement.

A Novel Application of Indocyanine Green Immunofluorescence in Emergent Colorectal Surgery.

Here, we report on the feasibility of ICG fluorescence imaging to localize lesions in emergent minimally invasive surgery. A 49-year old female presented to the emergency department with a previously unknown malignant bowel obstruction. She was taken emergently to the operating room for a laparoscopic extended right hemicolectomy, based on tumor location from imaging. With intraoperative difficulty localizing the lesion, an on-table colonoscopy was performed. When the tumor was encountered, peritumoral ICG injections were performed, and the fluorescence lymphoscintigraphy was performed intraoperatively in an attempt to visualize the primary tumor laparoscopically. Intraoperative ICG Immunofluorescence allowed precise, real-time localization of the mass in the descending colon. This information changed the course of the operation, as a laparoscopic left hemicolectomy was then performed instead of the planned extended right hemicolectomy. The patient underwent an end-to-end anastomosis without the need for a defunctioning ileostomy. From this case, we demonstrate the use of ICG fluorescence imaging for tumor localization in the emergent setting is safe, feasible, and effective. This information gained from this technology enables real-time decision making, and can even change the operative plan in the emergent setting for the best patient outcomes. What does this paper add to the existing literature? This paper offers a novel application of an emerging technology- ICG fluorescence- that in this capacity allowed precise, real-time localization of a previously unknown mass in the emergent setting, and changed the course of the operation.

An unusual inguinoscrotal hernia with renal involvement.

We present a case of a 74-year-old man who, while in intensive treatment unit for an upper gastrointestinal bleed, decompensated cardiac failure and concurrent pneumonia, was found to have a large right hydronephrotic pelvic kidney and bladder within the hernia. After discharge, he was medically optimised for 7 months before undergoing an elective open mesh repair of his hernia. During the procedure, drainage of a large hydrocoele was performed to facilitate reduction of the hernia. Postoperatively, he underwent ureteric stenting due to a persistent hydronephrosis with impairment of his renal function. He subsequently made a good recovery and was discharged home with outpatient follow-up planned.

Neonatal visual evoked potentials in infants born to mothers prescribed methadone.

OBJECTIVE: Drug misuse in pregnancy is associated with impaired infant visual development. Pilot data showed abnormal flash visual evoked potentials (VEPs) in neonates exposed to methadone in utero, but results were confounded by intrauterine growth restriction, gestation, and ongoing drug misuse. This large cohort study aimed to clarify the effects on neonatal flash VEPs of maternal drug misuse in pregnancy, including prescription of substitute methadone and subsequent development of neonatal abstinence syndrome. METHODS: This was a prospective cohort study. Flash VEPs were recorded within 3 days of birth from 100 healthy infants of drug-misusing mothers prescribed substitute methadone during pregnancy and 50 comparison infants matched for birth weight, gestation, and socioeconomic deprivation. VEP morphology was classified as mature, typical, or immature, and amplitudes and implicit times of the major waveform components measured. Drug exposure was determined by maternal history, maternal and infant urine, and meconium toxicology. RESULTS: VEPs from maternal drug-exposed infants were more likely to be of immature waveform (P < .001) and were smaller in overall amplitude (median 27 µV vs 39 µV, P < .001) compared with non-drug-exposed infants. Most infants were exposed to illicit drugs in addition to prescribed methadone; differences in VEP parameters were independently associated with maternal prescribed methadone and persisted after correcting for birth weight, cigarette smoking, and excess in utero alcohol exposure. CONCLUSIONS: In utero exposure to prescribed substitute methadone is associated with altered flash VEPs in the newborn period and these infants may warrant early clinical visual assessment.

The template technique for breast mound planning when using abdominal flaps for breast reconstruction.

Delayed breast reconstruction with abdominal flaps typically involves a process of 'trial and error' when moulding the flap into a satisfactory breast mound. This moulding process is crucial to the final aesthetic result. We present a template technique to preoperatively plan the skin envelope of each reconstruction. Templates are quick and simple to construct, and are tailor-made based on several measurements from the contralateral breast. The technique is versatile and can be adjusted for use with Wise-pattern breast reduction or mastopexy. In our experience, the template technique reliably attains natural shape and good symmetry when compared with unplanned flap moulding.