White phosphorous civilian hand burns - An aid to timely treatment of a rare entity.

First discovered in 1669, white phosphorus is well known for its use in military warfare (Davis, 2002). Its application has since been expanded to include industrial disinfectants, fertilisers and fireworks (Davis, 2002). Exposure to white phosphorus can lead to severe chemical burns with high morbidity and potentially fatal systemic effects. Fortunately, civilian casualties from this potent agent are remarkably rare with few reports in the literature to date (Frank et al., 2008; Aviv et al., 2017). We present the case of a 27-year-old fisherman who sustained a chemical burn to his right hand from a substance suspected to be white phosphorus. We propose an evidence-based algorithm to guide non-military physicians literature on the acute management of white phosphorus burns to optimise timely emergency management of this uncommonly encountered substance.

Management Experiences of Post-Gastrectomy Severe Alkaline Reflux Esophagitis.

Alkaline reflux esophagitis is a recognized complication of procedures that compromise the lower esophageal sphincter (LES), including gastrectomy. Incidence of reflux is dependent on the reconstructive procedure, with Roux-en-Y (RY) esophagojejunostomy commonly accepted as the optimal method. The authors report their experience of 5 patients who underwent remedial intervention for severe alkaline reflux esophagitis following gastric cancer surgery, over a 6-year period (2014-2020). Primary diagnoses encompassed 4 gastric adenocarcinomas and 1 gastric neuroendocrine tumor. Four patients previously underwent total gastrectomy and 1 subtotal gastrectomy with RY reconstruction. Onset of postoperative reflux symptoms ranged from 2 weeks to 3 years. Failing medical management, all patients underwent jejunojejunal anastomosis and Roux limb length revision with surgical jejunostomy. At follow-up, 4 out of 5 patients had some degree of symptom resolution and one with unresolved symptoms. The authors report our experience of managing this complication following gastrectomy with jejunojejunal anastomosis and Roux limb length revision.

PD-1 blockade attenuates surgery-mediated immunosuppression and boosts Th1 immunity perioperatively in oesophagogastric junctional adenocarcinoma.

Introduction: This timely study assesses the immunosuppressive effects of surgery on cytotoxic Th1-like immunity and investigates if immune checkpoint blockade (ICB) can boost Th1-like immunity in the perioperative window in upper gastrointestinal cancer (UGI) patients. Methods: PBMCs were isolated from 11 UGI patients undergoing tumour resection on post-operative days (POD) 0, 1, 7 and 42 and expanded ex vivo using anti-CD3/28 and IL-2 for 5 days in the absence/presence of nivolumab or ipilimumab. T cells were subsequently immunophenotyped via flow cytometry to determine the frequency of T helper (Th)1-like, Th1/17-like, Th17-like and regulatory T cell (Tregs) subsets and their immune checkpoint expression profile. Lymphocyte secretions were also assessed via multiplex ELISA (IFN-γ, granzyme B, IL-17 and IL-10). The 48h cytotoxic ability of vehicle-, nivolumab- and ipilimumab-expanded PBMCs isolated on POD 0, 1, 7 and 42 against radiosensitive and radioresistant oesophageal adenocarcinoma tumour cells (OE33 P and OE33 R) was also examined using a cell counting kit-8 (CCK-8) assay to determine if surgery affected the killing ability of lymphocytes and whether the use of ICB could enhance cytotoxicity. Results: Th1-like immunity was suppressed in expanded PBMCs in the immediate post-operative setting. The frequency of expanded circulating Th1-like cells was significantly decreased post-operatively accompanied by a decrease in IFN-γ production and a concomitant increase in the frequency of expanded regulatory T cells with an increase in circulating levels of IL-10. Interestingly, PD-L1 and CTLA-4 immune checkpoint proteins were also upregulated on expanded Th1-like cells post-operatively. Additionally, the cytotoxic ability of expanded lymphocytes against oesophageal adenocarcinoma tumour cells was abrogated post-surgery. Of note, the addition of nivolumab or ipilimumab attenuated the surgery-mediated suppression of lymphocyte cytotoxicity, demonstrated by a significant increase in tumour cell killing and an increase in the frequency of Th1-like cells and Th1 cytokine production. Conclusion: These findings support the hypothesis of a surgery-mediated suppression in Th1-like cytotoxic immunity and highlights a rationale for the use of ICB within the perioperative setting to abrogate tumour-promoting effects of surgery and ameliorate the risk of recurrence.

The educational value of the multi-disciplinary meeting (MDM) in surgical oncology: A systematic review and thematic content analysis.

Multidisciplinary meetings are an important part of cancer care and surgical planning. However, there is also an important educational role of MDMs in training the next generation of surgical oncologists. This systematic review (SR) aimed to examine the current educational role of the surgical oncology MDM and identify areas for improving educational value. Medline, OVID, EMBASE, CINHIL and Web of Science were searched using a predefined search strategy in keeping with the PRISMA statement. Data was analysed and synthesized in narrative format and thematic content analysis was performed. Three main groups of studies were identified, those with: 1. A simulated non-clinical MDM (3/13), 2. clinical MDMs with a defined educational intervention (1/13) and 3. observational studies that described the educational benefit of the clinical MDM with no intervention (9/13). Satisfaction rates were high and learning outcomes improved where an intervention to improve the educational content of the MDM had been implemented(simulated or non-simulated). Respondents considered the MDM a valuable tool for learning non-technical skills and training surgical oncologists and medical students. Using defined interventions e.g. debriefing post MDM, or simulation can improve the educational benefit for learners. Qualitative analysis identified clinical knowledge, decision making and the acquisition of non-technical skills as the key themes within included studies.

Dual Intra-Articular Fracture of the Body and Hook of Hamate: A Delayed Presentation.

Fractures of the hamate bone are an unusual clinical entity. Dual fractures involving both the body and the hook of the hamate are even more unique, with only two previous cases described in the literature, to our knowledge. Clinicians are often unfamiliar with the presenting signs of this unusual injury, and subsequently, diagnosis is often delayed or missed entirely. We describe the case of a 19-year-old male who sustained an intra-articular body of hamate fracture with an ipsilateral hook of hamate fracture in his dominant hand. He presented 10 days following the initial injury and was managed with open reduction and internal fixation (ORIF).

Erysipelothrix rhusiopathiae Prosthetic Joint Infection in an Immunocompromised Patient: A Case Report.

CASE: We report the case of an immunosuppressed 65-year-old man with prosthetic joint infection (PJI) 23 years postoperatively because of Erysipelothrix rhusiopathiae, through hematogenous seeding of cutaneous erysipeloid. Immunotherapy was discontinued, washout was performed, and antimicrobial therapy was guided by laboratory sensitivities. The patient was discharged on suppressive oral ciprofloxacin monotherapy. First-stage revision was performed at 5 months after presentation-subsequent aspiration at 1 year postoperatively demonstrated no organisms and no leucocytes. At 18-month follow-up, the patient continues to do well and has elected not to proceed with second-stage surgery. CONCLUSION: E. rhusiopathiae is a rarely seen pathogen in PJI-it should be considered with immunosuppression and relevant exposure risks. The patient achieved good clinical outcome and has experienced no sequelae to date.