Non-melanoma skin cancer activity during the COVID-19 pandemic- A single UK tertiary centre experience.

The pandemic caused by SARS-CoV-2 virus, also known as COVID-19, has generated shockwaves in medical and surgical practice. It has necessitated re-deployment of staff and resources to cater for the unpredictable increase in footfall and demand on healthcare systems. This study aimed to investigate how the restructuring of our service altered the triage and management of non-melanoma skin cancer (NMSC) during the pandemic's first wave rise and peak. We retrospectively analysed all patients who underwent a skin excision under local anaesthetic which revealed the presence of a basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) on histopathological analysis between 1st February 2020 - 31st May 2020 compared with the same period in 2019. There was a 158% increase in patients with excision of lesions confirmed on histopathological analysis as a NMSC during the COVID-19 period (168 vs. 65). In 2020, more excisions were performed by consultants (42.9% v 21.5%, p = 0.002) with a lower proportion of excisions with a close margin (27.7% v 17.8%, p = 0.096) and an involved margin (3.1% v 1.8%, p = 0.62). Five of these patients had their further management altered due to service constraints at this time The resource constraints secondary to the pandemic have yielded beneficial service adaptations with the incorporation of a more efficient model for the NMSC service. The sustainability of this model and its impact on training will require further examination when non-urgent and benign elective workload is slowly reinstated and plastic surgery trainees return to their original posts.

A retrospective analysis of rates of allergic reaction to Patent V blue dye used in sentinel lymph node biopsies for melanoma.

Sentinel lymph node biopsies are a well-established component of the assessment and treatment pathway for patients with cutaneous melanoma in the UK. Commonly utilised techniques involve the use of blue dye which has an established risk of inducing allergic reactions in patients. Such reactions can be life-threatening, and this risk is important to highlight to patients. We conducted a retrospective review of all patients who had undergone this procedure at our melanoma centre in Cambridge, UK. From a group of 715 patients who received blue dye as part of the procedure, six patients suffered an allergic reaction (0.84%) with one of these treated as anaphylaxis. Our incidence of anaphylaxis is almost ten times greater than that reported in the NAP6 report led by the National Institute of Academic Anaesthesia and significantly higher than reported by others. We propose several reasons why our results differ from previous estimates. This study has focused only on patients undergoing a sentinel node procedure for melanoma, others have focused on such procedures performed on patients with breast cancer and some have combined the two. The administration technique, volume and anatomical distribution of disease all differ significantly from melanoma, possibly influencing rates and severity of allergic reactions.

In vitro and in vivo evaluation of some antimicrobials and disinfectants against bacterial pathogens from hoof lesions in dairy cattle.

BACKGROUND: Lameness in dairy cattle is prevalent worldwide and has serious economic and welfare implications. Nevertheless, it is an overlooked and least studied dairy problem in Pakistan. AIMS: This study was executed for in vivo and in vitro evaluation of antimicrobials and disinfectants against bacterial pathogens from hoof lesions of commercial dairy cattle. METHODS: For in vitro studies, 23 bacterial isolates (n=10 Staphylococcus aureus, n=8 Fusobacterium necrophorum, and n=5 Bacteroides) from hoof lesions were used for antimicrobial and disinfectants susceptibility testing. In vivo trials were carried out among 4 groups of dairy cows suffering from hoof lesions using different combinations of antimicrobials, non-steroidal anti-inflammatory drugs (NSAIDs), and disinfectants either parenterally or topically. RESULTS: Results indicated that most of the isolates of S. aureus, F. necrophorum, and Bacteroides were resistant to penicillin, amoxicillin, trimethoprim + sulphamethoxazole, oxytetracycline, and tylosin. Ciprofloxacin and gentamicin were the most effective antimicrobials (in vitro) against all three bacterial pathogens. Comparison of in vitro efficacy of disinfectants showed that copper sulfate was the most effective disinfectant against the three pathogens followed by povidone-iodine and chloroxylenol. In vivo trials revealed that ciprofloxacin at 5 mg/kg/day intramuscular (IM) for 7 days, flunixin meglumine at 2.2 mg/kg/day IM for 7 days, and copper sulfate (5% solution) as foot-bath twice daily for 21 days was the most effective treatment regimen to treat lameness in commercial dairy cows. CONCLUSION: It was concluded that in vitro antibiogram and disinfectant studies were useful tools to assess the effectiveness of routinely used antimicrobials and disinfectants for the treatment of lameness.

A new clinical presentation: breast implant pneumocapsule and pneumothorax following penetrating chest wall trauma.

Pneumothorax resulting from traumatic thoracic injury is a potentially life-threatening emergency requiring prompt recognition and management with an intercostal drain. A 34-year-old woman was brought into the emergency department after sustaining a stab injury to the right upper outer quadrant of the right breast. She described noticing a jelly-like substance from her wound, on the background of a prior cosmetic breast augmentation. On examination, it was noted that the right breast was significantly swollen. Computed tomography demonstrated a large right sided pneumothorax with associated punctured right breast implant, a 'pneumocapsule' and extensive subcutaneous emphysema of the breast. This case highlights that the fibrous tissue capsule around a breast implant can function as an anatomical space in continuity with the thoracic cavity, masking the diagnosis of pneumothorax in penetrating trauma.

Achieving Self-Directed Integrated Cancer Aftercare (ASICA) in melanoma: protocol for a randomised patient-focused pilot trial of delivering the ASICA intervention as a means to earlier detection of recurrent and second primary melanoma.

BACKGROUND: Melanoma is common; 15,906 people in the UK were diagnosed with melanoma in 2015 and incidence has increased fivefold in 30 years. Melanoma affects old and young people, with poor prognosis once metastatic. UK guidelines recommend people treated for cutaneous melanoma receive extended outpatient, hospital follow up to detect recurrence or new primaries. Such follow up of the growing population of melanoma survivors is burdensome for both individuals and health services. Follow up is important since approximately 20% of patients with early-stage melanoma experience a recurrence and 4-8% develop a new primary; the risk of either is highest in the first 5 years. Achieving Self-directed Integrated Cancer Aftercare (ASICA) is a digital intervention to increase total-skin-self-examination (TSSE) by people treated for melanoma, with usual follow up. METHODS: We aim to recruit 240 adults with a previous first-stage 0-2C primary cutaneous melanoma, from secondary care in North-East Scotland and the East of England. Participants will be randomised to receive the ASICA intervention (a tablet-based digital intervention to prompt and support TSSE) or control group (treatment as usual). Patient-reported and clinical data will be collected at baseline, including the modified Melanoma Worry Scale (MWS), the Hospital Anxiety and Depression Scale (HADs), the EuroQoL 5-dimension 5-level questionnaire (EQ-5D-5 L), and questions about TSSE practice, intentions, self-efficacy and planning. Participants will be followed up by postal questionnaire at 3, 6 and 12 months following randomization, along with a 12-month review of clinical data. The primary timepoint for outcome analyses will be12 months after randomisation. DISCUSSION: If the ASICA intervention improves the practice of TSSE in those affected by melanoma, this may lead to improved psychological well-being and earlier detection of recurrent and new primary melanoma. This could impact both patients and National Health Service (NHS) resources. This study will determine if a full-scale randomised controlled trial can be undertaken in the UK NHS to provide the high-quality evidence needed to determine the effectiveness of the intervention. ASICA is a pilot study evaluating the effectiveness of the practice of digitally supported TSSE in those affected by melanoma. TRIAL REGISTRATION: Clinical Trials.gov, NCT03328247 . Registered on 1 November 2017.

Bacterial count and predisposing factors of Clostridium perfringens (targeting CPA gene) infection along with antimicrobial sensitivity in diarrheic sheep in Pakistan.

Clostridium perfringens (C. perfringens) is a normal inhabitant in the gut of animals. It may proliferate rapidly in favorable conditions and produces lethal toxins. These toxins may cause lethal effects in the intestines and systemically it may cause enterotoxaemia. In disease conditions, the presence of C. perfringens CFU/g in fecal sample can be of diagnostic value. This study aims to determine the bacterial counts and predisposing factors of C. perfringens (targeting CPA gene) infection in addition to an in-vitro antimicrobial trial in entero-toxemic sheep in Pakistan. A total of 192 diarrheic sheep irrespective of age, gender and breed were selected and the CFU/g was determined from the fecal samples. The study showed that 34.9% of the samples had elevated level of bacterial count compared to the normal (104-107 CFU/g). Out of the total, 7.8% of the samples had subnormal bacterial count (CFU/g), while, 57.3% of the samples showed bacterial counts in the normal ranges. The confirmation of selectively isolated C. perfringens was done by amplification of 324bp CPA gene fragment using polymerase chain reaction (PCR). The in-vitro antimicrobial sensitivity trials showed that penicillin, ciprofloxacin and ceftriaxone are 100% efficacious against C. perfringens, while, bacitracin, ampicillin and amoxicillin were found to be least effective. The key determinants in this study which support the in-vivo growths of C. perfringens were; carbohydrate rich diet and overcrowding with the odds ratios (OR) of 5.44 and 2.26, respectively. This study concludes that C. perfringens is highly prevalent in sheep population of Pakistan. The incidence of enterotoxaemia can be minimized by controlling the factors which enhance its in-vivo growth. The diseased animal associated with elevated C. perfringens levels can be effectively cured using any one of the penicillin, ciprofloxacin and ceftriaxone.

l-Cysteine improves antioxidant enzyme activity, post-thaw quality and fertility of Nili-Ravi buffalo (Bubalus bubalis) bull spermatozoa.

The effects of l-cysteine in extender on antioxidant enzymes profile during cryopreservation, post-thaw quality parameters and in vivo fertility of Nili-Ravi buffalo bull spermatozoa were studied. Semen samples from 4 buffalo bulls were diluted in Tris-citric acid-based extender having different concentrations of l-cysteine (0.0, 0.5, 1.0, 2.0 and 3.0 mm) and frozen in 0.5-ml French straws. The antioxidative enzymes [catalase, super oxide dismutase and total glutathione (peroxidase and reductase)] were significantly higher (P < 0.05) at pre-freezing and post-thawing in extender containing 2.0 mm l-cysteine as compared to other groups. Post-thaw total motility (%), progressive motility (%), rapid velocity (%), average path velocity (µm s-1 ), straight line velocity (µm s-1 ), curvilinear velocity (µm s-1 ), beat cross frequency (Hz), viable spermatozoa with intact plasmalemma (%), acrosome and DNA integrity (%) were higher with the addition of 2.0 mm l-cysteine as compared to other groups (P < 0.05). The fertility rates (59 versus 43%) were higher (P < 0.05) in buffaloes inseminated with doses containing 2.0 mm of l-cysteine than in the control. In conclusion, the addition of 2.0 mm l-cysteine in extender improved the antioxidant enzymes profile, post-thaw quality and in vivo fertility of Nili-Ravi buffalo bull spermatozoa.

Risk factors involved in spread of HCV in patients from sub urban Rawalpindi and their association with existing genotypes.

The current epidemiological study was designed to trace the involved risk factors in Hepatitis C Virus (HCV) spread and to identify any association between HCV genotypes and risk factors. Blood samples were taken from 400 participants and viral genotyping was performed in order to find any possible relationship between the risk factors and genotypes. Major genotypes included 3, 1, 4 and several untypeable ones with prevalence rates 65%, 22.5%, 2.75% and 9.75% respectively. Surgery and dental procedure were strongly related to the spread of genotype 3b, while genotype 1b was strongly related to blood transfusion and dental procedures as a single combination risk factor. On the other hand genotypes 1a, 3a, 4 and the untypeable genotypes, were equally affected by all reported risk factors. The probability of occurrence of genotype 3a with reference to dental procedures was 11%. Dental procedures, unsafe injection and surgical procedures are the main risk factors while the blood transfusion in combination with dental procedures has emerged as a potent risk factor in the transmission of HCV.

A Novel Combined Hybrid Approach to Enable Revascularisation of a Trauma-Induced Subclavian Artery Injury.

INTRODUCTION: This case highlights the complexity of upper limb revascularization after a subclavian artery traumatic injury and strengthens the role of a hybrid/multi-disciplinary approach to such injuries. REPORT: A 45-year-old male patient presented with an acute right upper limb following a traumatic injury to the right subclavian artery due to a motor vehicle accident (MVA). Associated injuries included an unstable cervical spine injury, a large open right clavicular injury, and a brain injury, which limited the potential revascularisation options available. The arm was revascularised using a hybrid endovascular/open surgical approach, namely embolization of the proximal subclavian artery (just distal to vertebral artery) and a right common femoral artery to distal axillary artery bypass using prosthetic material. DISCUSSION: Blunt injuries to the subclavian artery are often high impact, complex and associated with multiple injuries to surrounding structures, which limit the role of standard procedures used in the elective setting. This case highlights the role of multidisciplinary team involvement, using a hybrid approach and a novel distal inflow site to restore upper limb perfusion.

Free tissue transfer in head and neck reconstruction: 100 consecutive cases.

OBJECTIVES: Free flap reconstruction of head and neck defects is a rapidly changing field. We present a case series in this field in which we critically assess our survival rates and complications, and we highlight specific technical variables that may be associated with improved outcomes. METHODOLOGY: This case series from a tertiary medical centre comprises 100 consecutive head and neck microvascular free flap reconstructions. Medical notes were reviewed specifically for indications, adjuvant and neoadjuvant chemoradiotherapy, complications, and outcome of the free flap. RESULTS: The overall flap survival rate was 99%, with a 6% return-to-theatre rate. Three cases had a general complication in the form of a non-flap compromising haematoma that necessitated a return to theatre for an evacuation. Specific microvascular anastomosis-related complication rate was 2% requiring salvage revision. One flap was lost due to infection. Of the 100 cases, 87% were fasciocutaneous free flaps, 7% were musculocutaneous, 5% were osseocutaneous, and one was a skin/cartilage free flap. With regard to indications for reconstruction, oncological resection accounted for 86% of cases; a total of 12% had mandibular bone involvement that required osseocutaneous reconstruction. CONCLUSIONS: We have highlighted specific technical steps we used that may have contributed to our positive results. Moreover, we encourage the use of standardised postoperative monitoring guidelines for all multidisciplinary surgical teams involved in head and neck patients; they facilitate communication and increase early detection of complications, permitting timely intervention, which may be critical for flap survival.

Systematic review of sentinel lymph node biopsy in anal squamous cell carcinoma.

BACKGROUND: Anal squamous cell carcinoma with lymph node metastases carries a poor outcome. There remains a need for a better method to diagnose inguinal lymph node metastases which is minimally invasive, accurate and avoids unnecessary irradiation to the groin with its associated significant co-morbidity. The aim of this study was to evaluate the role of sentinel lymph node (SLN) biopsy in anal squamous cell carcinoma. METHODS: The systematic review was conducted in accordance with PRISMA guidelines. The Medline, Central and Embase databases were searched using the terms 'sentinel lymph node' and 'anus neoplasms'. RESULTS: The systematic review identified 17 studies, containing 270 patients. SLN detection rate varied from 47% to 100%. The presence of nodal metastases varied from 0 to 44%. The complication rate varied from 0 to 59%. The rate of development of subsequent inguinal lymph node metastases in those previously SLN biopsy-negative (a surrogate marker for false negative rate) ranged from 0 to 18.75%. CONCLUSION: SLN biopsy is a feasible method of assessing lymph node status in patients with anal squamous cell carcinoma. Longer follow up is required to evaluate the proportion of patients who are SLN biopsy-negative and subsequently develop nodal metastases. More studies are required to ascertain whether SLN biopsy should be the main method of assessing inguinal lymph node involvement in patients with anal squamous cell carcinoma.

Employment outcomes in people with bipolar disorder: a systematic review.

OBJECTIVE: Employment outcome in bipolar disorder is an under investigated, but important area. The aim of this study was to identify the long-term employment outcomes of people with bipolar disorder. METHOD: A systematic review using the Medline, PsychInfo and Web of Science databases. RESULTS: Of 1962 abstracts retrieved, 151 full text papers were read. Data were extracted from 25 papers representing a sample of 4892 people with bipolar disorder and a mean length of follow-up of 4.9 years. Seventeen studies had follow-up periods of up to 4 years and eight follow-up of 5-15 years. Most studies with samples of people with established bipolar disorder suggest approximately 40-60% of people are in employment. Studies using work functioning measures mirrored this result. Bipolar disorder appears to lead to workplace underperformance and 40-50% of people may suffer a slide in their occupational status over time. Employment levels in early bipolar disorder were higher than in more established illness. CONCLUSION: Bipolar disorder damages employment outcome in the longer term, but up to 60% of people may be in employment. Whilst further studies are necessary, the current evidence provides support for extending the early intervention paradigm to bipolar disorder.

The utility of CT angiography in planning perineal flap reconstruction following radical pelvic surgery.

INTRODUCTION: Closure of the perineum following radical excision of pelvic tumours can prove to be a complex surgical problem. A number of pedicled flaps have been used for perineal reconstruction in order to reduce post-operative complications such as infection and abscess formation. The aim of this case series was to analyse the use of pre-operative computer tomography (CT) angiography to guide flap selection for perineal reconstruction following radical excision of pelvic tumours. METHODS: We conducted a retrospective review to identify all patients who underwent CT angiography prior to radical excision of pelvic tumours and planned flap reconstruction over an 18 month period. Six patients were identified and are presented in this case series. Patients' medical records, histology reports, pre-operative investigations and CT angiograms, complications and follow-up were reviewed. RESULTS: The mean patient age was 58.3 years, with a male to female ratio of 1:2. Four out of six patients (66.6%) underwent pre-operative radiotherapy. The deep inferior epigastric arteries (DIEA) were visualised in all six cases (100%) and the pre-operative CT angiography helped guide flap choice in all cases (100%). In one case, narrowing of the DIEA vessels was noted precluding the use of a DIEA-based flap. One patient had a minor superficial wound dehiscence. CONCLUSION: Pre-operative CT angiography allows accurate visualisation of the DIEA system including perforator vessels. CT angiography is a useful tool, providing the surgical team with significant additional information to aid pre-operative planning and optimise reconstructive choice and outcome.

The role of type-2 turkey astrovirus in poult enteritis syndrome.

An experimental study was conducted to determine the comparative pathogenicity of type-2 turkey astrovirus (TAstV-2) obtained from turkey flocks afflicted with poult enteritis syndrome (PES) and from turkey flocks displaying no apparent signs of infection. In total, ninety 7-d-old poults, which tested negative for the presence of astrovirus, rotavirus, coronavirus, and reovirus by reverse transcriptase (RT) PCR , were divided evenly into 3 groups: A, B, and C. Birds in group A were inoculated orally with turkey astrovirus-positive intestinal contents from birds affected with PES. Group B received turkey astrovirus-containing intestinal contents from apparently healthy flocks. Group C served as a negative control and was given PBS. Clinical signs of diarrhea, depression, and dullness were observed in group A. Birds in group B also showed clinical signs similar to those in group A, although the signs were milder in nature. Birds in group C did not show any clinical signs. At 16 d postinoculation, the BW of birds in group A was significantly lower than that of birds in groups B or C. In addition, the bursa size was reduced in group A, but not in groups B or C. Birds in groups A and B, but not in group C, were found to shed turkey astrovirus in their feces, as detected by RT-PCR. These results provide a preliminary indication that TAstV-2 from PES birds may be more pathogenic than TAstV-2 from apparently healthy poults. Further studies are needed to determine if pathogenic and nonpathogenic strains of TAstV-2 exist in the environment. These results also reinforce our previous observations that astrovirus is involved in PES, causing significant retardation in growth and weight gain.

Intrabiliary rupture of hepatic hydatid cyst: role of ERCP.

We report a case of hepatic hydatid cyst presenting with obstructive jaundice following cholecystectomy. ERCP showed intrabiliary cyst rupture with biliary obstruction due to cyst remnants. Endoscopic sphincterotomy was performed and cyst debris removed with complete resolution of symptoms.