Multiple Distal Femoral Osteochondromas Encasing Popliteal Neurovascular Bundle.

Multiple hereditary exostosis syndrome is a rare diagnosis with approximately 1:50000 incidence prevailing in males. The exostoses or osteochondromas are benign but have the potential for malignant transformation in 1-5%. There is a strong genetic component, with exostosis (EXT) signaling pathways being an underlying cause. They can be symptomatic, with pain and functional deficit as the main complaints. We present a case of a 17-year-old male who presented with pain and anatomical deformity in his left lower femur. Magnetic resonance imaging revealed multiple osteochondromas compressing the popliteal neurovascular bundle. Excision of the osteochondromas was performed to decompress the neurovascular bundle in a multidisciplinary approach. Histological examination demonstrated no evidence of malignancy. Currently, there is no consensus for patients diagnosed with multiple osteochondromas regarding further investigation and/or screening for malignant transformation.

Evaluating Keratoplasty for Fuchs' Endothelial Corneal Dystrophy: A Literature Review.

Fuchs' endothelial corneal dystrophy (FECD) is progressive corneal endothelium dysfunction, characterised by corneal oedema, and potential blindness if left untreated. Keratoplasty is the only definitive treatment to restore vision in FECD, with different surgical techniques being described. The corneal transplant has been described as the most commonly performed and most successful allogenic transplant globally; therefore, it is crucial to dissect it further since a large proportion of the population worldwide is likely to be impacted. We feel that an updated literature review is both very relevant and necessary at present and aim to amalgamate more recent data on the topic (including meta-analyses, systematic reviews, and randomised control trials (RCTs), among others). We acknowledge that the paucity of reliable data limits progress for FECD and that there are existing ethical complexities in performing prospective trials on patients.  Traditionally, the surgery for FECD was limited to penetrating keratoplasty (PK), yet recent developments have introduced more advanced procedures and adapted the existing ones, to provide treatment specific to the disease-affected corneal layers. The questions we will address encompass: how does the severity of FECD govern the treatment options available, what are the differences between PK and types of endothelial keratoplasty (EK), what are the expected clinical outcomes of each of these operations, what are the potential concerns with the idealistic descemetorhexis surgery, and what do we envisage for times to come? Besides this, novel minimally-invasive pharmacological techniques are now being trialled, such as Rho kinase (ROCK) inhibition and cultured endothelial cells (CECs), which may drastically improve the dependence on corneal donors. We examine and critically appraise the literature to explore the understanding of FECD, and the treatment options that exist: historically, currently, and those anticipated for the future.

The Risks Associated With Computed Tomography Scans: An Assessment of the Readability and Reliability of Online Text Available for Patient Information and Guidance.

Introduction Computed tomography (CT) scanning has become a fundamental aspect of many diagnostic pathways and therapeutic procedures. However, it is not without risk. Many patients are unaware of the exposure to ionising radiation that is involved with undergoing a CT scan, as well as the associated increase in cancer risk with cumulative exposure. Controversy over which clinician is responsible for advising a patient regarding CT risk often means that patients are left uninformed and unaware. Those who choose to seek further guidance online do so with the risk of encountering poor quality, difficult-to-read medical text, which may leave them even more confused or misinformed. Aim This study aimed to assess the readability, quality, and accuracy of the information available to patients online regarding CT scans and their associated risks. Method An internet search of 180 websites was collated using three search terms, each entered into three search engines. The terms used were 'CT Risk', 'CT Harm', and 'Dangers of a CT Scan'. Unique websites generated were assessed for readability using four readability formulae: The Flesh-Kincaid Grade Level, the Flesch Reading Ease Score, the Gunning Fog Index, and the Simple Measure of Gobbledygook (SMOG) Index. The text on each website was also evaluated for quality and accuracy using the Discern tool. Mean readability scores were calculated and compared against the defined standard required for the information intended for the general public. A two-tailed t-test was also carried out to assess statistical significance. Results Of the 180 websites collated, 77 were unique. 76.62% of websites (59/77) met the readability target for the Flesch-Kincaid Grade Level, and 66.23% (51/77) met the target for the Gunning Fog Index, which was for text to be readable at the Grade 8 level (or by children aged 13-14). 59.74% (46/77) met the target for the SMOG Index, which for healthcare information, was defined as Grade 6 Level, or children aged 11-12. Only 11.69% of websites (9/77) met the target for the Flesch Reading Ease score. 55.84% of websites satisfied the pre-defined standard for three out of four readability criteria, however, only 11.69% satisfied all four criteria, limited by the scores obtained by the Flesch Reading Ease formula. The websites generated a mean Discern score of 3.58, meaning the average quality of the information was deemed to be 'fair', with no serious shortcomings. Conclusion More than 50% of websites satisfied three readability criteria simultaneously. However, there is still scope for improvement, both in terms of enhancing the readability of the remaining websites, and also ensuring that all websites review the proportion of polysyllabic words in the text, which is the emphasis of the Flesh Reading Ease Score. In addition, physicians and radiologists have a responsibility to inform patients of the risks associated with CT scans, and to direct them to supplementary good-quality information and resources.

Delayed Lower Motor Neurone Facial Nerve Palsy Following a Traumatic Head Injury.

Delayed facial nerve weakness secondary to head injury is rare. The mechanism of immediate facial nerve paralysis is obvious, however, the delayed presentation remains disputed. We report a 58-year-old gentleman who presents 6 days after being discharged following head trauma with a 2-day history of facial nerve paralysis (House-Brackmann grade 6). Computed tomography (CT) head showed a minimally displaced longitudinal squamous temporal bone fracture initially with nerve conduction studies and electromyograpy revealing a relative reduction in left facial motor amplitudes with moderate recruitment. He showed good progress following high-dose steroids and conservative management. Early involvement of ear, nose and throat (ENT) surgeons is crucial. The use of both high-resolution CT scanning and nerve conduction studies will help guide management as early as possible and improve outcomes in these patients.

Blood transfusion demands in a tertiary otolaryngology, head and neck centre: A 5-year retrospective cohort study.

OBJECTIVES: To retrospectively analyse and report the utilisation of red blood cell (RBC) transfusion in a tertiary otolaryngology, head and neck centre in the United Kingdom. BACKGROUND: Twenty-seven per cent of RBC transfusions were for surgical indications in a 2014 England and North Wales survey. Currently, there is limited literature on RBC transfusions in Otolaryngology. METHODS/MATERIALS: All inpatients admitted primarily under the care of the Otolaryngology, Head and Neck service between January 2015 and December 2019 were analysed. The primary outcomes of interest were number of units of RBC transfused over 5 years and distribution across clinical indications. Secondary outcome measure was cost of RBC transfusions over the same time period. RESULTS: Most patients receiving transfusions are aged in their sixth and seventh decades. Epistaxis patients utilised 105 RBC units over the 5 years (56% of total RBC units) with emergency epistaxis accounting for 78% of use. Post-operative Head & Neck Cancer surgery with and without reconstruction required 47 RBC units over 5 years (25% of total RBC units). The mean cost incurred by the department over the 5-year period was £6171.49 (SD 1460.25). The cost has fallen by over £2000 over the 5-year period. CONCLUSION: Blood transfusion use has fluctuated over the last 5 years. Epistaxis and post-operative Head and Neck cancer cases account for significant use compared with other patient groups. Prehabilitation strategies will add value towards mitigating future consumption of RBC.

Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions.

BACKGROUND: Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures. METHODS: A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis. RESULTS: A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus. CONCLUSION: This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.

Large cell neuroendocrine carcinoma of the uterine cervix.

We report a case of large cell neuroendocrine carcinoma of the uterine cervix. A 33-year-old woman presented with a 4-month history of irregular vaginal bleeding and suspicious cervix. Transvaginal ultrasound showed a 3×3.8 cm cervical mass with a marked increase in the blood flow. MRI pelvis showed an exophytic tumour with left external iliac lymph node metastasis. Immunohistochemistry of the tumour cells showed strong positivity for the neuroendocrine markers synaptophysin and a very high Ki67 proliferation index. A diagnosis of high-grade large cell neuroendocrine carcinoma of the uterine cervix was made with FIGO stage IIA2. She was treated with chemotherapy and palliative radiotherapy but died 21 months after presenting. Neuroendocrine tumour of the uterine cervix is an extremely aggressive cancer with the late presentation-the need for a more rigorous treatment protocol as well as potential screening methods could improve outcomes for these patients.