Aural microsuction: an analysis of post-procedure patient safety incidents.

BACKGROUND: Aural microsuction can be associated with delayed syncopal and vertiginous events, which can lead to serious adverse patient safety incidents. OBJECTIVE: This article highlights the serious risks associated with microsuction. MATERIALS AND METHODS: We performed a retrospective review of the hospital risk database over a 2-year period. RESULTS: Three patients experienced severe adverse events post microsuction. Two patients fell down the stairs after microsuction, with one suffering a lower limb fracture. One patient experienced loss of consciousness and subsequent head trauma post microsuction. CONCLUSIONS AND SIGNIFICANCE: Whilst aural microsuction is universally accepted to be a low-risk procedure, subsequent serious morbidity can occur. Implementation and awareness of local safety policies are imperative to avoid post-procedure injury.

Free tissue reconstruction of a liquid nitrogen burn: a case report and literature review.

Due to its boiling point of -196°C, liquid nitrogen is a cryogenic substance which is commonly used in many industries for its cooling properties. However, this extreme cooling capability means it also has the potential to inflict severe full-thickness burns. Despite its widespread use in the workplace, very little has been described in the literature regarding complex reconstruction of liquid nitrogen burns. We present a case that is unique, not only in its unusual mechanism of injury, but also in that it is the first described case of free tissue reconstruction of cryogenic burns.

Parathyroid carcinoma: Current management and outcomes - A systematic review.

OBJECTIVE: Parathyroid carcinoma is rarely encountered in clinical practice. When faced with this clinical challenge, there is currently a paucity of evidence available for the optimal management of patients with parathyroid carcinoma. This systematic review synthesizes the available literature to evaluate the optimal management approach, thus providing guidance for future management. METHODS: A systematic review was conducted according to PRISMA guidelines using Ovid MEDLINE, EMBASE, and PubMed databases for studies, published in English, reporting on parathyroid carcinoma. Full text of potentially eligible articles were reviewed by two authors independently and eligible studies selected. Treatment options and associated outcomes were evaluated. Descriptive statistics were used to describe pooled patient cohorts. RESULTS: 3203 articles were initially identified using the search criteria with 59 full-text articles then screened for eligibility. Seven articles, all retrospective studies, concerning 2307 patients (median 224/study). Parathyroidectomy alone was the most frequently utilised surgical approach across all studies, followed by en-bloc resection (with adjacent thyroid and/or nodal tissue). There was no difference in post-operative morbidity, mortality or survival between surgical approaches (p < 0.005). Patients who underwent either form of surgery had longer overall survival than those managed non-operatively (p < 0.005). CONCLUSION: Surgical resection is the optimal treatment of parathyroid carcinoma. However there remains no consensus on the optimal extent of surgery, and as such future randomised prospective studies are necessary to evaluate the effects of different surgical approaches on morbidity, mortality and oncologic outcomes. Following resection, long-term surveillance with PTH is advised.

Immediate Breast Cancer Reconstruction with or without Dermal Matrix or Synthetic Mesh Support: A Review and Network Meta-Analysis.

BACKGROUND: The use of acellular dermal matrices (ADMs) and synthetic mesh as part of implant-based breast reconstruction (IBBR) has been widely adopted. The authors investigated the clinical efficacy and safety of human ADM (HADM), xenograft ADM (XADM), and synthetic mesh as part of IBBR in postmastectomy patients as compared with previous standard implant reconstruction techniques using only a submuscular pocket for coverage. METHODS: A systematic search for randomized controlled trials and observational studies was performed. A frequentist network meta-analysis was conducted using the R packages netmeta and Shiny. RESULTS: Thirty-one of 2375 studies identified met the predefined inclusion criteria. Traditional submuscular placement (no ADM or mesh) had fewer overall complications compared with HADM [OR, 0.51; credible interval (CrI), 0.34 to 0.74], but there was no significant difference between no ADM or mesh and XADM (OR, 0.63; CrI, 0.29 to 1.32) or synthetic mesh (OR, 0.77; CrI, 0.44 to 1.30). No one treatment was superior with regards to implant loss. No ADM or mesh was associated with fewer infectious complications than HADM (OR, 0.6; CrI, 0.39 to 0.89). Both no ADM or mesh (OR, 0.45; CrI, 0.27 to 0.75) and XADM (OR, 0.46; CrI, 0.23 to 0.88) had reduced seroma compared with HADM. CONCLUSIONS: Selecting the appropriate IBBR should evaluate effectiveness, adverse events, and cost. Although it is difficult to select a universal ideal IBBR, evaluation using this network analysis may help guide both physicians and patients in their choice of procedure, especially in the case of HADM, which in this study was shown to be significantly predisposed to complications of infection and seroma. Randomized data are required comparing XADM versus synthetic meshes, given the similar risk profiles but significant cost discrepancy between the techniques.

Cystic hygroma in adults: a single-centre experience and review of the literature.

Cystic hygroma (CH) is a benign congenital lymphatic malformation, occurring predominantly in children, typically as an asymptomatic neck mass. Surgical resection or sclerotherapy is the recommended treatment options. A retrospective review of four cases of adult-onset CH was performed over 2 years by a single surgeon across two institutions. Four patients (two females, median age 31.5 years) who presented with supraclavicular neck masses (range 5-17 cm) are discussed. Ultrasound and MRI demonstrated supraclavicular masses, suggestive of CH. All patients underwent surgical resection. Post-operative courses were uncomplicated, with a mean length of stay of 4 days. All histological samples returned as CH. As of yet, there are no guidelines on the management of CH. Individualised care tailored to each patient, following careful discussion is the most prudent approach. This study demonstrates that surgical resection is a safe and effective treatment for adults in this rarely encountered clinical entity.

Implementation of an on-site simulation programme during COVID-19 and the assessment of its impact on medical students' competence.

BACKGROUND: COVID-19 has greatly impacted medical students' clinical education. This study evaluates the usefulness of a rapidly implemented on-site simulation programme deployed to supplement our disrupted curriculum. METHODS: Students on surgical rotations received 4-hour tutor-led simulated patient sessions (involving mannikins with remote audio-visual observation) respecting hospital and public health protocols. Attitudes were questionnaire-assessed before and after. Independent, blinded, nonacademic clinicians scored students' clinical competencies by observing real patient interactions using the surgical ward assessment tool in a representative sample versus those completing same duration medicine clinical rotations without simulation (Mann-Whitney U testing, p < 0.05 denoting significance) with all students receiving the same surgical e-learning resources and didactic teaching. RESULTS: A total of 220 students underwent simulation training, comprising 96 hours of scheduled direct teaching. Prior to commencement, 15 students (7% of 191 completing the survey) admitted anxiety, mainly due to clinical inexperience, with only two (1%) anxious re on-site spreading/contracting of COVID-19. A total of 66 students (30%, 38 females and 29 graduate entrants) underwent formal competency assessment by clinicians from ten specialties at two clinical sites. Those who received simulation training (n = 35) were judged significantly better at history taking (p = 0.004) and test ordering (p = 0.01) but not clinical examination, patient drug chart assessment, or differential diagnosis formulation. Of 75 students providing subsequent feedback, 88% stated simulation beneficial (notably for history taking and physical examination skills in 63%) with 83% advocating for more. CONCLUSION: Our rapidly implemented simulation programme for undergraduate medical students helped mitigate pandemic restrictions, enabling improved competence despite necessarily reduced clinical activity encouraging further development.

The role of tranexamic acid in reducing post-operative bleeding and seroma formation in breast surgery: A meta-analysis.

INTRODUCTION: Tranexamic acid (TXA) reduces blood loss and blood transfusion requirements in surgery. Seroma and haematoma formation occur as complications of breast surgery. We aimed to perform a meta-analysis evaluating TXA in reducing post-operative haematoma and seroma formation for breast surgery. METHODS: A systematic review was performed in accordance with PRISMA guidelines. Results were expressed as dichotomous variables pooled as odds ratios (OR) with corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method. RESULTS: Seven studies including 1446 patients were included. There were 1830 breast surgery procedures performed with TXA administered in 797 cases (43.6%). There was a significant reduction in haematoma rates in the TXA group (TXA: 3.184% (22/691) vs Control: 6.787% (64/943), OR: 0.41, 95% CI: 0.20-0.86, P = 0.020). Based on surgical procedure, haematoma rates were similar for TXA and control groups in cancer surgery (P = 0.230). Haematoma rates reduced following TXA use in cosmetic procedures (TXA: 3.807% (15/394) vs. Control: 9.091% (34/374), OR: 0.41, 95% CI: 0.22-0.75, P = 0.004). Haematoma rates were also reduced in procedures where axillary lymph node dissection (ALND) was not performed; in the TXA group, 3.379% (22/651) developed a haematoma versus 6.623% (60/906) in the control group (OR: 0.45, 95% CI 0.27-0.77, P = 0.003). TXA administration did not impact seroma formation or infection rates. CONCLUSION: Perioperative administration of TXA may impact the incidence of haematoma in breast surgery, particularly in cosmetic procedures and procedures without ALND. Well-designed randomised studies are required to determine its true efficacy. TXA has no effect on seroma formation or infection in breast surgery.

Performance effects of simulation training for medical students - a systematic review.

Objective: Simulation based medical education (SBME) is fast becoming embedded into undergraduate medical curricula with many publications now describing its various modes and student self-reported impacts. This systematic review synthesizes the available literature for evidence of performance effects of SBME as an adjunct within traditional teaching programmes. Methods: A narrative systematic review was conducted according to PRISMA guidelines using Ovid MEDLINE, EMBASE, and PubMed databases for studies, published in English, reporting on general medical and surgical undergraduate SBME between 2010 to 2020. Two reviewers independently assessed potential studies for inclusion. Methods and topics of simulation with their assessments were evaluated. Descriptive statistics were used to describe pooled student cohorts. Results: 3074 articles were initially identified using the search criteria with 92 full-text articles then screened for eligibility. Nineteen articles, including nine randomised trials, concerning 2459 students (median 79/study), were selected for review. Cardiac scenarios were commonest (n=6) with three studies including surgical topics. Nine studies used mannequin simulators (median time/session 17.5minutes) versus standardised patients in seven (median time/session=82 minutes). Educational impact was measured by written (n=10), checklist (n=5) and OSCEs (n=3) assessment either alone or in combination (n=1, OSCE/written assessment). All articles reported a positive effect of SBME on knowledge including improved retention in three. Conclusion: SBME, as an adjunct to existing curricula, improves knowledge-based performance of medical students at least in the short-term. Future studies should broaden its topics, assess longer term impacts and cost-effectiveness while also considering whether and what areas of traditional undergraduate learning it can replace.

Evaluation of human adipose-derived stromal cell behaviour following exposure to Tamoxifen.

BACKGROUND AND AIM: Adipose-derived stromal cells (ASCs) are a promising cell source for novel tissue engineering approaches to breast reconstruction following cancer resection. However there is limited knowledge on the effect of adjuvant therapies such as hormonal therapy on ASCs, which may affect their efficacy in regenerative strategies. The present study aims to investigate the effects of Tamoxifen and its metabolites Afimoxifene (4-Hydroxy-Tamoxifen) and Endoxifen (N-desmethyl-4-hydroxytamoxifen) on patient-derived ASC viability, apoptosis, adipogenic differentiation and angiogenic potential. METHODS: ASCs were isolated from fat harvested from female breast cancer patients undergoing breast reconstruction surgery or cosmetic procedures. Oestrogen receptor (ER α, ß) expression was analysed using immunofluorescence. ASCs were then treated with various concentrations of Afimoxifene, Endoxifen and Tamoxifen (combination), and the impact on ASC viability and apoptosis determined. ASCs were cultured in adipogenic-differentiation media with or without tamoxifen and derivatives, and adipogenesis was measured using quantitative Real-time Polymerase chain reaction (qRT-PCR) and histological staining (Oil Red O). The effect on secreted VEGF levels was also quantified in ASC conditioned media RESULTS: ASCs were successfully isolated and characterised from human abdominal lipoaspirates or fat tissues (n = 8). ASCs subjected to varying doses of Tamoxifen and metabolites (up to 1000 nM) showed no decline in cell viability or increase in apoptosis, at physiological doses (upto 100 nM). Functional decline in adipogenic differentiation or gene expression was observed at supraphysiological concentrations of Tamoxifen (1000 nM). VEGF165 protein secretion in ASC-cell conditioned media was not significantly impacted irrespective of dosage. CONCLUSION: At physiologically relevant doses, Tamoxifen treatment did not result in any deleterious effect on ASC survival and functionality and is unlikely to negatively impact ASC based breast reconstruction strategies for breast cancer patients receiving this adjuvant hormonal therapy.

A retrospective cohort study of cutaneous squamous cell carcinoma of the scalp: features of disease and influence of sociodemographic factors on outcomes.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) is an increasingly prevalent and potentially fatal disease with considerable implications if not recognized early and treated promptly. Several disease features contribute to a higher risk profile and adverse outcomes in affected patients. AIMS: Given the clinical observation that elderly males from rural communities often present with large SCCs of the scalp, we sought to investigate and describe features of disease and sociodemographic factors from a cohort of patients with scalp SCCs. METHODS: Histology reports of scalp primary SCCs were retrospectively assessed. Disease and demographic features were recorded. Descriptive statistics were generated, and statistical analyses (Fisher's exact, Mann-Whitney U and Spearman's rank test) were utilized to examine relationships between high-risk disease features and sociodemographic features. RESULTS: Ninety-three occurrences of scalp SCC in 61 patients were assessed. The average age at presentation was 78.81 years. Males were predominantly affected at a 14:1 ratio. Half of all tumours were greater than 2 cm (47/93 (50.54%)). The geographical distance from treatment was significantly associated with larger tumours at presentation. (rs = .34 P = 0.002). Recurrence and metastasis rates were determined amongst 188 patients with a primary scalp SCC, and low rates were observed (2.66% and 2.13%, respectively). CONCLUSIONS: Elderly males are inordinately affected by scalp SCC compared to females. Those living further from care exhibited larger tumours at presentation. Data from this study characterize features of SCC of the scalp and provide evidence to suggest that rural isolation may act as a mediator of high-risk presentation and larger tumour size.

User Evaluation of a Novel Smart Insufflator for Laparoscopic Surgery-The EVA-15.

INTRODUCTION: There is resurging interest in the importance of effective, nuanced insufflation and personalised pneumoperitoneal pressure-management during laparoscopy. Here, we present user-evaluation data from a regulated, prospective, multispecialty study of a new insufflator (EVA-15, Palliare, Galway, Ireland) which provides high-frequency pressure-sensing, built-in smoke evacuation with pedal activation and highly responsive, high-flow gas provision. METHODS: With institutional ethics and regulatory body approval, a non-randomised, prospective clinical investigation was performed on 30 subjects undergoing laparoscopic surgery using an EVA-15 device. Cases were selected from a variety of specialties on a near-consecutive basis without specific exclusion criteria. Users (both surgeons and operating room nurses) completed a survey at case completion to capture ordinal categorical data on a 5-point Likert agreement scale (1 - Strongly disagree to 5 - Strongly agree) concerning (i) Settings and Setup Evaluations, (ii) Alarms and Displays Evaluations, (iii) Short Instruction Guide, and (iv) Insufflator Performance along with any additional feedback. RESULTS: Operations on 30 patients (mean age 54 y, 15 males) were studied with a questionnaire completed by operating room teams after individual consent. The procedures included general (n=13), upper (n=3) and lower (n=6) gastrointestinal surgery, bariatric (n=3), hepatobiliary (n=2) urology (n=2, both robotic prostatectomy) and gynaecology (n=1) operations. In all cases, the laparoscopic component was completed capably with the use of the EVA-15 device. The insufflator evaluation score across all categories was a median of 4, demonstrating satisfactory use and performance in all regards. CONCLUSION: The EVA-15 is a smart insufflator system that is capable of satisfactory performance across a spectrum of cases among different specialties.

A Review of Epidemiology and Cancer Biology of Malignant Melanoma.

Malignant melanoma is a neoplasm originating in the melanocytes in the skin. Although malignant melanoma is the third most common cutaneous cancer, it is recognized as the main cause of skin cancer-related mortality, and its incidence is rising. The natural history of malignant melanoma involves an inconsistent and insidious skin cancer with great metastatic potential. Increased ultra-violet (UV) skin exposure is undoubtedly the greatest risk factor for developing cutaneous melanoma; however, a plethora of risk factors are now recognized as causative. Moreover, modern oncology now considers melanoma proliferation a complex, multifactorial process with a combination of genetic, epigenetic, and environmental factors all known to be contributory to tumorgenesis. Herein, we wish to outline the epidemiological, molecular, and biological processes responsible for driving malignant melanoma proliferation.

Short-term outcomes in older patients with peritoneal malignancy treated with cytoreductive surgery and HIPEC: Experience with 245 patients from a national centre.

BACKGROUND: Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy. METHODS: A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units. RESULTS: Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the <65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the <65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group. CONCLUSION: This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Effect of Breast Cancer and Adjuvant Therapy on Adipose-Derived Stromal Cells: Implications for the Role of ADSCs in Regenerative Strategies for Breast Reconstruction.

Tissue engineering using Adipose Derived Stromal Cells (ADSCs) has emerged as a novel regenerative medicine approach to replace and reconstruct soft tissue damaged or lost as a result of disease process or therapeutic surgical resection. ADSCs are an attractive cell source for soft tissue regeneration due to the fact that they are easily accessible, multipotent, non-immunogenic and pro-angiogenic. ADSC based regenerative strategies have been successfully translated to the clinical setting for the treatment of Crohn's fistulae, musculoskeletal pathologies, wound healing, and cosmetic breast augmentation (fat grafting). ADSCs are particularly attractive as a source for adipose tissue engineering as they exhibit preferential differentiation to adipocytes and support maintenance of mature adipose graft volume. The potential for reconstruction with an autologous tissue sources and a natural appearance and texture is particularly appealing in the setting of breast cancer; up to 40% of patients require mastectomy for locoregional control and current approaches to post-mastectomy breast reconstruction (PMBR) are limited by the potential for complications at the donor and reconstruction sites. Despite their potential, the use of ADSCs in breast cancer patients is controversial due to concerns regarding oncological safety. These concerns relate to the regeneration of tissue at a site where a malignancy has been treated and the impact this may have on stimulating local disease recurrence or dissemination. Pre-clinical data suggest that ADSCs exhibit pro-oncogenic characteristics and are involved in stimulating progression, and growth of tumour cells. However, there have been conflicting reports on the oncologic outcome, in terms of locoregional recurrence, for breast cancer patients in whom ADSC enhanced fat grafting was utilised as an alternative to reconstruction for small volume defects. A further consideration which may impact the successful translation of ADSC based regenerative strategies for post cancer reconstruction is the potential effects of cancer therapy. This review aims to address the effect of malignant cells, adjuvant therapies and patient-specific factors that may influence the success of regenerative strategies using ADSCs for post cancer tissue regeneration.