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Benchmarking the outcomes of single-stage augmentation mastopexy against primary breast augmentation: a single surgeon's experience of 905 consecutive cases.
No full textBACKGROUND
Augmentation mastopexy may be performed as a one or a two-stage procedure. Due to the opposing force vectors involved in the augmentation and in mastopexy, some surgeons advocate a two-stage procedure. The literature appears divided on whether a single or two-stage operation has a more favorable complications profile. The purpose of this review was to benchmark the outcomes of single-stage augmentation mastopexy (SAM) against those of a commonly performed aesthetic breast surgery operation (primary breast augmentation, BA) performed by the same surgeon, in the same setting and over the same period.
METHODS
We reviewed electronic patient records of all consecutive female patients who underwent single-stage augmentation mastopexy and primary breast augmentation by the first author (P.M.) at our clinic, between April 2009 and May 2017 and had at least a 6 months' follow-up. The notes were analysed for patient demographics, implant characteristics and complications. Data from single-stage augmentation mastopexy was benchmarked against the outcomes of primary breast augmentations performed by the same surgeon, in the same time period and at the same clinic.
RESULTS
104 single-stage augmentation mastopexies and 801 primary breast augmentations were performed during this period with a mean follow-up of 15.4 months and 14.0 months respectively. The patients undergoing augmentation mastopexy were significantly more likely to be older, have a relatively higher BMI, have more children on average and were significantly less likely to use oral contraceptives. There was no statistically significant difference in the overall complication rate between patients who had single-stage augmentation mastopexy or primary breast augmentation.
CONCLUSION
Our experience suggests that single-stage augmentation mastopexy has comparable outcomes to those of primary breast augmentation. Smokers were more likely to have a re-operation due to postoperative complication (seroma), but the rate of implant change was not different
Reasons for underreporting of uraemic pruritus in people with chronic kidney disease: A qualitative study.
No full textCONTEXT
Uraemic pruritus, or itch, is common in people with chronic kidney disease (CKD) and has a negative impact on their lives and well-being. However, for reasons currently unknown, itch often remains unreported and therefore untreated.
OBJECTIVES
To explore reasons for underreporting of itch in order to provide pointers for improving itch reporting and management in people with CKD.
METHODS
We interviewed adult patients with CKD who self-reported experiencing itching in the last three years (n=25), nephrologists (n=10) and nurses (n=12) from three kidney services in the United Kingdom. Topic guides were informed by previous studies and a theoretical model of self-regulation. We conducted a thematic analysis of verbatim transcripts using Framework Analysis.
RESULTS
We identified three main themes reflecting factors that may influence whether itch is reported: knowledge on causes and treatment of itch (lack of awareness of the relationship between itch and CKD; lack of knowledge of treatment options); attitudes towards importance of itch as a health issue (patients' attitudes; clinicians' attitudes); and prompts for itch assessment during consultations (routine practice; itch as a marker; itch severity).
CONCLUSIONS
Underreporting of itch is related to patients being unaware of its causes, accepting it as something to live with, prioritising other health issues, and the length and timing of consultations. Healthcare professionals' assessment and management of itch vary widely and are not necessarily evidence-based. Better patient information, development of clinical practice guidelines, and incorporation of routine symptom assessments into care may improve itch reporting and management in people with CKD
Splenic preservation versus splenectomy in laparoscopic distal pancreatectomy: a propensity score-matched study.
No full textBACKGROUND
The laparoscopic approach in distal pancreatectomy is associated with higher rates of splenic preservation compared to open surgery. Although favorable postoperative short-term outcomes have been reported in open spleen-preserving distal pancreatectomy when compared to distal pancreatectomy with splenectomy, it is unclear whether this observation applies to the laparoscopic approach. The aim of this study is to compare laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with laparoscopic distal pancreatectomy with splenectomy (LDPS).
STUDY DESIGN
This is a UK wide, propensity score-matched study, including patients who underwent LSPDP or LDPS between 2006 and 2016. Short-term outcomes were compared between LSPDP and LDPS according to intention to treat. Additionally, risk factors for unplanned splenectomy were explored.
RESULTS
A total of 456 patients were included from eleven centers (229 LSPDP and 227 LDPS). We were able to match 173 LSPDP cases to 173 LDPS cases, according to intention to treat. No differences were seen in postoperative morbidity between the groups. The only identified risk factor for unplanned splenectomy was tumor size ≥ 30 mm.
CONCLUSIONS
Preserving the spleen during laparoscopic distal pancreatectomy is not associated with a lower postoperative morbidity compared to sacrificing the spleen. Tumor size is a risk factor for unplanned splenectomy
Large-duct cholangiopathies: aetiology, diagnosis and treatment.
No full textCholangiopathies describe a group of conditions affecting the intrahepatic and extrahepatic biliary tree. Impairment to bile flow and chronic cholestasis cause biliary inflammation, which leads to more permanent damage such as destruction of the small bile ducts (ductopaenia) and biliary cirrhosis. Most cholangiopathies are progressive and cause end-stage liver disease unless the physical obstruction to biliary flow can be reversed. This review considers large-duct cholangiopathies, such as primary sclerosing cholangitis, ischaemic cholangiopathy, portal biliopathy, recurrent pyogenic cholangitis and Caroli disease
Fit 4 surgery, a bespoke app with biofeedback delivers rehabilitation at home before and after elective lung resection.
No full textBACKGROUND
Pulmonary rehabilitation programme for lung surgery patients can reduce the risk of post-operative complications but compliance to programmes can be limited by access to health care. We developed a home-based rehabilitation app and tested its feasibility in patients undergoing lung resection surgery.
METHODS
A cohort study was conducted over 18 months at a regional thoracic unit. The Fit 4 Surgery app included ten exercises. Patients were instructed to exercise for at least three minutes for each exercise. Data was transmitted back to the researchers remotely. Data was also collected from a contemporaneous group of surgery patients who attended local outpatient-based Chronic Obstructive Pulmonary Disease rehabilitation classes. Quality of Life and outcomes data in the app group were collected. Patients were also interviewed about their experience of the app.
RESULTS
App patients had a shorter wait before surgery compared to patients attending rehabilitation classes (24 vs 45 days) but managed four times as many sessions (2 vs 9), improving incremental shuttle walk test distance by 99 ± 83 (p < 0.05) metres before surgery. Five themes were gathered from the interviews.
CONCLUSION
An app based programme of rehabilitation can be delivered in a timely fashion to lung surgery patients with demonstrable physiological benefits; this will need to be confirmed in further clinical trials.
CLINICAL TRIAL REGISTRATION NUMBER
ISRCTN00061628. Registered 27 May 2011
Investigation into repetitive concussion in sport (RECOS): study protocol of a prospective, exploratory, observational cohort study.
No full textINTRODUCTION
Sport-related concussion management remains a diagnostic dilemma to clinicians in all strata of care, coaching staff and players alike. The lack of objective diagnostic and prognostic biomarkers and over-reliance on subjective clinical assessments carries a significant health risk of undiagnosed concussive episodes and early return to play before full recovery increasing the risk of sustaining additional concussion, and leading to long-term sequelae and/or unfavourable outcome.
OBJECTIVE
To identify a set of parameters (neuroimaging with neurophysiological, biological and neuropsychological tests) that may support pitch-side and outpatient clinical decision-making in order to objectively diagnose concussion, determine the severity of injury, guide a safe return to play and identify the potential predictors of the long-term sequelae of concussion.
METHODS AND ANALYSIS
An exploratory, observational, prospective, cohort study recruiting between 2017 and 2020. The participants will have a baseline preseason screening (brain imaging, neuropsychological assessments, serum, urine and saliva sampling). If a screened player later suffers a concussion and/or multiple concussions then he/she will be assessed again with the same protocol within 72 hours, and their baseline data will be used as internal control as well as normative data. Inferential statistical analysis will be performed to determine correlations between biological, imaging techniques and neuropsychological assessments.
ETHICS AND DISSEMINATION
This study was approved by the East of England-Essex Research Ethics Committee on 22 September 2017-REC 17/EE/0275; IRAS 216703. The results of this study will be presented at national and international conferences and submitted for publication in peer reviewed journals.
TRIAL REGISTRATION NUMBER
ISRCTN16974791; Pre-results
Is blood pressure measured correctly in dialysis centres? Physicians' and patients' views.
No full textThe Medical Therapy of Craniopharyngiomas: The Way Ahead.
No full textCONTEXT
Craniopharyngiomas which are categorized as adamantinomatous (ACP) or papillary (PCP) have traditionally been treated with surgery and/or radiotherapy, although when the tumors progress or recur further therapeutic possibilities are very limited. Following recent advances in their molecular pathogenesis, new medical therapeutic options have emerged.
EVIDENCE ACQUISITION
The search strategy that we selected to identify the appropriate evidence involved the following mesh terms: ("Craniopharyngioma"[Mesh] AND "Craniopharyngioma/drug therapy"[Mesh] NOT ("review"[Publication Type] OR "review literature as topic"[MeSH Terms] OR "review"[All Fields]) AND ("2009/05/01"[PDat]: "2019/04/28"[PDat]).
EVIDENCE SYNTHESIS
Mutations of β-catenin causing Wnt activation with alterations of the MEK/ERK pathway are encountered in the great majority of patients with ACP; specific alterations also stratify patients to a more aggressive behavior. In most PCP there is primary activation of the Ras/Raf/MEK/ERK pathway secondary to BRAF-V600E mutations. BRAF inhibitors, such as dabrafenib or vemurafenib, either alone or in combination with the MEK inhibitors trametinib and cobimetinib, have been administered to patients with PCP producing clinically useful and, in some cases, sustained responses. In contrast to PCP, drugs targeting β-catenin and its downstream MAPK pathway in ACP have so far only been used in in vitro studies, but appear to be promising new targets clinically.
CONCLUSIONS
The identification of specific genetic alterations in patients with craniopharyngiomas has expanded the therapeutic options, providing evidence for a a customized approach using newer molecular agents. More studies including a larger number of carefully selected patients are required to evaluate the response to currently available and evolving agents alone and in combination
Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT.
No full textBACKGROUND
Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI.
OBJECTIVE
To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds.
DESIGN
Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved.
SETTING
Usual NHS care.
PARTICIPANTS
Patients undergoing elective/non-elective abdominal surgery, including caesarean section.
INTERVENTIONS
Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'.
MAIN OUTCOME MEASURES
Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers.
DATA SOURCES
Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals.
RESULTS
Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, = 133; glue, = 129; no dressing, = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments.
LIMITATIONS
Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres.
CONCLUSIONS
A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks.
TRIAL REGISTRATION
Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1)
Encephalitis on deployment in Kenya: think beyond the infections.
No full textA 34-year-old female soldier presented with fever and behavioural changes while deployed in Kenya and was diagnosed with encephalitis. The patient underwent urgent aeromedical evacuation to the Queen Elizabeth Hospital, Birmingham for further management. Microbiology tests excluded common infectious causes that are endemic in the East Africa region. However, an autoantibody screen was positive for antibodies against the N-methyl-D-aspartate receptor (NMDAR). Full body imaging confirmed the presence of limbic encephalitis and an ovarian mass suggestive of a teratoma. The patient was diagnosed with ovarian teratoma-associated anti-NMDAR encephalitis, a potentially fatal disease. The patient underwent surgery to remove the teratoma and commenced immunotherapy with steroids, plasma exchange and rituximab. This case highlights the diagnostic challenges of fever with behavioural changes in military personnel deployed in a tropical environment