Background: Prophylactic negative pressure wound therapy (NPWT) is a promising technology for preventing wound complications in closed surgical incisions. We aimed to evaluate the association of prophylactic NPWT with rates of wound complications for closed incisions in breast surgery and compare them with those of conventional dressings. Methods: This meta-analysis was conducted according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A systematic search of Medline, Embase, CINAHL and Cochrane Library was undertaken for articles in which prophylactic application of a single use NPWT device was compared with standard dressings for total wound complications, surgical site infection (SSI), seroma, haematoma, wound dehiscence and necrosis. Results: Seven studies met the inclusion criteria for analysis, reporting on 1,500 breast incisions in 904 patients. On random effects analysis, NPWT was associated with a significantly lower rate of total wound complications [pooled odds ratio (OR), 0.36; 95% CI, 0.19–069; P=0.002], SSI (pooled OR, 0.45; 95% CI, 0.24–0.86; P=0.015), seroma (pooled OR, 0.28; 95% CI, 0.13–0.59; P=0.001), wound dehiscence (pooled OR, 0.49; 95% CI, 0.32–0.72; P=0.000) and wound necrosis (pooled OR, 0.38; 95% CI, 0.19–0.78; P=0.008). There was no significant difference in rates of haematoma (pooled OR, 0.8; 95% CI, 0.19–3.2; P=0.75). Significant heterogeneity existed amongst included studies for rates of total wound complications but not for the other endpoints. Conclusions: Compared with standard dressings, prophylactic application of NPWT significantly reduced the rate of total wound complications, SSI, seroma, wound dehiscence and wound necrosis when applied to closed incisions on the breast.
Background: Parathyroid crisis is a rare complication of untreated primary hyperparathyroidism. Severe cases can lead to marked central nervous system dysfunction.
Background: Women under 50 account for 25% of breast cancer (BC). Currently, there exists no national surveillance programme to screen women who are at an elevated risk of BC. Methods: A programme was established to evaluate risk in women attending the Cork BC centre offering surveillance to those identified as elevated risk as per the National Institute for Clinical Excellence (NICE) criteria. International measures of screening performance were applied, data collated and analysed from 2013–2018. Results: A total of 17,838 individual risk assessments were performed during the study period of which 538 women were recruited to the moderate and 153 to the high-risk screening programmes. For the purpose of this study, known genetic carriers were excluded from these categories at recruitment. Attendance was 96% for the 1,546 invitations issued. A total of 18 cancers were identified (15 invasive) giving an overall detection rate of 12 cancers per thousand mammograms performed. The detection rate for BreastCheck in 2017 was 6.8 cancers per 1,000 mammograms. Specifically, the projected detection rate in the high-risk group was 19.6 and moderate group 10 per 1,000 mammograms. Benign radiological recall rate was 9% compared to the BreastCheck rate of 4%. Of the cancers identified in those screened women under 50, 70% were T1 and N0. In matched women diagnosed through the traditional symptomatic programme, 70% were N1. Conclusions: A targeted surveillance programme directed at women with an elevated risk of BC has high compliance and identifies BC earlier than that diagnosed through the symptomatic service. Identification rates compare favourably with the national screening programme.
Background: The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease.
Abstract Introduction The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease. Method This systematic review was conducted according to PRISMA guidelines. A systematic search of Medline, Embase and Cochrane Library was undertaken for articles which compared the use of a tourniquet versus no tourniquet in patients undergoing trans-tibial amputation for peripheral vascular disease. The main outcomes included intra-operative blood loss, post-operative transfusion requirement, need for revision surgery and 30-day mortality. Result Four studies met the inclusion criteria for quantitative analysis with a total of 267 patients. A tourniquet was used in 130 patients. Both groups were matched for age, gender, co-morbidities and pre-operative haemoglobin. In patients undergoing trans-tibial amputation, tourniquets were associated with significantly lower intra-operative blood loss (Mean difference= -147.6mls; P=0.03) and lower transfusion requirements (pooled odds ratio (OR), 0.12, p=0.03). The need for stump revision (OR, 0.7; p=0.48), proceeding to transfemoral amputation within 30 days (OR, 0.67; p=0.25) and 30-day mortality (OR, 0.65; p=0.41) all favoured tourniquet use but the differences were not found to be significant. Conclusion Tourniquets can reduce intra-operative blood loss and transfusion requirements in patients undergoing trans-tibial amputation without increasing ischaemic complications and need for revision surgery. Take-home message Tourniquets are safe to use in trans-tibial amputation for severe peripheral vascular disease and can reduce intra-operative blood loss without increasing ischaemic complications.
Posterior reversible encephalopathy syndrome (PRES) is a reversible leukoencephalopathy characterised by subcortical vasogenic oedema and neurological signs. We present the case of a 64-year-old woman who presented to hospital with symptomatic primary hyperparathyroidism. Her parathyroid hormone (PTH) level on admission was elevated at 1,330ng/l (normal range15-68ng/l) and her serum calcium measured 4.83mmol/l (normal range 2.25-2.54mmol/l). Technectium-99m sestamibi scan demonstrated a focus of radiotracer uptake consistent with a right upper parathyroid adenoma or carcinoma. After commencing appropriate medical treatment, the patient developed intractable seizures necessitating endotracheal intubation. Magnetic resonance imaging of her brain revealed bilateral symmetrical T2 hyperintensities in the posterior circulation consistent with PRES. Following stabilisation and further medical treatment for hypercalcaemia, the patient underwent a parathyroidectomy. Preoperative rapid PTH assay measured 1,021ng/l. Following excision, PTH levels fell to just 10ng/l. She was extubated in the intensive care unit on postoperative day 1 and made an uneventful recovery. At her 6-week follow-up appointment, all neurological symptoms had resolved. PRES is a rare neurological entity more often seen in the setting of hypertension, immunosuppression and renal failure. The development of new neurological manifestations in the setting of known risk factors should raise suspicion for the underlying diagnosis.
Background: Primary hyperparathyroidism (PH) is a common cause of hypercalcaemia (0.3% of the population) and is characterized by high concentrations of calcium and parathyroid hormone (PTH). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e., sestamibi scans that allows localization of areas of parathyroid hyperactivity.
Abstract Introduction Primary Hyperparathyroidism (PH) is common cause of hypercalcaemia (0.3% of the population). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e. sestamibi scans allowing localisation of areas of parathyroid hyperactivity. Method Due to the disagreement in the literature regarding which intra operative adjunct is best used in MIRP surgery to decrease recurrence, the rationale for this study is to examine and compare the performance of these adjuncts in consecutive patients i.e. 1. Intra operative PTH assay (IOPTHA) 2. Tc-99m radio-guidance using a gamma probe and the 20% rule 3. Frozen section analysis. Result 45 MIRP procedures were carried out between 01/07/2018 and 30/10/2019. 77.8% were females; mean age was 62 years (range 30 - 79). Final pathology showed that in 43 of the cases parathyroid tissue was correctly removed; thyroid tissue was identified for the other 2 cases. 20% rule was positive in 43 out of the 45 cases and negative in 2 (sensitivity 100%, specificity 100%). A drop in IOPTHA greater than 50% was found in 41 out of the 45 cases but not in 4 (sensitivity 93.9%, specificity 100%). Frozen section was 100% concordant with final pathology (45/45). AUC analysis showed no significant difference in the performance of these tests (p = 0.15) but was around 1 for 20% rule and Frozen section. Conclusion When radio-guidance and frozen sections are added to IOPTHA, the success rate of parathyroidectomy is markedly improved. Using them together will greatly reduce recurrent hyperparathyroidism. Take-home message When radio-guidance and frozen sections are added to Intra-operative PTH assays in Minimally Invasive Radio-Guided Parathyroidectomy, the success rate of parathyroidectomy is markedly improved. Using them together as in our study will greatly reduce the incidence of recurrent hyperparathyroidism and thus recurrent surgery.
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