Staff Publication

Are Temporary Tracheostomies a necessity for free flap surgery? (2016)

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Type of publication:
Conference abstract

Author(s):
*Sandhu B.; *Mihalache G.; *Bhatia S.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2016; vol. 54 (no. 10)

Abstract:
Controversy still surrounds the use of tracheosteomies in maxillofacial oncology surgery with free flaps. Many surgeons place tracheostomies in patients for airway protection post-operatively due to suspected swelling, removing the tube at approximately 10 days. However, patients undergoing this extensive surgery may not require routine tracheostomy and few maxillofacial units across the UK employ this principle. The aim of this study was to determine tracheostomy need within maxillofacial free flap surgery, and the associated complications, including extended recovery.A retrospective study was carried out of 40 patients whom underwent excision of tumours with free flap reconstruction from January 2013 to December 2015, with comparison to 2010-2012 where tracheostomies were routinely used. Analysis was made of hospital stay duration and post-operative complications.From the results of this study we can see that only 5% of cases underwent tracheostomies compared to 75% of the previous three years. All tracheostomy cases of 2013-2015 experienced chest or tracheostomy wound infections, compared to 31% of the 2010-2012 cases. The average hospital stay for those with temporary tracheostomies was 15-16 days and those without was 10 days for across the six years. There have been no reported cases of airway obstruction post-operatively in those cases where tracheostomies have not been placed following free flap surgery, including fibula free flaps. As a unit it has been concluded to avoid placing a temporary tracheostomy in all cases where possible. This is to avoid postoperative complications, reduce hospital stay and improve the quality of recovery from the patient's perspective.

A Case Report of the Management of a Severe Scalp Wound with Combination Treatment including Negative Pressure Therapy with Skin Cell Spray (2016)

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Type of publication:
Conference abstract

Author(s):
*Sandhu B.; *Messahel A.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2016; vol. 54 (no. 10)

Abstract:
Facial injuries can lead to extensive scarring, causing physical discomfort, anxiety and social isolation for patients. The optimum method of wound healing would be primary closure, however in cases where this is not possible other options must be explored. This case report involves a 40 year old female who sustained a severe scalp wound following a road traffic accident, causing partial ejection from the vehicle. The patient was transferred to our care seven days after receiving treatment to the affected area by an emergency department. Examination revealed an 8 cm right frontal scalp region wound present, which was clearly acutely infected with areas of full thickness skin necrosis and generalised overlying slough across the defect. The lower region of the wound involved an area of 2.5 cm exposed bone. There was also weakness noted of the temporal branch of the right facial nerve with reduced brow movement. Following thorough debridement and lavage, combination treatment consisting of negative pressure vacuum therapy and allogenic skin spray application was instigated. Negative pressure allowed for contraction of the wound edges for granulation, and reduced dehiscence risk. It also increased vascularisation of the exposed bone region inferiorly and significant reduction in wound size. Fresh allogenic human keratinocyte suspension allowed for complete healing of the defect. This involved epithelisation of the superficial layer of the wound, with no remaining exudate and complete bone coverage.This successful result is exemplary of a non-surgical therapy for extensive wounds in aesthetically challenging areas.

Adult distal radius fractures classification systems: essential clinical knowledge or abstract memory testing? (2016)

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Type of publication:
Journal article

Author(s):
*Shehovych, A, *Salar, O, *Meyer, Cer, *Ford, D J

Citation:
Annals of the Royal College of Surgeons of England, Nov 2016, vol. 98, no. 8, p. 525-531

Abstract:
Classification systems should be tools for concise communication, which ideally can predict prognosis and guide treatment. They should be relevant, reproducible, reliable, properly validated and most importantly simple to use and understand. There are 15 described distal radius classification systems present in the literature in the past 70 years, of which 8 are discussed in this paper. For each classification, we give an insight into its history, strengths and weaknesses, and provide evidence from the literature on reliability and reproducibility. Sadly, on completion of this paper we have not found a distal radius fracture classification that proved to be useful. Failings range from poor reproducibility and reliability, and over-complexity mainly emanating from the inability to classify this spectrum of injury in all of its manifestations. Consequently, we would suggest that classification systems for acute adult distal radius fractures are not useful clinical knowledge but mainly historical and/or research tools. Moreover, we would discourage trainees from spending time learning these classifications, as they serve not as essential clinical knowledge but more as forms of abstract memory testing.

Recurrent laryngeal nerve palsy due to displacement of a gastric band (2016)

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Type of publication:
Journal article

Author(s):
*Fussey, J M, *Ahsan, F

Citation:
Annals of the Royal College of Surgeons of England, Nov 2016, vol. 98, no. 8, p. e152

Abstract:
The left recurrent laryngeal nerve is at increased risk of compression by oesophageal pathology due to its long course through the neck and thorax. Here we report a case of left vocal cord palsy secondary to displacement of a gastric band, resulting in oesophageal dilatation and neuropraxia of the left recurrent laryngeal nerve. Vocal cord function partially improved following removal of the gastric band.

The impact of body mass index on organs at risk in breast axillarynodal radiotherapy (2016)

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Type of publication:
Conference abstract

Author(s):
*Pettit L., *Welsh A., *Puzey-Kibble C., *Williams M., *Santos J., *Wardle G., *Khanduri S.

Citation:
Radiotherapy and Oncology, April 2016, vol./is. 119/(S558)

Abstract:
Purpose or Objective: There has been recent move within the U.K. to contour the nodal CTV for patients receiving adjuvant radiotherapy for breast cancer. Axillary radiotherapy (ART) following a positive sentinel lymph node biopsy is becoming more common for certain groups of patients. Organs at risk (OAR) should be delineated and considered during the planning process. Body mass index (BMI) has been shown to impact upon spinal cord and brachial plexus doses in irradiation of the supraclavicular fossa. The impact upon the OAR in the axilla has not yet been well documented. Material and Methods: Patients undergoing ART between 01/04/15-01/10/15 were identified. Non – contrast radiotherapy planning CT scans were taken. External beam radiotherapy was planned with extended tangents using a field in field approach with an additional low weighted anterior oblique field if deemed appropriate for adequate dose coverage. Dose delivered was 40.05 Gy in 15 fractions. BMI was calculated by: weight(kg)/height (m)2. CTV's were contoured in accordance with the RTOG contouring atlas. OAR including ipsilateral lung, humeral head and brachial plexus were delineated. Results: Fifteen patients were identified. Six patients had a BMI between 20-25, 3 between 25-30, 5 between 30-40 and 1 BMI>40. Mean ipsilateral lung V12 was 10.44% (range 2.3%- 14.33%). Mean V12 did not vary with BMI (BMI 20-25;mean V12=9.33%, BMI 25-30; mean V12=8.52%, BMI 30-40;mean V12=9.51%, BMI>40 mean V12=6.38%, p=0.55 Chi-Squared). The mean humeral head maximum dose was 35.2 Gy (range 1.2-41.5 Gy). Mean humeral head maximum dose did not vary with BMI (BMI 20-25; mean=34.2Gy, BMI 25-30;mean=27.8Gy, BMI 30-40; mean=40.3Gy, BMI>40; mean=38.2Gy, p=0.49 ttest). The ipsilateral brachial plexus D2 mean was15.6Gy (range 1.2-37.4 Gy). Mean ipsilateral brachial plexus D2 dose did not vary with BMI(p=0.21 t-test). Conclusion: BMI did not significantly impact upon OAR dosage although this series is limited by a small sample size. Ipsilateral lung and brachial plexus were comfortably within departmental tolerance. A planning risk volume of 10 mm around the humeral head has now been adopted within the department. It is recognised that intravenous contrast provides better quality images for delineating OAR in particular for the brachial plexus. However, this impacts upon resources in terms of radiographer scanning time. Adequate time needs to be allocated in consultant and physics teams job plans to enable high quality delineation and subsequent radiotherapy plans to be produced.

Link to more details or full-text: https://user-swndwmf.cld.bz/ESTRO-35/ESTRO-35-Abstract-book3/584

Thyroid tolerance in adjuvant supraclavicular fossa nodalradiotherapy in breast cancer (2016)

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Type of publication:
Conference abstract

Author(s):
*Pettit L., *Welsh A., *Khanduri S.

Citation:
Radiotherapy and Oncology, April 2016, vol./is. 119/(S558)

Abstract:
Purpose or Objective: Hypothyroidism is the most commonly reported long-term toxicity following radiotherapy to structures near to the thyroid gland. Emami suggested the thyroid gland tolerance as 45Gy (TD 5/5) although a much wider range of 10-80 Gy has been reported in the literature. When irradiating the supraclavicular fossa (SCF) in adjuvant radiotherapy for breast cancer, it is inevitable that the thyroid gland will receive a high dose of radiation due to its proximity to the target volume. Recently there has been a move to CT based delineation of the CTV and organs at risk (OAR) in patients requiring nodal radiotherapy for breast cancer compared with the previous bony land mark/field based techniques. Dose received by the thyroid gland and subsequent late toxicity has not yet been well studied in breast cancer. Material and Methods: Patients undergoing external beam radiotherapy to the breast or chest wall plus SCF between 01/04/15-01/10/15 were identified. Radiotherapy planning contrast enhanced CT scans were taken. External beam radiotherapy was planned with tangents using a field in field approach with a matched direct anterior field. A low weighted posterior field was added if deemed appropriate for adequate dose coverage. Angle corrections were used as appropriate. A dose of 40.05 Gy in 15 fractions prescribed at depth was employed. CTV's were contoured in accordance with the RTOG contouring atlas. The thyroid gland was prospectively delineated and D5% was recorded. Results: Seventeen patients undergoing adjuvant SCF radiotherapy were identified. T stage was as follows: T1:2 patients, T2:9 patients, T3:4 patients, T4a:1 patient,T4d:1 patient. N stage; N1:1 patient, N2:14 patients, N3:2 patients. Fourteen were hormone receptor positive, 3 hormone negative. Twelve were HER2 negative, 5 HER2 positive. Mean D5% thyroid was 37.9Gy (range 7-42.7 Gy). Excluding one patient with a previous hemi-thyroidectomy, the mean D5% thyroid was 39.8 Gy (range 16-42.7 Gy). An abnormality requiring referral to a surgeon for was discovered in one patient. Conclusion: Our departmental tolerance for the thyroid gland was set as 40Gy (for 2.67Gy per fraction). It is hard to achieve this without compromise of the CTV. The effect modern chemotherapy/targeted agents may have on this prior to receiving radiotherapy is inknown. Baseline TSH recording is desirable. Long-term follow up to detect clinical or biochemical thyroid dysfunction is needed to inform practice but would present challenges with capacity in busy oncology departments.

Link to more details or full-text: https://user-swndwmf.cld.bz/ESTRO-35/ESTRO-35-Abstract-book3/585

Very late rupture of a post-traumatic abdominal aortic pseudoaneurysm (2017)

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Type of publication:
Journal article

Author(s):
Haneen Abed, *William Robert Ball, *Timothy Stone, *Andrew Houghton

Citation:
BMJ Case Reports 2017:published online 27 January 2017

Abstract:
Post-traumatic abdominal aortic pseudoaneurysms remain a rare yet severe complication of aortic injuries and may present many years later. Clinical presentations vary, from the traditional aneurysmal symptoms of abdominal and/or back pain with or without a pulsatile mass, to a fatal rupture. We present the case of a man aged 42 years, with a history of blunt abdominal trauma 14 years ago, presenting with symptoms of non-specific lower abdominal pain and a recent history of straining due to constipation. Clinical examination revealed umbilical bruising, in keeping with Cullen’s sign, and extensive postsacral bruising. This case highlights some of the atypical manifestations of aneurysmal rupture and the importance of early recognition and management.

Link to full-text: http://casereports.bmj.com/content/2017/bcr-2016-218356.full.pdf

Best practice in management of type 2 diabetes (2016)

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Type of publication:
Journal article

Author(s):
*Morris, David Stuart

Citation:
Nurse Prescribing, 2016, vol./is. 14/Sup10(0-5)

Abstract:
This article will highlight best practice in managing type 2 diabetes in adults. HbA1c is the preferred diagnostic test for type 2 diabetes, the threshold for diagnosis being 48 mmol/ mol. Structured education is the cornerstone of management of type 2 diabetes with a focus on diet, exercise and weight loss. Multiple risk factors for complications need to be addressed including hypertension, dyslipidaemia and smoking (the most important factors in targeting macrovascular disease) and hyperglycaemia (more important in targeting microvascular disease). It is important to recognise that HbA1c targets need to be individualised. Metformin remains the first-line drug for hyperglycaemia in type 2 diabetes. Sulphonylureas, pioglitazone, DPP-4 inhibitors and SGLT-2 inhibitors are all recommended as possible add-on therapies to metformin, the choice again depending on individual circumstances. GLP-1 agonists and insulin can be considered in more intractable cases of hyperglycaemia.

"Chaplains for Wellbeing" in Primary Care: A Qualitative Investigation of Their Perceived Impact for Patients' Health and Wellbeing (2016)

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Type of publication:
Journal article

Author(s):
*McSherry, Wilfred, Boughey, Adam, Kevern, Peter

Citation:
Journal of Health Care Chaplaincy, Oct 2016, vol. 22, no. 4, p. 151-170

Abstract:
Although Health Chaplaincy services are well-established in hospitals in the United Kingdom and across the world, Primary Care Chaplaincy is still in its infancy and much less extensively developed. This study explored the impact the introduction of a Primary Care "Chaplains for Wellbeing" service had upon patients' experience and perceived health and well-being. Sixteen patients participated in one-one interviews. Transcripts were analyzed using interpretative phenomenological analysis (IPA). Patients reported circumstances that had eroded perceived self-efficacy, self-identity, and security manifesting as existential displacement; summarized under the superordinate theme of "loss." "Loss" originated from a number of sources and was expressed as the loss of hope, self-confidence, self-efficacy, and sense of purpose and meaning. Chaplains used a wide range of strategies enabling patients to rebuild self-confidence and self-esteem. Person-centered, dignified, and responsive care offered in a supportive environment enabled patients to adapt and cope with existential displacement.