1512 A Service Evaluation of Transoral Laser Resection Procedures for Oral Cancer and Dysplasia

Aim

The use of the diode laser is a frequently employed treatment modality in primary surgical excision, especially for early oral cancer. This is due to advantages offered in precision of excision, and potential reduced post-operative pain compared to other excision methods. Additionally, haemostasis can often be obtained simultaneous to excision. Despite frequent use of laser excision for oral cancer/dysplasia, there is limited information on the incidence of postoperative complications.

Method

Data was collected retrospectively by review of electronic healthcare records for a 5-year period (Jan 2015-Jan 2020) for patients who underwent transoral laser excision of oral dysplasia in a major UK teaching hospital. The number of short (<30 days) and longer-term complications was evaluated and categorised using the Clavien-Dindo classification.

Results

A total 260 patients received diode laser resection for oral cancer/dysplasia in this period. Approximately one third of patients had the diagnosis of SCC and 52% of patients were treated on a day case basis. Approximately one third of patients experienced postoperative complications.; including positive or close resection margins (16%), bleeding (8%), superficial infection (6%) and significant postoperative pain (2%). A total of 16% of patients required further treatment in theatre (Clavien-Dindo IIIb).

Conclusions

The use of lasers for excision of oral tumours and dysplastic lesions is a frequently employed modality, offering advantages to the operating surgeon (improved haemostasis, excellent manoeuvrability) and patients (reduced pain and scarring). Complications are largely predictable in nature, but the surgical team should be aware of potential issues to ensure safe, effective patient care.

Two decades of neuroscience publication trends in Africa

Neuroscience research in Africa remains sparse. Devising new policies to boost Africa's neuroscience landscape is imperative, but these must be based on accurate data on research outputs which is largely lacking. Such data must reflect the heterogeneity of research environments across the continent's 54 countries. Here, we analyse neuroscience publications affiliated with African institutions between 1996 and 2017. Of 12,326 PubMed indexed publications, 5,219 show clear evidence that the work was performed in Africa and led by African-based researchers - on average ~5 per country and year. From here, we extract information on journals and citations, funding, international coauthorships and techniques used. For reference, we also extract the same metrics from 220 randomly selected publications each from the UK, USA, Australia, Japan and Brazil. Our dataset provides insights into the current state of African neuroscience research in a global context.

896 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of > 62.5mL/Hr for hip fracture patients.

Method

Three prospective audits, each including 100 consecutive acute hip fracture patients, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included implementation of admission/post-take checklist tools and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

In cycle one and two, many patients received inadequate fluids (46/100 and 56/100 respectively). There was no significant difference in the incidence of AKI between patients receiving adequate or inadequate fluid in either cycle (p < 0.05).

In cycle three, more patients received adequate fluids (79/100, p < 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI (2/79, 2.5% vs 3/21, 14.3%; p < 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

205 Internal Herniation of The Caecum and Ascending Colon Through the Foramen of Winslow: A Case Report

Introduction

An internal hernia occurs when part of the bowel protrudes through a mesenteric or a peritoneal orifice which could be either normally present or acquired. These hernias usually represent a challenge to diagnose. Of the natural anatomical orifices is the Foramen of Winslow through which the caecum and the ascending colon could herniate.

Case

Report

Conclusions

With the scarcity of similar cases, we currently have no consensus of management. Dealing with the hernia at laparotomy would be usually the choice of the surgeon depending on tissue viability and other operative findings.

P9: MANAGEMENT OF ESOPHAGEAL FOOD BOLUS OBSTRUCTION AT A UNIVERSITY TEACHING HOSPITAL – A RETROSPECTIVE ANALYSIS

Introduction

Despite the fact that esophageal food bolus obstruction is a common surgical problem, there are no clear guidelines on its management. Medical treatment with Buscopan and Glucagon is mostly in-effective, requiring a therapeutic Oesophago-Gastro-Duodenoscopy (OGD).

Method

All consecutive cases of food bolus obstructions (FBO) presenting to the Emergency Department (ED) for 18 month period between 01/01/2018 and 30/06/2019 were retrospectively reviewed.

Result

A total of 30 patients were admitted with food bolus obstruction via ED (1.67 per month). Females (67%) constituted most of these patients. Average age was 55 with range of 19-83. 84% of patients presented with Dysphagia, while Odynophagia (10%) and chest pain (6%) were other presenting symptoms. Average duration of symptoms was 17 hours (Range 2 – 48 hours). 44% of patients had OGD done under sedation while others (56%) had under General Anaesthesia (GA). In 70% of cases, food bolus was pushed into stomach, while it was retrieved out in 20%. In 10%, it had already spontaneously passed in stomach on OGD. The etiology of FBO was inflammatory in 60% cases, while an esophageal stricture was seen in 10% only. In 30% cases no cause of FBO was identified. Post-OGD length of stay was on average 1.15 days (range 12 hours – 7 days). 2 patients had aspiration pneumonia prolonging their hospital stay, there was no esophageal perforation or mortality.

Conclusion

Esophageal food bolus obstruction is a common surgical problem, OGD under GA is a safe recommended procedure, which often picks up an underlying pathology.

Take-home message

Esophageal food bolus obstruction is a common surgical problem, OGD under GA is a safe recommended procedure, which often picks up an underlying pathology.

113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of >62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids.

Methods

Three prospective audits, each including 100 consecutive acute hip fracture patients aged >55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p < 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p < 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p < 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Case of Renal Aspergillosis after Heart Transplant: Diagnosis and Treatment

Invasive aspergillosis (IA) is a severe complication after heart transplantation (HTx), with a high mortality rate. Invasive pulmonary aspergillosis (IPA) is the most common presentation. We herein describe a unique case of Renal aspergillosis (RAsp) diagnosed on month 10 post-HTx with no known risk factors for IPA in cardiac transplant recipients. The diagnosis of RAsp was made based on radiographic findings, renal biopsy, and tissue cultures. The patient initially received combined antifungal therapy (caspofungin and voriconazole) without radical or partial nephrectomy, followed by voriconazole maintenance monotherapy with favorable clinical outcomes.

CNS Post-Transplant Lymphoproliferative Disorder in a Heart Recipient: A Case Report

Solid organ recipients have increased risk of malignancy in comparison with general population. Although post-transplant lymphoproliferative disorders are the second most common cancer in transplanted patients, primary CNS lymphoma is a rare presentation of these disorders. Among the wide range of neurologic complications in post- transplant period, some characteristics could be helpful for diagnosing of this disorder. Rarity of CNS lymphoma may lead to late diagnosis of this disease while early detection has utmost importance for better management of it. Here, we describe a heart recipient young woman with focal neurologic symptoms 14 months after transplantation and some features that could be helpful for on-time diagnosis.

Clinical and imaging predictors of recovery in patient with pulmonary emboli

Background

Post-pulmonary emboli impairment (PPEI), comprised significant morbidity and mortality. A single center registry of patients with PE was established in order to estimate patients' risk, monitor clinical management and develop a simple model to assess the risk for PPEI for the entire spectrum of patients treated in general clinical practice.

Methods

For developing the mentioned model, apart from approved imaging parameters, potential novel imaging parameters were also evaluated. Recovery were assessed according to Pulmonary Embolism Thrombolysis (PEITHO) trial definition (Figure 1).

Results

140 patients have been registered with at least 6-month imaging follow up. PPEI was confirmed in 75 (53.6%) patients with PE. The prognostic value of traditional and novel imaging parameters on 6-month complete recovery were summarized in Table. A multivariable logistic regression model was developed using 140 patients. Previous PE, HRfollowing five in-hospital-parameters accounted for simple prognostic model for incomplete recovery: history of PE, heart rate≥110, serum blood urea nitrogen level, RV/LV ratio and right atrium area, The overall prediction ability was excellent with 80.6 overall percentage for PPEI.

Conclusions

PPPEI rate was considerable in our study. Our proposed simple prediction model might have a role on identification of patients at risk for PPEI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Paper currency harbours antibiotic-resistant coliform bacteria and integron integrase

AIMS

This study was designed to analyse the prevalence of class 1 and class 2 integron integrase genes among antibiotic-resistant coliform bacteria isolated from paper currency circulating in Pakistan.

METHODS AND RESULTS

A total of 500 individual currency notes were collected from different food vending sites at Lahore, Pakistan. Bacterial population were identified by biochemical and PCR techniques. Antimicrobial susceptibility testing was performed by disc diffusion assay. The highest bacterial population on currency was found from street vendors and butcher shops. Escherichia coli was found to be the most prevalent coliform bacteria followed by Klebsiella sp. and Enterobacter sp. PCR amplification of antimicrobial resistance gene showed the presence of ampC, bla_TEM , bla_NDM-1 , qnrA, tet(A) and tet(B) genes among coliform isolates. A total of 47 integron integrase bearing strains of coliform bacteria were analysed. Sequence analysis showed the presence of dfrA1-aadA1, dfrA1, dfrA5, dfrA7, aadA1, aadA4 cassette arrays in class 1 integron and dfrA1-sat2-aadA1 in class 2 integrase genes.

CONCLUSION

Circulating currency was heavily contaminated with antimicrobial-resistant coliform bacteria bearing class 1 and class 2 integron integrase genes.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study describes a potential threat of severe bacterial infections due to improper hand hygiene and community sanitation when dealing with the currency notes.

INCIDENCE OF BREAST LYMPHEDEMA AND PREDICTORS OF ITS DEVELOPMENT IN PATIENTS RECEIVING WHOLE BREAST RADIATION THERAPY AFTER BREAST-CONSERVATION SURGERY

One common adverse effect following breast-conservation surgery and adjuvant radiation is lymphedema. While lymphedema of the arm has been well-characterized, there has been less investigation into lymphedema of the breast. We sought to characterize rates of breast lymphedema (BLE) in women with early-stage breast cancer and identify potential predictors in its development. Two hundred and thirty consecutive patients treated with lumpectomy and adjuvant whole breast radiation therapy (WBRT) from January 2016 - June 2017 were included. All patients were seen in our lymphedema monitoring clinic for baseline and at least one follow-up lymphedema measurement. BLE grades were assigned by trained nurses in the lymphedema clinic. Data regarding patient demographic and treatment factors were extracted from the electronic medical record. Comparisons between groups were made using Chi-Square analysis performed in SAS. The median age of the sample was 62 (range 31-90). Median follow-up from surgery was 15.3 months. Forty-three patients were diagnosed with lymphedema of the breast (18.7%). Rates of grade 1 and 2 BLE were 93% and 7%, respectively; there were no cases of severe lymphedema. Sixty-three percent of cases resolved by last follow-up with treatment recommendations. There was no association between development of BLE and patient factors investigated, including age, T stage, radiation dose and fractionation, lymph node biopsy, number of lymph nodes removed, development of arm lymphedema, and use of chemotherapy. Tumor subtype was found to be significant (P = 0.04) and there was a trend towards significance for receipt of trastuzumab (P = 0.09). BLE is a distinct entity from arm lymphedema and is a common finding in women treated with breast-conserving surgery and adjuvant WBRT. It is a generally mild and self-limiting process. There were no treatment or patient-related factors that correlated with increased risk of lymphedema development in our sample except for HER-2 positive disease and receipt of trastuzamab.

Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations

BACKGROUND

Pulmonary arteriovenous malformations (PAVMs) generate a right-to-left shunt. Impaired gas exchange results in hypoxaemia and impaired CO2 clearance. Most patients compensate effectively but some are dyspneic, and these are rarely the most hypoxaemic.

AIM

To test degrees of concurrent pathology influencing exercise capacity.

DESIGN

Replicate, sequential single centre, prospective studies.

METHODS

Cardiopulmonary exercise tests (CPETs) were performed in 26 patients with PAVMs, including individuals with and without known airflow obstruction. To replicate, relationships were tested prospectively in an independent cohort where self-reported exercise capacity evaluated by the Veterans Specific Activity Questionnaire (VSAQ) was used to calculate metabolic equivalents (METs) at peak exercise (n = 71). Additional measurements included oxygen saturation (SpO2), forced expiratory volume in 1 s (FEV1), vital capacity (VC), fractional exhaled nitric oxide (FeNO), haemoglobin and iron indices.

RESULTS

By CPET, the peak work rate was only minimally associated with low SpO2 or low arterial oxygen content (calculated as CaO2=1.34 × SpO2 × haemoglobin), but was reduced in patients with low FEV1 or VC. Supranormal work rates were seen in patients with severe right-to-left shunting and SpO2 < 90%, but only if FEV1 was >80% predicted. VSAQ-calculated METS also demonstrated little relationship with SpO2, and in crude and CaO2-adjusted regression, were lower in patients with lower FEV1 or VC. Bronchodilation increased airflow even where spirometry was in the normal range: exhaled nitric oxide measurements were normal in 80% of cases, and unrelated to any PAVM-specific variable.

CONCLUSIONS

Exercise capacity is reduced by relatively mild airflow limitation (obstructive or restrictive) in the setting of PAVMs.