Fahad Mujtaba Iqbal

A Bibliometric Analysis of the 100 Most-cited Articles in Rhinoplasty.

Introduction: Citation analysis aims to quantify the importance and influence of a published article within its field. We performed a bibliometric analysis to determine the most highly cited articles within rhinoplasty and their impact on current practice. Methods: The 100 most-cited articles relating to rhinoplasty, between and inclusive of January 1864 to September 2015, were extracted from Web of Science in October 2015. Title, source journal, publication year, total citations, average citations/year, type of article, level of evidence, country of origin, main focus, use of outcome measures, incorporation into “Selected Readings in Plastic Surgery,” and funding status were recorded. Results: The total number of citations per article ranged from 61 to 276 (1.5–12.1 average citations per year). Surgical technique was the focus of 53% of articles, particularly those for reconstruction (75%). The United States produced 72% of articles compared with 8% from the United Kingdom. The top 100 articles were published within 20 journals; “Plastic and Reconstructive Surgeons” contributed the most articles (n = 57). None of the articles achieved level 1 or 2 of evidence (Oxford Centre for Evidence-Based Medicine levels of evidence, 2011), with most achieving level 4 evidence (n = 64). Case-series were the most popular methodology (n = 37). Few articles used validated outcome measures (n = 21). Twenty-nine percent were referenced in “selected readings.” Eighty-nine percent were unfunded studies. Conclusions: These top 100 articles are used in current teaching material and underpin surgical decision making. Developing and using validated objective assessment tools will benefit surgeons, patients, and the greater scientific community in objectively evaluating techniques with the most favorable results.

Feeling blue, going green and finding other attractive alternatives: a case of biphasic anaphylaxis to patent blue and a literature review of alternative sentinel node localisation methods.

Patent blue dye is used for sentinel lymph node localisation in order to stage the axilla in patients with breast cancer. Patent blue is one of the most common dyes used across the UK, however, the incidence of adverse effects seems to be increasing. This case highlights our experience of a biphasic anaphylactic reaction to patent blue dye, and we conduct a brief literature review of alternative and more novel methods to adequately visualise the lymphatics for sentinel lymph node biopsy.

Pre-operative axillary staging: should core biopsy be preferred to fine needle aspiration cytology?

Objective To determine the diagnostic accuracy of ultrasound guided fine needle aspiration (FNA) cytology and core needle biopsy (CNB) of axillary lymph nodes pre-operatively in newly diagnosed operable primary breast cancer. Methods An observational study for all patients who underwent pre-operative FNA cytology or CNB during September 2013–August 2014 was conducted at our institution (County Hospital, Stafford, UK). The accuracy of pre-operative axillary staging was compared to the post-operative histology. For this sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated. Results A total of 81 consecutive patients were evaluated by axillary ultrasound. Patients identified with potentially abnormal axillary lymph nodes underwent definitive surgery. Seven patients had positive cytology/histology who did not undergo definitive surgery and were excluded (N = 74) from the study. CNB had a sensitivity of 100% versus 72% (p = 0.006) for FNA cytology. Both had 100% specificity and PPV. The NPV of CNB was 100% versus 72% for FNA cytology. Among 35% of patients that underwent FNA cytology required repeat procedure versus 2.6% of patients who underwent CNB. 0/38 patients that had CNB required a second operation while 7/43 patients with negative FNA cytology had positive lymph nodes identified at sentinel lymph node biopsy (SLNB) requiring surgical re-intervention with axillary node clearance. Conclusion CNB was superior to FNA cytology when interrogating the axilla. We recommend CNB to be adopted routinely in pre-operative axillary staging to reduce surgical re-intervention.

Double-edged sword of radiotherapy: a cause of secondary angiosarcoma after breast conservation therapy

Angiosarcomas are rare and aggressive malignant tumours of vascular or endothelial origin that can originate in the breast. They can be classified as primary or secondary, with the latter most commonly due to postoperative radiotherapy as part of breast conservation therapy (wide local excision and adjuvant radiotherapy) for breast cancer. We report a case of postirradiation secondary angiosarcoma in a 56-year-old woman, alongside a review of the current literature, to inform clinicians of its clinical presentation and characteristics as a high index of clinical suspicion is required for an accurate diagnosis.

Marjolin's ulcer: a rare entity with a call for early diagnosis

Marjolins ulcer (MU) is an umbrella term covering squamous cell carcinoma (SCC), basal cell carcinoma and malignant melanoma that develop in chronic wounds, sinuses or scars. Cutaneous (non-MU) SCC is related to excessive sun-exposure, with Fitzpatrick skin types I and II being more susceptible. Radiation, genetic disorders (eg, Xeroderma pigmentosum) and immunosuppression, are other important risk factors often involved in the development of cutaneous malignancies and may also be involved in the development of MU. MU, first described by Jean-Nicholas Marjolin in 1828, is more aggressive than non-MU SCC, with a higher potential for early metastasis. A high index of suspicion and early histological diagnosis in chronic wounds and unstable scars with recent changes in characteristics offer the best prognosis with treatment. We present a case alongside a literature review contrasting the characteristics of MU and non-MU SCC, and suggest a management plan for early MU identification and prevention.

Collapse in the elderly: rivastigmine-induced heart block and a literature review of the pharmacology of acetylcholinesterase inhibitors used in Alzheimer’s disease

Falls resulting in neck of femur fractures are common in the elderly. Often multiple comorbidities can make management and diagnosis of such a polyfactorial condition difficult, particularly with Alzheimer’s dementia (AD). Indeed, poorly managed AD may contribute to falls. We present our management of an 87-year-old woman, on rivastigmine for AD, who presented with a collapse episode—attributed to rivastigmine—resulting in a neck of femur fracture. Furthermore, we perform a literature review of the pharmacology of acetylcholinesterase inhibitors and how their use in AD may contribute to bradyarrhythmias.

Reply to: Subcutaneous implant breast reconstruction: The importance of objectively assessing the outcomes

We would like to thank Onesti et al. for their interest in our publication in EJSO [1]. Pre-pectoral implant breast reconstruction is an emerging technique with promising results and potential advantages and it is gaining popularity among breast reconstructive surgeons and patients. Our comprehensive literature review showed that the quality of the available data is still not optimal based mainly on small, single centre cohorts with short follow-up. As highlighted in our paper and also by Onesti et al. in their Letter to the Editor, another important issue is the limited use of validated tools for the objective evaluation of aesthetic and functional outcomes including post-operative pain and recovery and also for the assessment of patients’ satisfaction and quality of life after pre-pectoral implant breast reconstruction. We would like to encourage all efforts to address these significant issues and emphasize the importance to conduct well-designed studies using validated tools including the questionnaires used by Onesti et al. (EORTC QLQ C-30 and EORTC QLQ BR-23) [2,3] as well as the more recently validated BREAST-Q questionnaire [4] that has been specifically developed to capture patient satisfaction and quality of life data after breast surgery. These questionnaires should ideally be used both at baseline and following treatment to allow more reliable evaluation of the results. In conclusion, we agree with Onesti et al. that there is need for a more structured and coherent approach to evaluating the results of novel techniques always having as guide our duty to ensure patient safety. It is also important to work collaboratively to advance our knowledge and contribute in the rapid dissemination of results of proven improved techniques for the benefit of our patients.

Blood donations: justifying blood donor restrictions.

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Breast lumps: a rare site for rheumatoid nodules

Granulomatous mastitis (GM) of the breast is a rare benign inflammatory disease and its presentation closely mimics breast cancer. Its diagnosis is mainly based on histology and there is no consensus agreement regarding its management. We report a case of a 60-year-old woman presenting with a right breast lump associated with a history of rheumatoid arthritis and raised rheumatoid factor. Following triple assessment (history and examination, imaging and biopsy), GM was diagnosed and she was treated conservatively.