Iman Azmy

Association of adult celiac disease with surgical abdominal pain : A case-control study in patients referred to secondary care

Background:Acute abdominal pain is the most common indication for surgical admission. Nonspecific abdominal pain (NSAP) may account for up to 40% of cases. There has been no published prospective study in which adult patients presenting with acute abdominal pain are investigated for celiac disease. Aims:We aimed to assess the association of celiac disease with surgical abdominal pain. Patients and Methods:A case-control study was undertaken involving 300 consecutive new unselected patients presenting with acute abdominal pain (in a university hospital) and healthy controls (age and sex matched) without abdominal pain (n = 300). Initial investigations for celiac disease were immunoglobulins, IgA/IgG anti-gliadin (AGA), and endomysial antibodies (EMA). Any patient with a positive IgA AGA, EMA, or only IgG AGA in the presence of IgA deficiency was offered a small bowel biopsy to confirm the diagnosis. Results:There were 33 patients with abdominal pain who had positive antibodies, of whom 9 had histologically confirmed celiac disease (6 EMA positive; 3 EMA negative). One antibody positive patient (EMA in isolation) declined duodenal biopsy and the remaining 23 had normal duodenal mucosa. Within the control group, there were 2 cases of celiac disease. Compared with matched controls the association of acute abdominal pain with celiac disease gave an odds ratio 4.6. (P = 0.068, 95% confidence interval, 1.11–19.05). When only considering NSAP the prevalence of celiac disease was highly significant at 10.5% (9 of 86, P = 0.006). Patients’ symptoms improved on a gluten-free diet at 12- to 18-month follow-up. Conclusion:Celiac disease was diagnosed in 3% of patients who presented with unselected acute abdominal pain to secondary care. Targeting patients who have NSAP or celiac associated symptoms/diseases may improve the diagnostic yield.

Breast implant associated anaplastic large cell lymphoma: The UK experience. Recommendations on its management and implications for informed consent

BACKGROUNDnBreast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, Non-Hodgkin lymphoma arising in the capsule of breast implants. BIA-ALCL presents as a recurrent effusion and/or mass. Tumours exhibit CD30 expression and are negative for Anaplastic Lymphoma Kinase (ALK). We report the multi-disciplinary management of the UK series and how the stage of disease may be used to stratify treatment.nnnMETHODSnBetween 2012 and 2016, 23 cases of BIA-ALCL were diagnosed in 15 regional centres throughout the UK. Data on breast implant surgeries, clinical features, treatment and follow-up were available for 18 patients.nnnRESULTSnThe mean lead-time from initial implant insertion to diagnosis was 10 years (range: 3-16). All cases were observed in patients with textured breast implants or expanders. Fifteen patients with breast implants presented with stage I disease (capsule confined), and were treated with implant removal and capsulectomy. One patient received adjuvant chest-wall radiotherapy. Three patients presented with extra-capsular masses (stage IIA). In addition to explantation, capsulectomy and excision of the mass, all patients received neo-/adjuvant chemotherapy with CHOP as first line. One patient progressed on CHOP but achieved pathological complete response (pCR) with Brentuximab Vedotin. After a mean follow-up of 23 months (range: 1-56) all patients reported here remain disease-free.nnnDISCUSSIONnBIA-ALCL is a rare neoplasm with a good prognosis. Our data support the recommendation that stage I disease be managed with surgery alone. Adjuvant chemotherapy may be required for more invasive disease and our experience has shown the efficacy of Brentuximab as a second line treatment.

A new insight into non-specific abdominal pain.

This review aims to change clinical practice and alert clinicians to consider that unrecognised coeliac disease may present acutely with abdominal pain. Targeting patients who have non-specific abdominal pain or coeliac-associated symptoms/diseases may improve diagnosis.

Seat belt injury causing bisection of the breast: A case report

Seat belt use has been mandatory in the United Kingdom since 1983 for front seat passengers, and since 1991 for rear seat users. This measure has hugely reduced the risk of serious injuries and death associated with road traffic accidents. However, this restraint system is associated with a particular pattern of injuries in the configuration of the seat belt, namely sternal fractures, bowel trauma or spinal injuries. There have been multiple publications on these injuries which have now been termed ‘seat belt syndrome’ or ‘seat belt injuries’. We report a case of breast bisection as a result of seat belt trauma with description of the reconstructive procedure. A 67 year old lady was involved in a road traffic accident resulting in severe bruising across her right breast from her seat belt. There were no open wounds and she did not require any medical treatment at this stage. Over the subsequent weeks, she noticed a worsening deformity of her right breast. Her past medical history included rheumatoid arthritis affecting her hips for which she took Naproxen 500 mg BD, and she was otherwise fit and well. She had attended regular mammograms that had been normal. She first attended the breast unit three months after her accident and was noted to have severe indentation of her right breast in line of her seat belt (Figure 1). A mammogram and ultra-sound scan was performed which revealed extensive fat necrosis. Core biopsies were performed despite a low index of suspicion by the radiologist. This showed fat necrosis with no suspicious features. Surgery was offered to correct the indentation of her breast. Ten months following the accident, she underwent a complex reconstructive procedure performed under general anesthetic. The edges of diagonal depression were incised and de-epithelised. The nipple areolar complex was

Grit and tidiness: could what we know help us achieve success?

We read with great interest the recent paper by Halliday et al ,1 who evaluated the relationship between grit and burnout in a group of UK hospital doctors and generalxa0practitioners. Their finding that high levels of grit are associated with lower levels of burnout in UK doctors serves as an interesting observation and provides useful information to medical students and doctors alike. Notably, as the authors conclude, an understanding of an individual’s level of grit may be useful to identify doctors at a greater risk of burnout.1 Put another way, realising one’s level of grit may enable an individual to optimise their environment and thus help them achieve success, both personally and professionally.nnIn the …

The impact of “Be Clear on Cancer” campaign on breast care services provided by a specialist oncoplastic unit – A retrospective case control study

INTRODUCTIONnBe Clear on Cancer (BCOC) was a national campaign to raise awareness of breast cancer in women over seventy years old. Cancer Research UK conducted this campaign from 03 February 2014 to 15 March 2014. This study assesses its impact on breast care services.nnnMETHODSnBCOC campaign guidelines for hospital trusts were used as standard comparator for this retrospective case-control study. All new patients referred to breast clinic over four months from February 2014 were included, and compared to the same period in 2013. Information was recorded for referrals, biopsy rates and pathological diagnoses. Intra & inter-group comparisons were performed.nnnRESULTSn1646 patients were included. An increase of 25.2%(nxa0=xa0184) was observed in referrals in 2014(nxa0=xa0915) compared to 2013(nxa0=xa0731). Cancer detection rates went down significantly (Pxa0=xa00.002,Chi-square) in 2014 (5.1%,nxa0=xa047) compared to 2013 (9.0%,nxa0=xa066) due to the increase in number of referrals. In the over 70s group, a higher than predicted increase of 64.2%(nxa0=xa052) in all referrals, and 8%(nxa0=xa044) in two-week wait referrals was observed. The number of biopsies and cancers detected remained stable although the proportions undergoing biopsies (2014-29.3%,nxa0=xa039/133 versus 2013-38.3%,nxa0=xa031/81) or being diagnosed with cancer (2014-19.5%,nxa0=xa026/133 versus 2013-30.9%,nxa0=xa025/81) declined significantly (Pxa0=xa00.001,McNemar) during the campaign due to an inflation in the number of referrals. Despite the overall reduction, cancer detection rate for biopsies performed remained significantly high in the over 70s (66.7%,nxa0=xa026/39) when compared with the under 70s (23.9%,nxa0=xa021/88) during the campaign.nnnCONCLUSIONSnAlthough Be Clear on Cancer campaign resulted in a significant increase in breast cancer referrals, it did not translate into an increase in biopsy rates or cancer detection rates. The amount of work generated for the hospital because of this campaign was far greater than the predicted increase from campaign pilots. Therefore, the overall effectiveness of this campaign is questionable.

Encysted haematoma formation following a latissimus dorsi flap-based breast reconstruction

Sir, Haematoma formation is common after elective and emergency surgery. Around 3%of breast surgery patients return to theatre in the early postoperative period for the evacuation of haematoma [1]. Occasionally, the haematoma can be surrounded by a pseudo-capsule; thus producing a well localized, palpable lump that appears encapsulated, cystic or mixed echo on ultrasound. This is known as an encysted haematoma. The formation of an encysted haematoma following breast cancer and reconstructive surgery has not been previously communicated. To the best of our knowledge, we present the first case of an encysted haematoma following breast reconstruction surgery. A 68-year-old lady underwent right mastectomy and sentinel node biopsy for Paget’s disease of the nipple and high-grade ductal carcinoma in situ. Five months later, she had a delayed right breast reconstruction using latissimus dorsi (LD) myocutaneous flap. Suction drains were placed at the time of surgery and were subsequently removed before discharge. The patient made an uneventful recovery and was discharged from hospital a week later. She presented 2 months later complaining of persistent discomfort and feeling of a lump on the right side of her back. Examination confirmed a 3-cm smooth, mobile mass with seroma under the LD scar. Considering her symptoms, the decision was made to perform wound exploration under general anaesthesia. Intra-operatively, two separate Bpebble-like^masses were excised and sent for histological examination (Fig. 1). The patient felt comfortable in the immediate postoperative period and made an uneventful recovery. Histology confirmed excision of two encysted nodular lesions measuring 37×32×12 mm and 15×15×4 mm with similar microscopic features of the central area of degenerating blood and fibrin arranged in concentric lines (lines of Zahn), surrounded by a pseudo-capsule of fibrous tissue with no definitive epithelial or endothelial lining. The appearances confirmed the diagnosis of encysted haematomas. The patient came back for a follow-up 4 weeks later and complained of the feeling of a lump in the same area. Clinical examination confirmed a 1.5-cm mobile mass. This was investigated with an ultrasound scan (USS) that demonstrated a mobile, well-defined 40×20×15 mm mixed echo-texture lesion underneath the right LD flap scar containing some calcifications surrounded by a small amount of fluid. This was suggestive of an encysted haematoma. USS also picked up a second 13-mm lesion, similar in appearance but completely immobile (Fig. 2). A further surgical exploration was undertaken and three more mass lesions were excised that appearedmacroscopically similar to the previously excised encysted haematomas (Fig. 3). The two larger suspected encysted haematomaswere sent for histology that confirmed the diagnosis with microscopic features similar to the previously excised lesions. No breast or muscle tissue was identified in any of the specimens. The patient did not experience any further problems and recovered well from surgery. Follow-up has not shown any cancer recurrence to date. The patient is happy with the final appearance of her breast reconstruction. An informed consent was obtained from the patient for this case report. Encysted haematomas have not been reported previously following breast surgery. There are case reports of encysted haematomas following spontaneous haemorrhage, blunt trauma and surgery [2–5]. Anatomical sites of these haematomas vary greatly as they have been reported in the orbit, neck, mediastinum, pericardium, pleural cavity, perinephric, para-aortic, retroperitoneum, lesser sac, * Fayyaz A. K. Mazari fayyaz.mazari@nhs.net

Cost-effectiveness of one-stage versus two-stage breast reconstruction in the United Kingdom

Aim: Permanent expanders allow for breast reconstruction as a single stage. These prostheses are more expensive than conventional tissue expanders, but this excess cost is markedly offset as only one operation is required. However, if the revision rate is sufficiently high, then this effect is negated. We aim to compare costs of one-stage vs . two-stage reconstruction at a single center, taking into account explantation and unexpected admissions following complications. Methods: A retrospective review was carried out on all patients who underwent one-stage and two-stage reconstruction over a 5-year period by a single surgeon. A cost analysis was performed taking into account, explantation and additional admissions. Results: One hundred and forty-three one-stage and 45 two-stage procedures were included. The explantation rate for one-stage procedures is 36%, at a mean of 12.9 months postimplantation, the majority of which were exchanged for silicone implants to improve cosmesis. Four (9%) of the two-stage procedures were explanted a mean of 18 months postreconstruction. Overall, one-stage reconstructions were significantly more expensive than the two-stage group ( P = 0.016). Conclusion: There are many benefits of one-stage breast reconstruction. However, it does not appear to be cost-effective when additional admissions for explantation surgery are taken into account.

Outcome of single-stage breast reconstruction using the Natrelle 150 expander implant.

AbstractThe Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3–65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P < 0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P < 0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.