Jeremy Rodrigues

Contrast-enhanced magnetic resonance angiography for preoperative imaging in DIEP flap breast reconstruction.

Background: Contrast-enhanced magnetic resonance angiography has been shown to be very accurate for identifying the perforator size, location, and intramuscular course, and the associated venous system, without exposing the patient to ionizing radiation. This study reports the authors experience using this imaging modality in a large patient series. Methods: A retrospective review of patients who had undergone preoperative contrast-enhanced magnetic resonance angiography followed by free abdominal flap breast reconstruction was conducted. The results of imaging were compared with intraoperative findings, and surgical outcomes were compared with scan data. The results were compared with control data in patients who did not undergo presurgical imaging. Results: One hundred thirty-two patients underwent contrast-enhanced magnetic resonance angiography presurgical imaging, and the results were compared with 84 controls. The imaging was found to be accurate for evaluating the perforator anatomy for free abdominal flap planning, with a high concordance between imaging and intraoperative findings. Without presurgical angiography, the ratio of deep inferior epigastric perforator (DIEP) flap–to–free transverse rectus abdominis musculocutaneous flap harvest was 0.9:1; with presurgical imaging, the ratio was 1.6:1 (p < 0.05). With presurgical angiography, there was a mean reduction in operating time of 26 minutes for unilateral DIEP flap harvest and 40 minutes for bilateral harvest, although these values were not significant. There was a significant reduction in the partial flap failure rate with preoperative imaging. Conclusions: Presurgical imaging using contrast-enhanced magnetic resonance angiography demonstrates a high concordance with intraoperative findings. In this series, the percentage of flaps that were raised as DIEP flaps was significantly increased in patients who underwent preoperative imaging, and the partial flap failure rate was significantly reduced. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Figure. No caption available.

A cross-sectional study of the presence of United Kingdom (UK) plastic surgeons on social media

INTRODUCTION AND AIMSnTo determine the uptake and usage of websites and social media (SM) by UK consultant (attending) plastic surgeons.nnnMETHODSnProfessional profiles of full BAPRAS members were searched on Facebook, Twitter, LinkedIn, RealSelf, YouTube, ResearchGate in May 2013. Additional surgeons were identified from the follower lists of @BAPRASvoice and @BAAPSMedia. Website ownership was determined on Google. Searches were repeated three times. Dual BAAPS-BAPRAS members were identified from www.baaps.org.uk.nnnRESULTSnThere were 156 (48.3%) dual BAAPS-BAPRAS members and 36 BAPRAS-only members. Fifty seven (18%) surgeons had no account on any platform whereas 266 (82%) were on at least one platform. One hundred and sixty four (51%) had personal websites whilst 37 (11%) had profiles on partnership websites. One hundred and sixteen (36%) had no website presence whilst 2% had websites under construction. The platform most surgeons use is LinkedIn (52%) whilst smaller proportions used Facebook (4%) and Twitter (22%). Surgeons had a mean of 126 (range: 0-3270) Twitter followers and 368 (range: 7-3786) fans/likes of their Facebook profiles. Time spent in postgraduate practice was not predictive of website ownership or SM use. However, dual BAAPS-BAPRAS members were significantly more likely to own a personal website, Twitter, RealSelf and YouTube accounts.nnnCONCLUSIONSnThere has been an increase in the uptake of social media by UK plastic surgeons, especially in those with aesthetic surgery interests. However, very few surgeons have optimised their web presence. Continued education and appropriate usage guidance may promote uptake, particularly by reconstructive surgeons.

Clostridium difficile infection in general surgery patients; identification of high-risk populations

BACKGROUNDnRisk factors associated with Clostridium difficile infection (CDI) in general surgical patients are poorly characterised. This study aimed to characterise the incidence and associations of C. difficile positivity (CDP) in general surgical inpatients to aid in the design of future policies regarding focused screening and risk-stratification mechanisms in this patient subpopulation.nnnMATERIALS AND METHODSnDischarge, laboratory and coding data from all general surgery inpatients admitted to a large tertiary referral general surgical unit, between March 2005 and May 2007, were examined.nnnRESULTSn21,371 patient records were interrogated. 101 (0.47%) CDP cases were identified from laboratory records and compared with non-CDP controls for age, gender, length of stay (LOS), admission to intensive care unit or high dependency unit (ICU/HDU), co-morbidities and surgical procedures. Univariate analysis identified a range of risk factors associated with positivity. Multivariate analysis identified malignancy, gastrointestinal disease, anaemia, respiratory disease, circulatory disease, diabetes mellitus, those undergoing gastrointestinal surgery and increasing age to be independently associated with CDP status.nnnCONCLUSIONSnThis study identifies incidence and risk factor associations of those who tested CDP in a large contemporary general surgery inpatient population. Focused screening programmes based on high-risk populations may provide information on further risk factors and allow risk-stratification. Further healthcare worker education regarding risk factors may reduce the clinical impact of CDI by encouraging increased vigilance and therefore earlier detection.

External cardiac compression during cardiopulmonary resuscitation of patients with left ventricular assist devices

A best evidence topic was written according to a structured protocol to determine whether there is evidence that cardiopulmonary resuscitation (CPR) by compressing the chest is safe and effective in patients with left ventricular assist devices (LVADs). Manufacturers warn of a possible risk of device dislodgement if the chest is compressed. AMED, EMBASE, MEDLINE, BNI and CINAHL were searched from inception to March 2014. Animal studies, case reports, case series, case-control studies, randomized controlled studies and systematic reviews were eligible for inclusion. Opinion articles with no reference to data were excluded. Of 45 unique results, 3 articles merited inclusion. A total of 10 patients with LVADs received chest compression during resuscitation. There was no report of device dislodgement as judged by postarrest flow rate, autopsy and resumption of effective circulation and/or neurological function. The longest duration of chest compression was 150 min. However, there are no comparisons of the efficacy of chest compressions relative to alternative means of external CPR, such as abdominal-only compressions. The absence of high-quality data precludes definitive recommendation of any particular form of CPR, in patients with LVADs. However, data identified suggest that chest compression is not as unsafe as previously thought. The efficacy of chest compressions in this patient population has not yet been investigated. Further research is required to address both the safety and efficacy of chest compressions in this population. Urgent presentation and publication of further evidence will inform future guidance.

Are UK junior doctors being taught to teach

Editor – Teaching is central to doctoring, as is acknowledged in the Hippocratic Oath and more modern guidance such as the General Medical Council (GMC) publication Guidelines for Good Medical Practice. Medical training has traditionally been considered an apprenticeship and the importance of experiential learning is reaffirmed by the most recent revision of the GMC’s Tomorrow’s Doctors. Teaching involvement also constitutes part of competitive selection processes for career progression. A variety of private courses are available to develop doctors’ teaching skills.

Twelve tips for running successful junior doctor-led teaching programmes for medical students

Background: Medical students value teaching by junior doctors and find it comparable to consultant-led teaching. Although several junior doctor-led teaching programmes have been developed, there is insufficient information in the literature to guide junior doctors planning on developing such programmes. Aim: This article gives junior doctors 12 practical tips on how they might develop and run successful teaching programmes for medical students. Results: The 12 tips are (1) Clearly define the scope of your programme, (2) Ensure student-defined learning goals are included at an early stage, (3) Inform and involve your fellow junior doctors in teaching, (4) Plan teaching rotas in advance, (5) Learn to teach effectively by attending courses, (6) Promote your programme to medical students as widely as possible, (7) Use varied and interactive teaching methods, (8) Establish rapport with students, (9) Include assessment as part of the teaching programme, (10) Seek feedback from attendees and senior faculty, (11) Establish rules for tutorials and (12) Secure formal recognition for your scheme. Conclusions: These 12 tips may help junior doctors to develop and manage successful teaching programmes. It may also be a useful guide for senior faculty advising junior doctors who aspire to establish such teaching programmes.

The use of larvae therapy to debride full thickness burns in the anaesthetically unfit patient: the Nottingham experience.

Since antiquity the use of maggot or larval therapy has been well described in the management of chronic and necrotic wounds [1–6]. Whilst the use of this modality dramatically declined after the 1940s with the revolutionary era of antibiotic therapy, there has been a rebirth in more recent years with the realisation that this modality can provide an effective solution to debride chronic wounds often contaminated with resistant organisms and especially in the anaesthetically compromised patient. Much of the published literature focuses on the use of maggots on wounds arising in pressure sores, venous stasis ulcers, neuro-vascular ulcers and those resulting from trauma [1–6]. Whilst there have been reports of the use of larval therapy on acute burns [7], its role in full thickness burns with extensive thick eschar is not well described, perhaps due to the potentially limited effectiveness of larvae at removing the dry burn eschar; Chan et al. [4] suggest that dry wounds are a contraindication for larvae therapy. Attempts to replicate this process with enzymatic debriding agents such as Debrase Gel Dressing (MediWound) may produce good effects, but are often associated with a degree of pain. This can persist for the duration of treatment. Symptoms such as itching may also limit their usefulness [8,9]. We present three cases in which larvae therapy was used to successfully debride patients with full thickness burns whose

The outcomes of displaced paediatric distal radius fractures treated with percutaneous Kirschner wire fixation: a review of 248 cases.

AbstractnThis study aimed to evaluate the effect of manipulation under anaesthesia (MUA) and Kirschner wire (K-wire) fixation of displaced, paediatric distal radius fractures on residual radiological angulation, displacement, and shortening, as well as functional outcomes, including complication rates. A retrospective review was conducted of all paediatric patients undergoing MUA and K-wire fixation for an extra-articular distal radius fracture over a period of 5xa0years. A total of 248 patients were included in the study with a mean age of 9.9xa0years (3–15). Mean follow-up was 6.6xa0weeks (4–156). There was a statistically significant increase in median dorsal angulation (pxa0<xa00.0001) between initial post-operative and follow-up radiographs at the time of K-wire removal. The number of K-wires used did not have a significant effect on dorsal angulation (pxa0=xa00.9015) at time of K-wire removal, nor did the use of an above or below elbow cast (pxa0=xa00.3883). Seventeen patients required a further general anaesthetic (5 revision operations, 12 removal of migrated K-wires). Eighty-seven percentage of (215 patients) of patients had normal function at follow-up post-K-wire removal. Angulation at time of K-wire removal of more than 15° was significantly associated with reduced functional outcome (pxa0=xa00.0377). A total of 41 patients (17xa0%) had complications associated with K-wire use. We conclude that though K-wire fixation is an effective technique, it does not prevent re-angulation of the fracture and is associated with a significant complication rate. Given the remodelling potential and tolerance to deformity in children, surgeons should give careful thought before utilising this technique for all displaced or angulated paediatric distal radius fractures. If used, 1 K-wire with immobilisation in a below elbow cast is sufficient in most cases.n

Academic mentoring in surgery: applying the near-peer principles to the training hierarchy: including medical students.

considered a precursor of CRPS Type 1. 4. A prophylactic fasciectomy of the remaining normal palmar fascia is carried out to try to avoid further palmar disease arising in this hand. With modern instrumentation, this actually leaves little dead space, without the risk of haematoma feared by McCash. Arguably, this reduces the likelihood of further development of disease, as pointed out many years ago to the senior author, and practiced routinely, by Professor Buck-Gramcko.

An audit of best evidence topic reviews in the International Journal of Surgery.

INTRODUCTIONnIJS launched best evidence topic reviews (BETs) in 2011, when the guidelines for conducting and reporting these reviews were published in the journal.nnnAIMSn(1) Audit the adherence of all published BETs in IJS to these guidelines. (2) Assess the reach and impact of BETs published in IJS.nnnMETHODSnBETs published between 2011 and February 2014 were identified from http://www.journal-surgery.net/. Standards audited included: completeness of description of study attrition, and independent verification of searches. Other extracted data included: relevant subspecialty, duration between searches and publication, and between acceptance and publication. Each BETs number of citations (http://scholar.google.co.uk/), number of tweets (http://www.altmetric.com/) and number of Researchgate views (https://www.researchgate.net/) were recorded.nnnRESULTSnThirty-four BETs were identified: the majority, 19 (56%), relating to upper gastrointestinal surgery and none to cardiothoracic, orthopaedic or paediatric surgery. Twenty-nine BETs (82%) fully described study attrition. Twenty-one (62%) had independently verified search results. The mean times from literature searching to publication and acceptance to publication were 38.5 weeks and 13 days respectively. There were a mean 40 (range 0-89) Researchgate views/article, mean 2 (range 0-7) citations/article and mean 0.36 (range 0-2) tweets/article.nnnCONCLUSIONSnAdherence to BET guidelines has been variable. Authors are encouraged to adhere to journal guidelines and reviewers and editors to enforce them. BETs have received similar citation levels to other IJS articles. Means of increasing the visibility of published BETs such as social media sharing, conference presentation and deposition of abstracts in public repositories should be explored. More work is required to encourage more submissions from other surgical subspecialties other than gastrointestinal specialties.