Josephine Barry

The impact of routine open nonsuction drainage on fluid accumulation after thyroid surgery: a prospective randomised clinical trial

BackgroundThyroid drains following thyroid surgery are routinely used despite minimal supportive evidence. Our aim in this study is to determine the impact of routine open drainage of the thyroid bed postoperatively on ultrasound-determined fluid accumulation at 24 hours.MethodsWe conducted a prospective randomised clinical trial on patients undergoing thyroid surgery. Patients were randomly assigned to a drain group (n = 49) or a no-drain group (n = 44) immediately prior to wound closure. Patients underwent a neck ultrasound on day 1 and day 2 postoperatively. After surgery, we evaluated visual analogue scale pain scores, postoperative analgesic requirements, self-reported scar satisfaction at 6 weeks and complications.ResultsThere was significantly less mean fluid accumulated in the drain group on both day 1, 16.4 versus 25.1 ml (P-value = 0.005), and day 2, 18.4 versus 25.7 ml (P-value = 0.026), following surgery. We found no significant differences between the groups with regard to length of stay, scar satisfaction, visual analogue scale pain score and analgesic requirements. There were four versus one wound infections in the drain versus no-drain groups. This finding was not statistically significant (P = 0.154). No life-threatening bleeds occurred in either group.ConclusionsFluid accumulation after thyroid surgery was significantly lessened by drainage. However, this study did not show any clinical benefit associated with this finding in the nonemergent setting. Drains themselves showed a trend indicating that they may augment infection rates. The results of this study suggest that the frequency of acute life-threatening bleeds remains extremely low following abandoning drains. We advocate abandoning routine use of thyroid drains.Trial registrationISRCTN94715414

Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer

Axillary ultrasonography (AUS) and fine‐needle aspiration cytology (FNAC) can establish axillary lymph node status before surgery, although this technique is hampered by poor adequacy rates. To achieve consistently high rates of FNAC adequacy, rapid on‐site evaluation (ROSE) of FNAC samples was introduced.

Type 1 hypersensitivity reaction to carboxymethylcellulose following intra-articular triamcinolone injection.

A 23-year-old male sustained a rotator cuff injury following a rugby injury and was given an intra-articular injection of 30 mg triamcinolone acetate (Adcortyl®) under ultrasound guidance. Ten minutes after leaving the radiology department he developed a rash. He returned and was seen within 45 min of the injection with generalized urticaria and associated periorbital angioedema. He gave no relevant past medical history but had a family history of atopy. He was dyspnoeic, hypotensive (BP 90/55 mmHg) and tachycardic (HR 130/min). He responded rapidly to intravenous chlorpheniramine and was discharged well after 24 hr observation. Skin prick test results are presented in Table 1. Initial skin prick testing to serial dilutions of Adcortyl®, triamcinolone acetonide 1% pet, benzyl alcohol 1% pet, and neat Hibiscrub© were negative. An intradermal injection of Adcortyl® diluted 1/1000 gave a 5 mm weal at 15 min. The constituents of Adcortyl® were provided by the manufacturer. The patient was prick skin tested to incremental concentrations of sodium carboxymethylcellulose in water and had a 5 mm weal at 0.2% at 15 min. Prick tests to triamcinolone acetonide 0.001%, 0.01%, 0.1%, 1%, and 10% in water, polysorbate 80 at 0.1%, 1%, and 10% in water were negative (Table 1).

Comparison of MRI and high-resolution transvaginal sonography for the local staging of cervical cancer.

The aim of this prospective study was to compare the diagnostic accuracy of transvaginal sonography (TVS) with that of MRI in the local staging of cervical cancer.

Bilateral inferior vena cava filter insertion in a patient with duplication of the infrarenal vena cava

BackgroundInferior vena cava (IVC) filter insertion is a commonly performed procedure for indications such as recurrent pulmonary emboli or contraindication to anticoagulation. Symptomatic duplication of the IVC is exceedingly rare with only a handful of cases being described in the literature.AimWe report an unusual case of a patient with symptomatic duplication of the IVC.ResultA 53-year-old woman presented at our hospital for resection of a cerebral metastasis from a non-small cell lung cancer following a recent diagnosis of bilateral lower limb deep venous thrombosis. This required perioperative reversal of anticoagulation and IVC filter insertion. Conventional venography performed during filter insertion documented the existence of a duplicated IVC.ConclusionWe present a case of a symptomatic duplication of the IVC requiring filter insertion. We review the developmental anatomy of the IVC along with the diagnostic findings and management strategies available.

Intussusception of the small bowel in an adult associated with nephrotic syndrome.

Sir, Here, we report our observations of a 39-year-old female who presented with progressive lower limb oedema over a 2-week period. She had no significant medical or family history. Physical examination revealed a right-sided pleural effusion and bilateral lower limb swelling. Laboratory investigations confirmed the clinical suspicion of nephrotic syndrome: albumin 14 g/L, creatinine 60 μmol/L, cholesterol 8.8 mmol/L, urinary protein–creatinine ratio (PCR) 997 mg/mmol. Complements were normal, and autoimmune serology was negative. Percutaneous renal biopsy was performed and demonstrated features consistent with minimal change disease. She was commenced on fluid and salt restriction and high-dose loop diuretics. She also received prednisolone 1 mg/kg orally [1]. Five days post-renal biopsy, she developed acute left-sided colicky abdominal pain. On physical examination, her abdomen was tender in the left iliac fossa with no signs of peritonism. The abdominal film was unremarkable. Abdominal ultrasound showed an iliocolic intussusception (Figure 1). Fig. 1 Transverse section of intussuception. Bull’s-eye sign/target/crescent-in-doughnut. A. Intussicepiens. Concentric rings of alternating hypoechoic and hyperechoic layers. B. Returning limb of intussuceptum. C. Mesentery of intussuceptum. Central ... She remained clinically and biochemically nephrotic at this time. She entered the remission phase of nephrotic syndrome between Days 7 and 10 after the initiation of therapy which coincided with the complete resolution of her abdominal pain. Gastrointestinal disturbances are frequently encountered in the course of nephrotic syndrome. The differential diagnosis considered included renal vein thrombosis, peptic ulcer disease and subacute bowel obstruction. Fortuitously, at the time of ultrasonography, the patient developed an episode of colicky abdominal pain, and the intussusception could be demonstrated. Ultrasonography is the diagnostic tool of choice to detect intussusception, although it can be operator dependent or limited by body habitus. Intussusception causes ‘telescoping’ of the bowel due to a lead point in the bowel, which in this case is due to incoordinate gut motility and bowel wall oedema. Intussusception is not infrequently described in the paediatric literature, but the usual cause in adults is secondary to a bowel tumour, which acts as a lead point for the invagination of the bowel [2]. Treatment of the underlying nephrotic syndrome resulted in resolution of the intussusception without the need for any intervention [3,4]. Infusions of albumin have also been described [5]. We conclude that nephrologists should consider intussusception in the differential diagnosis of abdominal pain in the setting of nephrotic syndrome as early recognition may improve prognosis. Conflict of interest statement. None declared.