We present two recent successfully litigated malpractice cases in which patients with cerebrovascular accidents were misdiagnosed as stroke mimics. The first was diagnosed as a hemiplegic migraine, which occurs in only 0.01% of the population. The second was diagnosed as a conversion disorder, which ultimately has a neurologic etiology in 4% of cases. In both cases, issues of poor patient communication and poor documentation were paramount in the legal outcome. We discuss caveats of stroke mimics, tissue plasminogen activator administration liability, and pitfalls in patient and family interactions.
INTRODUCTION The aim of this study was to evaluate the long-term outcome and durability of both autologous and implant-assisted latissimus dorsi reconstruction in a district general hospital over a 10-year follow-up period. METHODS A prospective cohort study was carried out using a detailed database of all latissimus dorsi flap reconstructions performed by a single consultant surgeon between 2003 and 2013 at the Royal United Hospital, Bath. The long-term outcome following reconstruction was assessed by analysing all episodes of 'reconstruction-specific' operations required from 6 months after the initial surgery. RESULTS The study included 110 patients with latissimus dorsi flap reconstructions, 21 autologous and 95 implant-assisted. Radiotherapy was given to 27 patients with reconstructed flaps. Mean follow-up was 69 months. Further reconstruction-specific surgery was needed in 27 (23%) cases, with 5 of these being post-radiotherapy flaps. Implant-related surgery was the most common reason for further surgery. Complications of the implant itself made up 52% of these cases, chronic sepsis being the most common. The rate of symptomatic capsular contracture requiring further surgery was 4.2%. Of these, one of four patients had undergone radiotherapy. DISCUSSION In our institution, latissimus dorsi reconstruction is durable and safe over the long term, with limited need for further substantial intervention to maintain a good outcome from the initial reconstruction. Autologous flaps were less likely to require further surgery over the long term compared with implant-based reconstructions. The low rate of symptomatic capsular contracture may be due to the protective mechanism provided by the extended harvest flap used.
Purpose
The B-MaP-C study investigated changes to breast cancer care that were necessitated by the COVID-19 pandemic. Here we present a follow-up analysis of those patients commenced on bridging endocrine therapy (BrET), whilst they were awaiting surgery due to reprioritisation of resources.
Methods
This multicentre, multinational cohort study recruited 6045 patients from the UK, Spain and Portugal during the peak pandemic period (Feb–July 2020). Patients on BrET were followed up to investigate the duration of, and response to, BrET. This included changes in tumour size to reflect downstaging potential, and changes in cellular proliferation (Ki67), as a marker of prognosis.
Results
1094 patients were prescribed BrET, over a median period of 53 days (IQR 32–81 days). The majority of patients (95.6%) had strong ER expression (Allred score 7–8/8). Very few patients required expedited surgery, due to lack of response (1.2%) or due to lack of tolerance/compliance (0.8%). There were small reductions in median tumour size after 3 months’ treatment duration; median of 4 mm [IQR − 20, 4]. In a small subset of patients (n = 47), a drop in cellular proliferation (Ki67) occurred in 26 patients (55%), from high (Ki67 ≥ 10%) to low (< 10%), with at least one month’s duration of BrET.
Discussion
This study describes real-world usage of pre-operative endocrine therapy as necessitated by the pandemic. BrET was found to be tolerable and safe. The data support short-term (≤ 3 months) usage of pre-operative endocrine therapy. Longer-term use should be investigated in future trials.
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