The current understanding is that small intracranial aneurysms (<7 mm) are not at a significant risk for rupture. However, there have been several published series of rupture and subarachnoid hemorrhage from aneurysms <5 mm. Three cases of intracranial aneurysms rupturing at <3 mm are presented in this paper. Patient age ranged between 38 and 57 years. The aneurysms were located in different parts of the circulation in the brain. This case series highlights that the size criterion alone is not adequate when evaluating patients with unruptured brain aneurysms for observational follow-up or treatment.
Nutcracker syndrome (NCS) is caused by compression of left renal vein (LRV), usually between the aorta and the superior mesenteric artery (SMA). This can lead to obstruction of flow into the inferior vena cava and secondary left renal venous hypertension. Despite potential serious consequences, diagnosing NCS is often challenging, circuitous and commonly delayed. We report an extremely unique case of NCS. A 34-year-old woman presented with left flank pain and discomfort. On investigation, it was found that high pressure in the LRV, due to compression by the SMA, had led to a large venous aneurysm that had caused pelviureteric junction obstruction and hydronephrosis. Management was with stenting of the LRV and coil embolisation of the venous aneurysm with excellent clinical outcome.
Simultaneousinvolvement of the supraclavicular and axillary lymphatic basins is known to occur in metastatic skin cancers. We present the case of a 35-year-old male with metastatic melanoma present in the right neck and axillary lymph nodes. He underwent a combined, in-continuity dissection of both basins using intraoperative ultrasound to ensure full clearance of lymph nodes from the cervicoaxillary canal, which otherwise would have been impossible to achieve without clavicle osteotomy. This allowed us to avoid a division of the clavicle and related morbidity. Postoperative imaging confirmed no residual disease, and no local recurrence subsequently. We conclude that intraoperative use of ultrasound can help guide surgeons trying to achieve clearance of metastatic disease in anatomically complex regions, avoiding unnecessary morbidity. Melanoma Res 33: 149-151
Spontaneous renal artery dissection and acute renal infarcts are rare occurrences and often misdiagnosed in clinical practice. We present four male patients, between 30-50 years of age, who have no underlying cardiac conditions, hypertension, or diabetes mellitus. They presented with abdominal/loin/flank pain due to spontaneous renal artery dissection and were all treated with endovascular stenting. Two patients had renal artery fibromuscular dysplasia, confirmed by CT angiogram, a rare pathology which is reported in literature to mostly affect women. All four patients recovered fully from the operation, with no post-operative complications noted. These patients were post-operatively managed medically with anti-platelet therapy for two years and did not experience any post-procedural complications at their 24-month follow up. Classically visceral artery dissection can be managed by anti-platelet therapy alone, however fibromuscular dysplasia can cause spontaneous dissection with renal infarcts and this requires urgent treatment with endovascular stents. Further research is needed on the post-procedural medical management guidelines.
Aim Incomplete informed consent can lead to patient dissatisfaction and litigation.1 Time constraints, legibility, human error, limit completion of consent forms, putting surgeons and trusts at risk of litigation.2 The aim of this project was to assess legibility and completeness of handwritten consent forms, with the objective to improve legibility to 100% and risks listed to 100% of those endorsed by the British Orthopaedic Association (BOA).3 Method An initial baseline study in multiple hospitals across the UK identified 113 patients who underwent hemiarthroplasties. The consent forms were assessed for legibility and risks included, compared to those listed by the BOA. Pre-populated risks stickers were introduced in 1 district general hospital (DGH) and 2 cycles repeated again (62 patients identified). Results Overall, 35% of consent forms 1 were illegible; 100% of the time in the risks section. Mean number of risks missing was 2.34 and most frequently missed risk was ‘death’ (missing on 35.5% of consent forms). In the DGH that introduced stickers, consent forms were 100% legible and 100% compliant to the standards set by the BOA when the stickers were used. However, sticker use remained low; only used 20% of the time in the second cycle, marginally increased from the previous cycle (18%). Conclusions A high proportion of consent forms are not completed to BOA standards and are illegible. Pre-populated stickers could aid in achieving 100% legibility and 100% risk inclusion. The stickers will be implemented in other trusts and methods to increase compliance with sticker use will be trialled.
Introduction As of 11th of March 2020, the World Health Organization (WHO) declared the novel coronavirus 2019 (COVID-19) a pandemic. It is estimated that urgent cancer referrals have reduced 70-89% across hospitals in England during the COVID-19 pandemic, in addition to reductions in attendance for the different treatment arms. The aim of our investigation is to assess the impact of COVID-19 on MDT outcomes and patients attending/receiving treatment as compared to before for head and neck cancer. Method Data was collected retrospectively over a period of 203 days (7th January to 28th July 2020), including 66 patients prior to COVID-19 being declared a pandemic and 116 patients since, at a regional cancer centre. A total of 182 patients undergoing treatment were identified. These patients were assessed by TNM staging, MDT outcomes and final initial treatment intents, which were compared to pre-COVID outcomes. Results With respect to MDT outcomes, there was an increase in the number of patients decided for surgery from 10.61% to 23.28% (p = 0.78) during the first wave of the pandemic. Patients decided for radiotherapy and chemotherapy increased by 12.49% and 4.31% respectively. Notably, there was a decrease in further investigations and referrals from 37.88% to 18.10%. Moreover, an increase in palliative treatment intent by 10.55% was noted during the pandemic. Conclusions As the UK enters into the next peak of the pandemic, with reduced capacity for elective surgery and outpatient clinics, it is essential to consider its impact on the standard of care delivered to current cancer patients.
Introduction: To explore the causes and management of renal infarction from pathologies such as renal artery fibromuscular dysplasia and spontaneous dissection. It is a rare occurrence and often misdiagnosed in clinical practice. Methods: We present four patients, between 30-50 years of age, who have no underlying cardiac conditions, hypertension or diabetes mellitus. They presented with abdominal/loin/flank pain due to spontaneous renal artery dissection and were treated with endovascular stents. Two patients had renal artery fibromuscular dysplasia, confirmed by CT angiogram. Results: All four patients recovered fully from the operation, with no post-operative complications noted. These patients were post-operatively managed medically with anti- platelet therapy for two years and have not experience any post-procedural complications at their 24-month follow up
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