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Background Recent studies have shown a decline in theatre efficiency and productivity coinciding with the coronavirus disease 2019 (COVID-19) pandemic. In this study, we evaluate trauma theatre task efficiency in three different time periods (April 2019, April 2020, and November 2020), and analyse if productivity has altered since the start of the pandemic. Methods The records of a total of 320 patients who underwent orthopaedic trauma surgery at a large district general hospital in April 2019, April 2020 (during the first wave of the pandemic) and November 2020 (during the second wave of the pandemic) were analysed. Primary outcomes measured include time to get to the theatre, anaesthetic preparation time, the sum of time of anaesthesia and surgical preparation time, duration of surgery and time to transfer to recovery. Patient demographics as well as the type of surgery were also analysed. Results The time to get to the theatre and anaesthetic preparation time significantly increased in April 2020 (p0.05). The duration of surgery and time to transfer to recovery significantly increased in April 2020 (p

Malignant oncocytoma is an extremely rare neoplasm of the salivary gland accounting for 0.5% of epithelial salivary gland malignancies and 0.18% of epithelial salivary gland tumors. We report a case of malignant oncocytoma of left parotid gland in a 61-year old female patient. Patient presented with a 6-year history of painless swelling in the left parotid region. Fine needle aspiration cytology of the swelling was suggestive of pleomorphic adenoma. A computed tomography scan performed did not reveal any features suggestive of malignancy. Patient underwent left superficial parotidectomy. However, histopathological examination of the specimen turned out to be malignant oncocytoma. Malignant oncocytoma of salivary glands have rare incidence and may have similar morphologic features with other neoplasms. Despite the tumor being large and malignant in this case, there was no facial palsy preoperatively. As histopathology is often diagnostic, the possibility of malignancy always must be kept in mind preoperatively even when there is no facial palsy or fine needle aspiration cytology not showing up malignancy.

Background: Number of cancelled electiveorthopaedic surgeries has increased over the last decade as strains on surgicalservices exacerbates. Being told an operation is cancelled is disappointing forthe patient, the clinician and is not without a financial loss. This experienceis frustrating for patients who are often not informed of cancellations bydoctors and sent home dissatisfied without clarity of treatment plans.Alternatives have to be sought to safeguard the patient experience, maintaincommunication and avoid wastage of resources. Methods: Over a 1-year period, 117 patientswere prospectively shortlisted with a cancellation on the day of surgery in adedicated elective orthopaedic unit. Questionnaire data assessed adherence toAssociation of Anaesthetists of Great Britain and Ireland Theatre Efficiencyguidance, including: healthcare professional informing patients; time offeredfor explanation; patient understanding and satisfaction as well as perceptionof being kept nil by mouth (NBM) longer than necessary. Opinions of alternativesatisfactory professionals to lead cancellation discussion was also evaluated. Results: 35.04% of cancellations were informedby consultants, 23.77% by junior doctors and 38.46% by nurses. Out of 10,patient understanding was 8.31 and satisfaction 6.37 for consultant leddiscussions against 5.12 and 4.07 for nurses, respectively. Overall, 35.04% ofpatients felt they were kept NBM longer than necessary vs. 60% of the 45patients told by nurses. 90.60% felt consultants were the ideal professional tolead cancellation discussions however 70.94% stated a registrar would besatisfactory. Conclusions: Cancelledelective surgery that a patient has mentally prepared for is extremelydemoralising. Poor peri-operative communication and management further worsensthe patient experience and represents sub-standard care. It is paramount thatguidelines exist where patients are informed of reasons for cancellation by asenior surgeon in a manner that accounts for availability of resources.

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments. Cite this article: Bone Joint J 2013;95-B:1158–64.

In our series of 710 consecutive laparoscopic total-extra-peritoneal hernia repairs over a period of 10 years (2001–2010), the authors report a rare case of delayed mesh infection developing 7 years postoperatively. A 56-year-old patient presented with diarrhoea and fullness in right iliac fossa region. Radiological imaging confirmed a floating mesh in a fluid-containing cavity. Subsequent exploration revealed a large preperitoneal cavity containing 550 ml of pus with a floating mesh in it. The mesh was removed and the patient was discharged after making a good recovery.

Management of rectal cancer has evolved over the years. In this condition preoperative investigations assist in deciding the optimal treatment. The relation of the tumor edge to the circumferential margin (CRM) is an important factor in deciding the need for neoadjuvant treatment and determines the prognosis. Those with threatened or involved margins are offered long course chemoradiation to enable R0 surgical resection. Endoanal ultrasound (EUS) is useful for tumor (T) staging; hence EUS is a useful imaging modality for early rectal cancer. Magnetic resonance imaging (MRI) is useful for assessing the mesorectum and the mesorectal fascia which has useful prognostic significance and for early identification of local recurrence. Computerized tomography (CT) of the chest, abdomen and pelvis is used to rule out distant metastasis. Identification of the malignant nodes using EUS, CT and MRI is based on the size, morphology and internal characteristics but has drawbacks. Most of the common imaging techniques are suboptimal for imaging following chemoradiation as they struggle to differentiate fibrotic changes and tumor. In this situation, EUS and MRI may provide complementary information to decide further treatment. Functional imaging using positron emission tomography (PET) is useful, particularly PET/CT fusion scans to identify areas of the functionally hot spots. In the current state, imaging has enabled the multidisciplinary team of surgeons, oncologists, radiologists and pathologists to decide on the patient centered management of rectal cancer. In future, functional imaging may play an active role in identifying patients with lymph node metastasis and those with residual and recurrent disease following neoadjuvant chemoradiotherapy.

A 52-year-old woman was admitted with neutropenic sepsis, 3 days following the final cycle of adjuvant chemotherapy for breast cancer. Her condition deteriorated with progressive abdominal distension, bilious vomiting and diarrhoea. Abdominal examination revealed a mild degree of peritonism. Five days later she passed a small bowel cast per rectum, showing gross fungal contamination on histology. She was managed conservatively with antibiotics and antifungal medications and nutritional support.

The role of laparoscopic ultrasound (LUS) during staging laparoscopy for pancreatic cancers is established but remains debatable in evaluating oesophagogastric cancers.A retrospective consecutive case series consisting of patients undergoing staging laparoscopy in two centres (centre A and B) was carried out over a 5-year period (2000-2005). Patients in centre B underwent LUS following laparoscopic assessment using a 7.5-MHz probe. Staging laparoscopy in both centres was performed using a standardised three-port protocol using a 30 degrees laparoscope. All suspicious lesions were sent for histological assessment for confirmation of malignancy.There were 201 patients in centre A (83 gastric, 138 lower oesophageal/junctional cancers) and 119 patients in centre B (51 and 68, respectively). There were no differences between the two centres for patient demographics and tumour site. There was no difference between the two centres for the detection of metastatic disease using laparoscopic assessment alone (A 13% versus B 20%, p = 0.12). However, there was a significant difference (13% versus 28%, p = 0.001) with the additional use of LUS in centre B. The findings in the additional 8% (n = 9) were para-aortic lymphadenopathy (n = 5), liver metastasis (n = 3) and local extension (n = 1). Five had gastric and four lower oesophageal/junctional cancers. The negative predictive value was 6.4% for centre A and 4.5% for centre B.The addition of LUS increased the detection rate of metastasis by 8% but there was little impact on the false-negative rate. LUS is useful in detecting metastatic lymphadenopathy beyond the limits of curative resection and liver metastasis.

Mucosa-associated lymphoid tissue (MALT) is a type of extra nodal malignant lymphoma seen in organs such as the stomach, thyroid and salivary glands. Furthermore, occurrence of colorectal MALT lymphoma is extremely rare. We report a case of a solitary rectal MALT lymphoma treated by surgical resection and radiotherapy. Lymphoma should be considered as a rare differential diagnosis when dealing with large bowel pathology. We would advocate the use of surgery as a primary treatment option for a medically fit patient.

Appendicitis in a remaining duplicate appendix is a rare phenomenon and we report such a case. The unusual presentation of this anomaly can cause diagnostic dilemmas. Awareness of this condition is important because failure to recognise the condition may lead to errors in diagnosis and subsequent management. A young woman was admitted with a 3 day history of sudden onset, severe, central abdominal pain radiating towards the right iliac fossa, anorexia, rigors and vomiting. Her only significant past history was open appendectomy 4 years previously for a gangrenous appendix. The patient was pyrexial on admission but haemodynamically …

Introduction and aim of study: there is recent evidence that the immune system plays an essential role in the pathogenesis of atherosclerosis, with both cellular and humoral mechanisms being involved. Heat-shock proteins (HSPs) have been detected in atherosclerotic lesions, and antibodies to HSPs have also been found to be raised in patients with carotid stenoses. The aim of our study was to examine the level of anti-HSP70 antibodies in patients with other vascular diseases. Materials and methods: a questionnaire was designed for the subjects in the study, with documentation of clinical details and ankle–brachial pressure index. Patients with concomitant infection, malignancy, hepatorenal failure, or recent surgery were excluded. Enzyme-linked immunosorbent assay (ELISA) was used to identify anti-HSP70 antibodies in the sera in different dilutions. Graphs of optical density (OD) vs. negative log dilution were plotted, the gradient of which was taken to be the estimated optical density for each subject (proportional to antibody level). Our groups consisted of controls (n =21, mean age 59.0±19.2), lower limb claudicants ( n =19, mean age 60.0±12.6), patients with lower-limb critical ischaemia ( n =22, mean age 68.5±10.07), and patients with abdominal aortic aneurysms ( n =20, mean age 69.9±6.2). Results: we found no correlation between age and the estimated OD in our subjects (Spearman's correlation coefficient ( r )=0.123, one-tailed p value was 0.135). Patients with intermittent claudication, critical lower limb ischaemia, and aneurysms had higher estimated OD, and therefore higher anti-HSP70 antibody levels, than controls (Mann–Whitney test p =0.0127, 0.0037, 0.0008, respectively). Conclusions: our data provide the first evidence of a correlation between anti-HSP70 antibodies and different types of vascular diseases, suggesting that HSP70 might be involved in the pathogenesis and propagation of atherosclerosis. Since the immune response to HSPs can be modulated, this opens up the possibility of new therapeutic approaches.