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The development of the bus rapid transit system (BRTS) is tremendously growing in developing countries of the world. In large cities, the projection of transportation intends to enhance economic growth and changes the image of the city for both residents and outsiders. The purpose of this research was to study the application of alternative options for energy efficient BRTS in developing countries. The BRTS has some of its accessibility patterns that relate to the socio-economic strata. A decision-making efficiency analysis methodology has been applied to analyze the comparative analysis of both conventional fuel and hybrid bus systems for the Multan city of Pakistan. The section-wise application of a hybrid energy-based bus system has been analyzed in comparison to the conventional bus system. Out of 21 stations, the efficiency-wise hybrid bus system remained superior or equivalent to the standard value of 1 except one midpoint section. The finding of the analysis indicates that the hybrid mechanism of buses can not only replace a conventional fuel-based system, but will also help as an energy-efficient and eco-friendly economical solution. This study will help to revolutionize the bus rapid transit system in developing countries.

Background: Autologous breast reconstruction using the extended latissimus dorsi flap has been infrequently reported. In the current study, the authors are reporting their own clinical experience with this method. A review of the literature is also discussed. Materials and Methods: Over a three year period, 14 patients underwent breast reconstruction using the extended latissimus dorsi (LD) flap. Patients with small to medium sized breasts were selected. The age of the patients ranged from 29 to 42 years with a follow-up period ranging from six to 18 months. The indications, flap-related complications and donor site morbidity and aesthetic results were evaluated. Results: The main indication to use the flap was dorsal donor site preference by patients. The remaining patients were either not suitable for a flap from the abdomen or wished to get pregnant and were offered the dorsal donor site. Neither total nor partial flap loss was recorded but donor site morbidity was mainly due to seroma, which was treated conservatively in all patients, except for one who required surgery. Another two patients suffered from wound breakdown and distal necrosis of the back flaps. Mild contour deformity was also noted on the back of all patients but caused no major concern. Indeed, the overall patient satisfaction was very high. Conclusion: The extended LD flap proved to be a good option for autologous breast reconstruction in selected patients. Patients should be warned of the potential for seroma and mild contour back deformity.

While upper limb lymphoedema following breast and axillary surgery is well established in the literature, breast lymphoedema is rarely documented. Our primary objective was to identify risk factors of breast lymphoedema, and our secondary aim was to assess the possibility of using a breast ultrasound scan to assess breast lymphoedema. This study was a case series analysis, including patients who had wide local excision for primary breast cancer treatment between January 2013 and January 2018. Patients' demographics, including age, weight, body mass index (BMI), breast volume, tumour characteristics, and histological findings, were noted. All patients had a clinical assessment and ultrasound scan 6 months and 12 months after surgery, comparing ipsilateral to the contralateral breast skin, subcutaneous thickness, as well as parenchymal changes. We have included two hundred eighty-six breast cancer; the mean age was 54.7 years SD 17.3, the mean weight was 76.5 kg SD 12.6, the mean BMI was 31.5 SD 5.2, and the mean breast volume was 1223 ml SD 179. This study identified breast lymphoedema in patients with clinically detected skin oedema in the absence of radiotherapy skin changes; skin and subcutaneous 5 mm added thickness more than the contralateral side, and based on that, 22 patients (7.7%) were found to have breast lymphoedema. We have also found that patients with high BMI, larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance had an increased incidence of breast lymphoedema. The incidence of breast lymphoedema in this cohort was 7.7%. We suggest that breast lymphoedema should be considered if skin and subcutaneous thickness are 5 mm more than the contralateral side in the absence of severe radiotherapy skin changes. Also, we have found that high body mass index (BMI), larger breast volume, upper outer quadrant tumours, and patients who had axillary lymph node clearance are associated with an increased incidence of breast lymphoedema., Competing Interests: Competing InterestsThe authors declare no competing interests., (© The Author(s), under exclusive licence to Indian Association of Surgical Oncology 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: The dual technique using blue dye in combination with a radioisotope is considered the gold standard for identifying sentinel lymph nodes (SLNs) in patients with breast cancer. Unfortunately, not all cancer centres have access to radioactive material, which jeopardizes the SLN identification rate and patient safety., Aim: We aimed to assess the safety and efficacy of mitoxantrone hydrochloride injection (MHI) for identifying axillary SLNs in patients with primary breast cancer., Patients and Methods: We have conducted a prospective non-randomized analysis of patients diagnosed with invasive breast cancer who agreed to participate in the study between December 2019 and December 2022. We have used the patient's medical records to collect the data. We have used the SLN intraoperative identification rate as a marker for the efficacy of the technique and both the immediate and delayed complication rates and routine blood tests as markers for the safety of the technique., Results: Out of the 296 patients, 289 (97.6%) had their SLNs identified using MHI, while seven patients (2.3%) had four-node sampling carried out because the SLNs were not identified. Liver functions were not significantly affected by MHI, and there was no technique-related readmission or reported morbidity or mortality., Conclusion: We have found that the MHI technique is still inferior to the combined radioactive directed technique and patent blue V dye in SLN identification. Yet, it may serve as a safe and reliable alternative in cases where the radioactive technique is unavailable., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Breast cancer (BC) risk increases with age; about a third of patients are diagnosed in age older than 65. Treatment of this age group remains controversial, leading to inferior outcomes with lower survival rates than younger patients. We aimed to evaluate performance status tools as well as the outcome of management of breast cancer in the geriatric population. We have conducted a retrospective database analysis looking into the management of breast cancer patients older than 65 years old presenting to our unit during the period between June 2015 and June 2019. All patients had triple assessment as well as multimodality performance status assessment with their treatment modalities, and outcomes are recorded and assessed. We have included 578 patients, 0.8% male and 99.2% female, and our patients' mean age was 71 years. Most of our patients scored one or two on the WHO/ECOG performance status score and Clinical Frailty Score, as well as ASA-PS score. 3.2% had no treatment, 4.3% had endocrine therapy only, 0.5% had primary endocrine therapy followed by surgery, and 92.3% underwent surgery with 4.1% complication rate. Patients who underwent breast-conserving surgery had adjuvant breast radiotherapy, and 23.7% had adjuvant chest wall radiotherapy, 78.8% had adjuvant endocrine treatment, and 4.8% had adjuvant chemotherapy out of which 30.7% had adjuvant chemotherapy and Herceptin. Objective assessment tools should be used for patients older than 65 years diagnosed with primary breast cancer to be able to scarify patients' individualised treatment options to reach the optimum outcome., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© Indian Association of Surgical Oncology 2021.)

Background  With recent advances in different breast cancer treatment modalities, breast conservation surgery (BCS) has gained popularity and has become the mainstay for the treatment of early breast cancer. The model of dedicated breast surgeons working in breast units is standard in some but not all countries. We have aimed to define surgical outcomes of oncoplastic breast surgery carried out by one general surgical oncologist. Patients and methods We have conducted a prospective non-randomised case series analysis to assess the oncologic and aesthetic outcome of tissue displacement oncoplastic breast techniques in managing unifocal early-stage breast cancer from January 2019 to January 2020. One surgical oncologist with 23 years of surgical oncology experience carried out all operations. Results We have included 50 female patients treated with variant oncoplastic volume displacement techniques. We have used the round block technique in 20%, the batwing technique in 18%, lateral mammoplasty in 20%, and medial mammoplasty in 2%. We have also carried out wise pattern therapeutic mammoplasty with inferior pedicle in 20% (10 patients), and vertical mammoplasty with superior pedicle in 20% (10 patients). While 8% of our patients had Clavien-Dindo system grade I Immediate complications, including the surgical site infection and postoperative seroma and haematoma, 2% of patients had grade II complications in the form of partial areola and nipple complex necrosis leading to delayed wound healing requiring secondary suturing. No delayed complications or mortalities were recorded. Eight per cent of patients required re-excision to clear margins, 74% had excellent results, 24% had good results, and 2% had fair results. In addition, 64% were very satisfied with their results, 32% were satisfied, while 4% were not satisfied with aesthetic results. Conclusion Based on our limited number of patients, we have found that tissue displacement oncoplastic techniques carried out by a general surgical oncologist are safe and reliable in providing satisfactory oncological outcomes with a low risk of delaying adjuvant therapy and acceptable aesthetic outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Monib et al.)

Although arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema, including axillary surgery, high body mass index (BMI), increased bra cup size, adjuvant chemotherapy, locoregional and radiotherapy boost, and upper outer quadrant tumors. We aimed to provide a review to help avoiding or management of breast lymphedema. The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct a literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative, and surgery to search the Embase database. All papers published in English were included with no exclusion date limits. A total of 2155 female patients were included in this review; age ranged from 26 to 90 years. The mean BMI was 28.4 of the studies that included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as BMI, breast size, tumor size, tumor site, type of surgery, and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including manual lymphatic drainage, self-massaging, compression bras, or Kinesio taping. Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Radial margin status is considered one of the most important prognostic predictor for patients undergoing breast-conserving surgery (BCT), not only related to regional recurrence but also to 5y survival, especially in patients with invasive disease., Aim: While our primary aim was to evaluate whether doing routine radial cavity shaves following at the time of primary conservative breast surgery will decrease the need for a second operation or not, our secondary aim was to assess time added to the operation to resect and mark the radial shaves, as well as patients' satisfaction with the results., Material and Methods: We have conducted a case series prospective analysis, including158 patients who underwent breast-conserving surgery looking into the histological status of resection margins and radial shaves, added time taken to take and mark the shaves as well as patients' satisfaction., Results: 158 female breast cancer patients have been included in our analysis, the mean age was 56 years; total number of lesions was 160. While 89.3% of lesions were palpable, 10.6% were not requiring wire-guided localisation. Mean tumour size was 24 mm SD 7, final histology revealed that 86.8% lesion was invasive ductal carcinoma, 5.6% invasive lobular carcinoma, 1.2% medullary carcinoma. 12.4% had invasive disease as well as DCIS, and 1.8% had DCIS only with no invasive disease. Mean preoperative breast volume was 723 ml, Mean wide local excision specimen weight was 73 g, and mean shave weight was 1.6 g. Total number of radial margins was 640, 81.8% was clear, 14.6% was close, and 3.4% was involved. Total number of shaves was 640 out of which 98.7% was clear 0.7% was close and 0.4% was involved. Out of the 160 lesions, 3.7% required a second procedure to clear margins, out of which 2.5% had re-excision for close or involved single shaves each while 1.2% had mastectomy due to close or involved two shaves each. Average time utilised in resection of radial shaves and marking was 7 min 0.6% of patients developed a haematoma, 1.8% had a Seroma, and 1.2% had wound infection. Mean hospital stay was 1day SD 1., Conclusion: Routine radial cavity shaves not only ensure microscopic clearance, reduce the need for re-excision with no significant added operating time but also has no impact on patients' satisfaction., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Lactating adenomas (LAs) are uncommon benign breast tumors that typically occur in the late pregnancy or lactation period and are among the most prevalent breast lesions during puerperium. They commonly present with a painless, rapidly growing, large, mobile breast lump either late in pregnancy or the postpartum period. Despite being a condition, a core biopsy is almost always required to exclude malignancy. We are presenting a case of a 34-year-old patient who was referred to our unit with a progressive increase in size of the pre-existing right breast lump that has been there before pregnancy. Due to the massive increase in size in a short period, the lump was removed shortly after delivery with an acceptable cosmetic outcome., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Monib et al.)

Breast augmentation has been gaining popularity over the last two decades to correct congenital breast asymmetry or increase breast size and projection. Augmentation options started with saline implants, then silicone implants, and, recently, autologous fat transfer. Unfortunately, breast implants are not without complications, some of which are common, like capsular contracture, implant failure and infection. Others are quite rare, such as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Most of these complications will eventually require explantation in most cases, as the patients' and implants' age and risk of complications increase. We present a 79-year-old patient who presented to our breast unit with a left breast lump with 50-year-old saline implants. A triple assessment revealed incidental right breast cancer treated with radiofrequency identification (RFID) tag-guided wide local excision, sentinel lymph node biopsy and bilateral explantation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Monib et al.)

Background In general, breast pain is one of the most common causes for referral to breast units; treatment-related breast pain is frequently seen in clinical practice but not well addressed in the literature. While our primary objective was to identify the incidence of persistent breast pain following breast-conserving surgery and possible risk factors, our secondary aim was to assess the possibility of using a breast ultrasound scan to detect parenchymal changes that can contribute to breast pain. Methods We have conducted a prospective study including patients who had wide local excision for primary breast cancer treatment between January 2017 and January 2019. Patients' demographics, including age, BMI, breast volume, and tumour characteristics, were noted. All patients had a clinical assessment and were asked standard questions about their breast pain each visit; they also had an ultrasound scan of the breast and axilla 6 and 12 months after surgery to look for parenchymal changes. Results A total of 239 female breast cancer patients were included in our analysis. The mean age was 43.9 years, mean weight was 72.8 kg, mean BMI was 27.4 and mean breast volume was 1173 ml. In total, 38.5% had standard wide local excision, and 61.5% had oncoplastic resection; the mean specimen weight was 74.6 grams. All patients had adjuvant whole breast radiotherapy. We found that patients with younger age, larger breast size, high BMI, oncoplastic resections, and persistent parenchymal changes are associated with an increased incidence of postoperative breast pain while the type of axillary procedure and adjuvant chemotherapy had no significant effect. Conclusion Persistent postoperative breast pain was noted in 33% of our patients. We have also indicated that younger patients, patients with larger breast, those with high BMI, with preoperative breast pain, who had oncoplastic resections, and patients with persistent parenchymal changes, as fat necrosis and scarring, are associated more with persistent breast pain., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Monib et al.)

Implant-based breast reconstruction is the most popular reconstruction option following mastectomy. However, it is not without complications, some of which can be trivial while others can lead to significant morbidity, especially in geriatric patients. Severe capsular contracture, implant failure, infection, or suspected breast implant-associated anaplastic large cell lymphoma are examples of complications that will eventually require explantation in most cases. As patients with implant-based reconstruction age, the risk of complications increases, which should be considered by treating physicians. We describe the case of a 90-year-old patient who presented to our emergency department after a fall with worsening confusion, which was attributed to a 60-year-old left breast implant rupture and a peri-implant infected hematoma confirmed with CT and ultrasound., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Mohammed et al.)

Mondor's disease is a rare, peculiar form of superficial thrombophlebitis which mainly affects the subcutaneous veins of the breast, anterior chest wall, neck, axilla, upper limbs and penis. In most cases, it presents with rapid development of a painful subcutaneous cord-like structure that later becomes less painful, but a fibrous band persists. Unfortunately, aetiology and management are not very clear, but it is a self-limiting condition in most cases. We are presenting a rare case of a patient who developed Mondor's disease in the antecubital fossa of the right arm following chemotherapy for breast cancer., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Monib et al.)

Background Vacuum-assisted breast biopsy (VABB) has recently been gaining more popularity as a modality to reach the final diagnosis, especially in indeterminate breast lesions, resulting in a decreased number of surgical interventions and unnecessary follow-ups. Objective While our primary aim was to look into the outcomes of the VABB technique, our secondary aim was to assess the impact of the method on changes in patients' management. Patients and methods This study was a retrospective database analysis of vacuum-assisted biopsies (VABs) carried out at our breast unit during the period between January 2011 and January 2018. All our cases were image-guided; the caliber of vacuum-assisted needles used was 8 gauge (G) and 11 G. Patient demographics, lesion characteristics, and outcomes were retrieved from patients' notes and the hospital database. Results A total of 122 female patients were included in the analysis, out of whom 41.8% (51 patients) were screen-detected, and 58.1% (71 patients) were symptomatic presentations. The mean lesion size on imaging was 14.8 mm (SD: 12.6); 50% (61 patients) had stereotactic vacuum-assisted breast biopsy (SVAB), and 50% (61 patients) had ultrasound-guided vacuum-assisted breast biopsy (US-VAB). Post-procedure histology was upgraded in 19.6% (24 patients), downgraded in 18.8% (23 patients), and remained unchanged in 61.4% (75 patients). Conclusion VABB is a safe and efficient procedure for the diagnosis and management of indeterminate and suspicious breast lesions. It provides an adequate amount of tissue, which can help in upgrading or downgrading histopathologically diagnosed patients, thereby decreasing the need for surgery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Monib et al.)

An inguinal hernia is one of the most common surgical conditions accounting for both elective as well as acute admissions. Amyand's hernia is a rare entity of inguinal hernia, which represents a very small percentage of all inguinal hernias. While in most cases it is an incidental finding encountered during routine repair of an inguinal hernia, in other cases, it might be the reason for acute presentation. We are presenting a case of a six-week-old male who was found intraoperatively to have not only the appendix but also the caecum in the hernia sac. We believe that a preoperative groin ultrasound scan would aid clinical diagnosis and facilitate surgical planning in these cases., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Phyllodes tumours of the breast are rare fibroepithelial stromal tumours which are morphologically very different from epithelial breast cancer. Its diagnosis and management has always been challenging till the World Health Organization (WHO) divided it into two-three subtypes in 2003, only then it was found that incidence and management and follow-up of these three subtypes need to be completely different to reach the optimum outcome. We are presenting a case of a 47-year-old female who presented relatively late (due to pandemic restrictions) with a large phyllodes tumour requiring mastectomy as well as adjuvant treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Inguinal hernia is probably one of the most common surgical conditions, with strangulation accounting for a good number of acute surgical admissions. It has always been known that direct hernias are less likely to strangulate due to wide hernial defects in comparison to indirect hernia. For that reason, some surgeons do not attempt repair of direct hernias in elderly patients. We present a relatively uncommon case of a 58-year-old gentleman who presented with clinical signs of an incarcerated inguinal hernia; which was found at exploration to be a strangulated direct hernia with small bowel perforation. We believe that direct inguinal hernia should always be included in the differential diagnosis of incarcerated or strangulated groin hernia., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Gastrointestinal stromal tumours (GISTs) are considered the most common mesenchymal neoplasms of the alimentary tract, yet they account for only 0.2% of all gastrointestinal neoplasms. We are presenting a case of a 68-year-old gentleman who was diagnosed with a 250 mm jejunal GIST only when he presented with abdominal pain and fullness in the upper abdomen. We believe that detailed medical history, followed by prompt investigations, will help in early diagnosis of small GISTs with less malignant potential, which in turn will lead to better outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Background: Hypocalcaemia is a common delayed complication after thyroidectomy. Several studies have identified risk factors and possible ways to prevent post-thyroidectomy hypocalcemia. The purpose of our study is to evaluate the effectiveness of an intraoperative methylene blue spray to identify parathyroid glands during thyroidectomy., Materials and Methods: We have conducted a prospective non-randomised cohort study with 50 patients who underwent hemithyroidectomy or total thyroidectomy between January 2019 and January 2020. During thyroidectomy, 1 ml (10 mg) of 1% methylene blue was sprayed over the parathyroid glands, the inferior thyroid artery, and the recurrent laryngeal nerve., Results: Our study included 50 patients with ages ranging from 18 to 80 years old (43.0±9.7). We were able to identify the parathyroid glands with the intraoperative methylene blue spray in 82% of cases, with no significant postoperative complications., Conclusion: Our study concludes that the methylene blue spray is a safe, feasible, and effective technique to identify parathyroid glands., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Background Solitary thyroid nodule (STN) is a well-documented entity. Autopsy data indicate a 50% prevalence of thyroid nodules >10 mm in patients without clinical evidence of thyroid disease. Prevalence of palpable nodules is 4-7%. Solitary thyroid nodules are often asymptomatic and found incidentally. Fine needle aspiration cytology is recommended to determine the nature of the thyroid nodule. 5-10% of the thyroid nodules are found to be malignant following thyroidectomy. Objective Our study aims to explore the relationship between solitary thyroid nodule size and malignancy. Methods A prospective, observational analysis looking at preoperative thyroid ultrasound scan findings and post-operative histology for a total of 100 female patients referred to our unit within a university hospital from November 2016 to April 2019. Statistical analysis including One-Way ANOVA was performed where appropriate. Results Total number of patients was 100 female patients divided according to the size of the nodule into three groups with the correlation between the size of the nodule and the incidence of malignancy. Group A: Patients with a STN <20 mm; eight patients; post-operative histology = all benign. Group B: Patients with a STN measuring 20-40 mm; 80 patients: 68 patients were benign, and 12 patients (12%) were malignant (incidence of malignancy in the group is 15%). Group C: Patients with a STN >40 mm; 12 patients: eight patients were benign, four patients were malignant, (incidence of malignancy = 33%). Correlation between the size of the nodule and the incidence of malignancy: Group A: 0/8 malignancy; Group B: 12/80 patients were malignant; Group C: 4/12 malignant. Conclusion Our results suggest that the size of a solitary thyroid nodule cannot be reliably used for at predicting malignancy and should not be influencing patient's management., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Shingles is a very well-known viral infection caused by the varicella-zoster virus leading to painful skin rash. Although shingles can occur anywhere, it most often appears as a single stripe of blisters around the hypochondriac region. We are presenting a rare atypical presentation of shingles, as our patient presented with a picture of the acute abdomen a couple of days prior to the eruption of skin lesions., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Monib et al.)

Background and objective Novel coronavirus 2019 (COVID-19) outbreak was first reported in Wuhan, Hubei Province in China in December 2019; it has then spread quickly and exponentially beyond the Chinese borders and is now regarded as a global pandemic. We aimed to evaluate the chest CT radiological characteristics and lesion distribution patterns in patients of COVID-19 pneumonia in London, UK. Methods We performed a retrospective study and reviewed data of patients with clinically suspected COVID-19 who underwent chest CT between February 1 and May 5, 2020. All patients underwent the reverse transcription-polymerase chain reaction (RT-PCR) test. Lung lesion characteristics and distribution patterns were evaluated by two radiologists. Fisher's exact test was used for statistical analysis, and a p-value of <0.05 was considered statistically significant. Results A total of 18 patients (nine men and nine women) were analyzed. All of them had bilateral patchy lesions in the chest CT images. There was no correlation between the severity score and mortality (p=0.790). The distinctive CT features included ground-glass opacity (GGO) and consolidative patchy amorphous lesions, bilateral posterior and peripheral multi-lobar lung involvement, pleural effusions, subpleural fibrotic lines, subpleural sparing, vascular engorgement, occasional crazy paving, occasional mediastinal lymphadenopathy, pleural thickening, lack of cavitation, and absence of reverse halo (atoll) signs. Conclusion CT can facilitate the diagnosis of COVID-19 pneumonia. Our UK cohort showed slight variations compared with previously reported Asian and continental European cases with respect to chest CT images., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Pakdemirli et al.)

Introduction: Small bowel lipomas are rarely encountered benign adipose growths found within the small intestine wall or mesentery. Limited up-to-date evidence exists regarding such lipomas. We aim to aid clinical decision-making and improve patient outcomes through this comprehensive review., Methodology: The terms 'small bowel,' 'small intestine,' 'jejunum' and 'ileum' were combined with 'lipoma.' EMBASE, Medline and PubMed database searches were performed. All papers published in English from 01/01/2000-31/12/2019 were included. Simple statistical analysis ( t -test, Anova) was performed., Results: 142 papers yielded 147 cases (adults = 138, pediatric = 9). Male = 88, female = 59 (average age = 49.9 years). Presenting symptoms: abdominal pain = 68.7%; nausea/vomiting = 35.3%, hematochezia/GI bleeding = 33.3%; anaemia = 10.9%; abdominal distension = 12.2%; constipation = 8.9%; weight loss = 7.5%. Mean preceding symptom length = 58.1 days (symptoms >1 year excluded (n = 9)). Diagnostic imaging utilised: abdominal X-Ray = 33.3%; endoscopy = 46.3%; CT = 78.2%; ultrasound = 23.8%. 124/137 (90.5%) required definitive surgical management (laparotomy = 89, laparoscopcic = 35). 9 patients were successfully managed endoscopically. Lipoma location: ileum = 59.9%, jejunum = 32%, mesentery = 4.8%. Maximal recorded lipoma size ranged 1.2-22 cm.Mean maximum lipoma diameter and management strategy comparison: laparotomy 5.6 cm, laparoscopic = 4.4 cm, endoscopic = 3.7 cm, conservative = 4.5 cm. One-way Anova test, p value = 0.21. Average length of stay (LOS) was 7.4 days (range = 2-30). T-test p value = 0.13 when comparing management modalities and LOS. 4 complications, 0 mortality., Conclusions: Important previously undocumented points are illustrated; a clearer symptom profile, diagnostic investigations utilised, size and site of lipomas, types and effectiveness of management modalities, associated morbidity and mortality. Open surgery remains the primary management. No statistically significant difference in LOS and lipoma size is demonstrated between management strategies. Endoscopic and laparoscopic techniques may reduce utilising invasive surgery in the future as skillset and availability improve., Competing Interests: No conflicts of interest., (© 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.)

Objectives Clinically suspicious novel coronavirus (COVID-19) lung pneumonia can be observed typically on computed tomography (CT) chest scans even in patients with a negative real-time polymerase chain reaction (RT-PCR) test. The purpose of the study was to describe the CT imaging findings of five patients with negative RT-PCR results on initial and repeated testing but a high radiological suspicion of COVID-19 pneumonia. Methods Out of 19 clinically and/or radiologically diagnosed COVID-19 patients from our institution, five patients were selected for our study who had typical findings of COVID-19 on CT scan despite two negative RT-PCR results. Two district general hospital radiologists reviewed the chest CT images without prior knowledge of the RT-PCR test results. Scans were analyzed for the density of opacification and the distribution of disease. Results Out of 19 patients, five (26%) had initial negative RT-PCR test findings but positive CT chest features consistent with COVID-19. All patients had typical CT imaging findings of COVID-19. These included one patient with purely ground-glass opacities (GGO) and four patients with mixed GGO and consolidation. The typical distribution of parenchymal involvement was bilateral, posterior, and peripheral. Of the five patients with negative RT-PCR and positive CT findings, the range of CT severity score was 5 to 14. The median score, seen in three patients, was a score of 5, which corresponded to mild disease. One patient had a score of 8, corresponding to moderate disease, and one patient had severe disease with a score of 14. Conclusion Lung parenchymal changes related to COVID-19 can be seen on chest CT clearly despite repeated RT-PCR negative results., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Pakdemirli et al.)

Chyle leak following axillary lymph node clearance is a rarely reported complication. We present a case of chylous leakage following axillary lymph node clearance, which was diagnosed on clinical grounds. Surgical re-exploration was undertaken due to ongoing high output. However, the chylous leak recurred post-operatively, if at a lower rate. The patient was subsequently managed successfully with conservative measures, primarily utilizing regular aspiration and compression bandaging to the axilla., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020.)

Subungual squamous cell carcinoma (SCC) is a rare malignant tumour with an indolent course and unknown aetiology. It is usually misdiagnosed as a benign lesion, resulting in delayed treatment. Although psoriasis is not a precancerous skin condition, the treatment modalities cyclosporine and psoralen with ultraviolet A (PUVA) might increase the risk of developing cutaneous SCC, although a relationship has not been confirmed. We describe a patient with psoriasis who had been treated with cyclosporine and PUVA 6 years previously. He developed back SCC 2 years later, a subungual skin lesion after another 2 years and presented to us 1 year later, when nail elevation and biopsy revealed SCC., Learning Points: Subungual squamous cell carcinoma (SCC) is often misdiagnosed as a benign condition so most cases are invasive by the time of diagnosis; nail elevation and biopsy are recommended in all suspicious cases.Although psoriasis is not an independent risk factor for subungual SCC, the cyclosporine and PUVA used to treat psoriasis are risk factors for cutaneous SCC.The aetiology for subungual SCC is still unclear, but it should be suspected in patients with psoriasis and a suspicious presentation., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2020.)

Lactating adenomas are benign breast tumours which normally present in the peripartum period. Aetiology, pathogenesis, best diagnostic modality and management are not yet clear in the literature. We present a case of a 32-year-old pregnant patient who was re-referred to us with a progressively increasing left breast lesion, pre-existing prior to pregnancy, which was found to be a huge lactating adenoma., Learning Points: Pregnant and lactating women should stay breast aware and perform monthly breast self-examinations to detect any abnormalities at an early stage.In the absence of specific ultrasound features to identify lactating adenoma, triple assessment, including core biopsy, is the mainstay of diagnosis.Lactating adenomas, especially those potentially related to a pre-existing breast lesion or large in size, should be reported in order to develop evidence-based management guidelines., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2020.)