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Lee R.M.H.,Maidstone Hospital | Eke T.,Norwich University
Journal of Cataract and Refractive Surgery | Year: 2013

A systematic literature search was performed to identify prospective randomized studies comparing akinetic (sub-Tenon, peribulbar, or retrobulbar) and kinetic (topical or topical and intracameral) local anesthesia for phacoemulsification surgery. Only studies that stated the rate of posterior capsule rupture or that stated without qualification that there were no intraoperative complications were included. Of the initial 3182 articles, 15 papers met the inclusion criteria. The number of eyes ranged between 26 and 282 per group (mean 95.4 eyes per group), with a total of 2862 eyes. Eleven articles mentioned posterior capsule rupture specifically; 4 stated that no intraoperative complications occurred. Eleven (0.74%) of 1494 eyes in the akinetic group and 11 (0.80%) of 1368 eyes in the kinetic group experienced posterior capsule rupture. The chi-square test confirmed the difference was not statistically significant (P = .84). This analysis indicates that there appears to be no clinically or statistically significant difference in the risk for posterior capsule rupture between akinetic and kinetic local anesthesia techniques. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. © 2013 ASCRS and ESCRS.


Morgan J.E.,University of Wales | Morgan J.E.,University of Cardiff | Bourtsoukli I.,University of Cardiff | Rajkumar K.N.,University of Wales | And 4 more authors.
Ophthalmology | Year: 2012

Purpose: To determine the accuracy with which the optic disc can be diagnosed as normal or glaucomatous according to the ISNT rule, whereby, in the normal eye, the neuroretinal rim area follows the order inferior (I) > superior (S) > nasal (N) > temporal (T). Design: Prospective, cross-sectional, observational, case series. Participants: Fifty-one normal individuals and 78 individuals with open-angle glaucoma exhibiting field loss (median mean deviation, -4.37 dB; interquartile range [IQR], -2.10 to -7.96 dB; median pattern standard deviation, 5.65 dB; IQR, 2.94 to 8.56 dB). The reference diagnosis was made by 2 experts on the basis of the appearance of the optic disc and of the corresponding visual field. Methods: Stereoscopic optic disc photographs, acquired for each individual, were digitized at high resolution and analyzed using a digital, quad-buffered, stereoscopic viewing system in which a Z screen was used to dissociate the images to the 2 eyes of the observer. Three expert observers, trained to fellowship standard in glaucoma, independently undertook planimetry of the neuroretinal rim and of the disc margin from 1 eye of each individual, using a cursor moving in stereoscopic space to minimize parallax errors. Software automatically calculated the neuroretinal rim area in 10°, 30°, 40°, and 90° segments. For the ISNT rule to be obeyed, the 3 Boolean comparisons of the neuroretinal rim area, I>S, S>N, and N>T, had to be true. If any of the comparisons returned false, the rule was considered not to have been obeyed. Values were compared at a precision of 0.0001 mm 2. Main Outcome Measures: The outcome of the ISNT rule in terms of the 3 Boolean comparisons of the neuroretinal rim area was specified in terms of the sensitivity, specificity, and hence, the positive and negative likelihood ratios. Results: Based on the ISNT rule being obeyed for 10° segments, the positive likelihood ratio among the 3 observers was 1.11 (95% confidence interval [CI], 0.991.25), 1.07 (95% CI, 0.941.21), and 1.06 (95% CI, 0.961.18), respectively. It was similar for the other segment sizes. Variants of the rule were not appreciably better. Conclusions: The ISNT rule has limited utility in the diagnosis of open-angle glaucoma. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. © 2012 American Academy of Ophthalmology.


Diepstraten S.C.E.,University Utrecht | Sever A.R.,Maidstone Hospital | Buckens C.F.M.,University Utrecht | Veldhuis W.B.,University Utrecht | And 4 more authors.
Annals of Surgical Oncology | Year: 2014

Purpose: This meta-analysis was designed to evaluate the utility of preoperative axillary ultrasound combined with US-guided lymph node biopsy if indicated (AUS ± biopsy), in terms of staging the axilla and preventing two-step axillary surgery in the form of sentinel node biopsy (SNB) followed by completion axillary lymph node (ALN) dissection. Methods: We systematically searched electronic databases for studies that addressed preoperative assessment of ALN status by AUS ± biopsy. A pooled estimate was calculated for the false-negative rate (FNR) of AUS ± biopsy (defined as the proportion of women with a negative AUS ± biopsy result subsequently proven to have a positive axilla) and sensitivity (defined as the proportion of women with a positive AUS ± biopsy result among all women with a tumor positive axilla). Results: The pooled FNR was 25 % (95 % confidence interval [CI] = 24-27) and the pooled sensitivity was 50 % (95 % CI = 43-57). There was substantial heterogeneity across studies for both FNR (I 2 = 69.42) and sensitivity (I 2 = 93.25), which was not explained by between-study differences in biopsy technique, mean/median tumor size, biopsy indication, or study design. Sensitivity was increased in studies with a high prevalence of ALN metastases. Conclusions: Preoperative axillary ultrasound-guided biopsy is a useful step in the process of axillary staging. Approximately 50 % of women with axillary involvement can be identified preoperatively. Still, one in four women with an ultrasound-guided biopsy-"proven" negative axilla has a positive SNB. © 2013 Society of Surgical Oncology.


Shah A.A.,Harvard University | Butler R.B.,Harvard University | Romanowski J.,Harvard University | Goel D.,Harvard University | And 2 more authors.
Journal of Bone and Joint Surgery - Series A | Year: 2012

Background: Although the results of the Latarjet procedure have been reported previously, there is little literature regarding the early complications of this procedure. The purpose of this study was to report our experience with the Latarjet procedure for glenohumeral instability and to highlight the initial complications that may occur following this procedure. Methods: Forty-seven patients (forty-eight shoulders) underwent the Latarjet procedure for anterior glenohumeral instability between January 2005 and January 2010. All shoulders had some osseous deficiency of the anterior glenoid rim or had undergone an unsuccessful prior soft-tissue Bankart repair. The minimum duration of patient follow-up was six months. Results: Forty-five shoulders were available for follow-up. The overall complication rate was 25% (twelve of the original forty-eight shoulders). Complications were divided into three groups: infection, recurrent glenohumeral instability, and neurologic injury. A superficial infection developed in three shoulders (6%); in all cases, the infection resolved following irrigation and debridement and administration of antibiotics for up to four weeks. Four shoulders (8%) developed recurrent glenohumeral instability; this occurred within eight months in two shoulders and at nineteen and forty-two months postoperatively in the other two. Five procedures (10%) resulted in a neurologic injury. Two of these involved the musculocutaneous nerve, one involved the radial nerve, and two involved the axillary nerve. The three musculocutaneous and radial nerve injuries involved sensory neurapraxia that resolved fully within two months. Both of the patients with axillary nerve dysfunction continued to have persistent sensory disturbances and one continued to have residual weakness that had not yet resolved fully at the time of the final follow-up. Conclusions: The overall complication rate of 25% is higher than that reported in the literature. Although most of these complications resolved completely, two patients continued to have residual neurologic symptoms. Patients should be informed of the risk of complications associated with the Latarjet procedure, although most of the potential complications will resolve. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery Incorporated.


Dey M.,Maidstone Hospital
Orbit (Amsterdam, Netherlands) | Year: 2013

To report an uncommon case of superior ophthalmic vein occlusion secondary to antiphospholipid syndrome. Interventional case report. A 41 year old man who presented with acute proptosis and ophthalmoplegia who was initially treated for orbital cellulitis. His CT scan showed changes consistent of that a superior ophthalmic vein thrombosis. He was managed with high dose intravenous steroid and commenced on anticoagulant therapy. He was subsequently diagnosed with antiphospholipid syndrome. Although superior ophthalmic vein occlusion is rare it is an important differential. This is the first reported case secondary to antiphospholipid syndrome.


Cynk M.,Maidstone Hospital
Therapeutic Advances in Urology | Year: 2014

Transurethral resection of the prostate (TURP) has remained the procedure of choice for the surgical treatment of bladder outflow obstruction for almost five decades, but holmium laser enucleation of the prostate (HoLEP) is now emerging as a challenger as the gold standard procedure. This review summarizes the evidence base for HoLEP, with particular reference to randomized, controlled (level 1) evidence. © The Author(s), 2013.


Background: Oral anticoagulant therapy (OAT) is used to prevent/treat thromboembolism. Major bleeding is common in patients on OAT; eg, warfarin increases intracranial hemorrhage (ICH) risk. Case: A 71-year-old male on warfarin (to reduce stroke risk) presented at Accident and Emergency Minor Injuries Unit with headache after reportedly sounding 'drunk'. On triage, the patient appeared lucid and well. However, International Normalized Ratio (INR) was 4.1. Head computed tomography (CT) indicated a large right-sided subdural hematoma. Prothrombin complex concentrate (PCC; Beriplex® P/N, CSL Behring) with vitamin K normalized the INR within minutes of administration. The patient underwent neurosurgery without complications, and was discharged after 5 days, with no residual neurological symptoms. Conclusions: ICH patients can present with no neurological signs. In OAT patients with headache, INR must be established; if ≥3.0, normalization of INR and head CT are essential. PCC is the best option to rapidly reverse anticoagulation and correct INR pre-surgery. © the author(s), publisher and licensee Libertas Academica Ltd.


Rowell N.P.,Maidstone Hospital
Breast | Year: 2010

Although some guidelines support the use of post-mastectomy radiotherapy where the resection margin is involved or close, the scientific basis of this practice is not established. This systematic review explores the relationship between margin status and subsequent relapse.Pooled data from 22 studies (18,863 women) identified an involved post-mastectomy margin in 2.5%, a close margin in 8.0% and muscle or fascia invasion in 7.2% of patients. In a meta-analysis of five studies of non-inflammatory breast cancer without radiotherapy, local recurrence was increased by an involved or close margin (relative risk 2.6; P<0.00001). The effect of muscle or fascia invasion was of borderline significance (relative risk 1.7; P=0.04). In two separate meta-analyses, risk of relapse was related to margin status in women with inflammatory breast cancer (relative risk 3.1; P<0.0001) but not in those undergoing skin-sparing mastectomy (relative risk 2.1; P=0.16). © 2009 Elsevier Ltd.


Gregson H.,Maidstone Hospital
Nursing standard (Royal College of Nursing (Great Britain) : 1987) | Year: 2011

To set up a surgical site infection (SSI) benchmark rate for caesarean sections and improve infection rates by monitoring and implementing compliance with the guidelines produced by the National Institute for Health and Clinical Excellence (NICE). A total of 2382 patients who had undergone caesarean section at Maidstone and Tunbridge Wells NHS Trust were monitored at two obstetric sites over a two-year period. A proactive infection surveillance system was used during the patients' hospital stay. Community midwives collected and returned post-discharge data on wound status. Patients were asked to return post-operative questionnaires 30 days after surgery, providing details of any wound problems. Compliance with NICE guidance on reducing SSIs was measured at both sites and changes were implemented accordingly. Infection rates before compliance with NICE guidance from July 2008 to June 2009 ranged from 5.7% to 9.0%. After introducing the guidelines, rates of SSI at site A and site B were reduced by 3.3% and 3.8% respectively. Rates of SSI at site A were reduced further to 1.3% on introduction of the hydrofiber and hydrocolloid dressing. Results suggest that the hydrofiber and hydrocolloid combination dressing assists in the reduction of SSI rates following caesarean section when used in combination with the NICE guidance.


Hussain M.,Maidstone Hospital | Acher P.,Maidstone Hospital | Penev B.,Maidstone Hospital | Cynk M.,Maidstone Hospital
Journal of Endourology | Year: 2011

Background and Purpose: Flexible ureterorenoscopic holmium laser lithotripsy allows retrograde management of renal calculi that previously needed alternative strategies. This study assesses the influences of stone size, density, and location on treatment outcomes from a large series. Patients and Methods: Data concerning patients who presented for ureterorenoscopic laser lithotripsy between May 2005 and September 2008 were retrospectively analyzed. Single-treatment success was defined as satisfactory visual clearance of stone bulk, radiopacities less than 2mm on noncontrast CT, and no further treatment. Results: One hundred and eighty-five patients had 236 treatments (median=51 years; range 18-83 years). Overall success rate was 90.7%. The mean ± standard deviation (SD) stone size was 13.1±8.5mm with significant differences between the successful (11.6±6.7mm) and nonsuccessful (27.8±10.0mm) outcome groups (P<0.0001, unpaired t test). Of treatments for stone size ±20mm, 96.5% were successful. Of 36 patients with stone size 7>20 mm, 21 (58.3%) were stone free after one treatment and 31 (86.1%) after two treatments. Hounsfield unit data did not differ significantly between the groups (mean±SD 858±388 vs 1115±643, P=0.146, unpaired t test). Stone locations were: Renal pelvis, caliceal diverticula, and upper pole, midpolar, and lower pole in 61, 9, 24, 27, and 115 cases with success rates of 85%, 100%, 83%, 93%, and 94%, respectively (P=0.899, chi-square test). Conclusion: Clearance rates of >90% can be achieved for stones up to 20mm with flexible ureterorenoscopy and holmium laser lithotripsy, but with larger stones, the stone-free rates reduce significantly. Therefore, 20mm should be regarded as the upper limit of stone size that can be cleared in a single procedure. Stone density and location do not influence outcome. Copyright © Mary Ann Liebert, Inc.

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