Delay In Definitive Treatment Research Articles

SAT-495 Thyrotoxicosis Presenting as Right Sided Heart Failure: Two Case Reports, Two Differing Outcomes Illustrating the Importance of Early Aggressive Treatment to Reverse Cardiac Dysfunction

Background: Graves’ thyrotoxicosis can lead to life-threatening right heart failure requiring urgent treatment. We present two such cases to illustrate management challenges and the importance of early definitive treatment. Clinical cases: The first case is a 41 year old female with Graves’ hyperthyroidism and severe right heart failure. Cardiac ECHO showed LVEF 76% with severe biatrial enlargement, TV regurgitation, and an enlarged RV. The liver was enlarged, transaminases were high, bilirubin was 24 mg/dl (0-1.4), and clotting was prolonged. Due to hepatic dysfunction, methimazole was held. She was not a candidate for I-131 as she had received iodinated contrast. Treatment with dexamethasone and SSKI normalized thyroid function over four days. She was discharged but presented two months later with worsened hyperthyroidism and right heart failure. She was a poor surgical candidate and I-131 was administered as definitive therapy. She developed PEA arrest the following day without recovery leading to withdrawal of care and death eight days later.The second case is also a 41 year old female with an 18 year history of Graves’ disease, intermittently compliant with methimazole. She presented with hyperthyroidism and severe right heart failure. The liver was enlarged, transaminases were high, bilirubin was 5.1 mg/dl, and clotting was prolonged. Cardiac ECHO showed LVEF 66% with severe biatrial enlargement, TV and MV regurgitation, enlarged RV, and increased RA pressure. Due to hepatic dysfunction, methimazole was held. She was not a candidate for I-131 as she had received iodinated contrast. She was prepared for thyroidectomy with aggressive heart failure treatment, dexamethasone, SSKI, and cholestyramine. Thyroid function normalized over six days and she underwent total thyroidectomy eight days after admission without complications. Postoperative cardiac ECHO showed marked improvement of cardiac parameters. Conclusion: Right heart failure is an uncommon and often overlooked complication that can arise in poorly managed or treatment-resistant Graves’ disease. It is life-threatening and requires aggressive normalization of thyroid function, treatment of heart failure, and timely definitive therapy with I-131 or thyroidectomy. Frequently complicated by liver abnormalities, the use of thionamides is questionable. Additionally, hospitalized patients have often been evaluated with iodinated contrast studies or treated with SSKI during the acute phase, which limit the use of I-131. Our cases show that dexamethasone, SSKI, and cholestyramine can rapidly normalize thyroid function. The first case ended in death, probably due to delay in definitive treatment, whereas the second patient had an early thyroidectomy with good outcome. We recommend aggressive treatment to normalize thyroid function and reverse cardiac dysfunction followed by early definitive therapy.

Analyzing the Time From Discovery to Definitive Surgical Therapy for Lung Cancer Based on Referral Patterns.

Surgery for early stage non-small cell lung cancer can be curative. A delay from diagnosis to surgery can lead to increased mortality. Our objective was to determine if referring patients to specialists before a thoracic surgeon caused a delay in definitive treatment. A retrospective review was conducted of patients who had surgery for non-small cell lung cancer by a single surgeon at our institution from 2013 to 2016. Patients were divided into 2 groups: those who saw a specialist before a thoracic surgeon and patients who were referred directly to a surgeon once the pulmonary nodule was identified on computed tomography (CT). The time from initial CT to resection was compared. Secondary analysis compared private insurance versus Medicare/Medicaid. Percentage of patients upstaged was compared. There was no significant difference between groups when comparing time from CT to surgery (79.88 vs. 79.90 d; P=0.58). There was a significant decrease in time from CT to surgery for patients with private insurance compared with Medicare/Medicaid patients (66.05 vs. 86.99 d; P=0.03) and fewer private insurance patients were upstaged (22.9% vs. 31.8%; P=0.32). More patients who saw a different specialist first were upstaged compared with patients sent directly to thoracic surgery (32.6% vs. 22.2%; P=0.22). When comparing time from CT detection of a lung nodule to surgery, no significant difference was found between patients sent to nonthoracic specialists first and those referred directly to a thoracic surgeon. There was a significant decrease in time from CT to surgery for patients with private insurance compared with Medicare/Medicaid.

Delays in definitive treatment for locally advanced cervical cancer: An analysis of disparities among a South Florida population between a university cancer center and a safety net hospital

Objective: According to a recently published National Cancer Data Base (NCDB) analysis, expected time to treatment initiation (eTTI) for patients diagnosed with locally advanced cervical cancer (LACC) is 44.3 days. Our study was designed to characterize the eTTI for a patient population diagnosed with LACC and treated in a South Florida cancer center serving a multiracial population, and to seek disparities between the patients treated at the university cancer center (UCC) and the safety net hospital (SNH).

Impact of icing weather conditions on the patients in helicopter emergency medical service: a prospective study from Northern Finland

BackgroundA high number of denied or cancelled HEMS missions are caused by poor weather conditions especially during winter season. Furthermore, many helicopter manufacturers have denied their helicopters to be operated in known icing conditions. Icing is a widely known phenomenon in aviation, but there is a lack of evidence about its influence on HEMS operations and patients.MethodsA prospective observational study of HEMS missions in Northern Finland was conducted over a 1-year period in 2017. A patient was included in the study when the use of helicopter was denied or cancelled due to icing weather conditions. Patients were categorised into two groups based on whether definitive treatment was delayed or not according to previously defined end-points.ResultsDuring the study period the Finnish northernmost HEMS unit received 1940 missions. A total of 391 missions (20%) could not be operated by helicopter because of poor weather conditions. In 142 of these missions (36%) icing was one of the limiting weather factors. The year-round incidence of icing was 7.3/100 missions. A total of 57 patients were included in the analysis. Icing weather conditions, resulting in denied helicopter flights, caused a delay in definitive treatment for 21 patients (37%). Definitive treatment was more often delayed in trauma and internal medicine patients than in neurological patients. Nevertheless, the patients whose definitive treatment was delayed were located closer to the hospital. The estimated time that would have been saved by helicopter transport was more than 60 min for 10 patients with delayed treatment.ConclusionsIn this study the incidence of icing weather conditions was substantial compared to all HEMS missions in year 2017. The delay in definitive treatment was accentuated among trauma and internal medicine patients. During the 1-year study period many patients whose definitive treatment was delayed would have had a notable (> 60 min) time saved by helicopter transport. A helicopter equipped with an adequate ice protection system for the weather conditions in Northern Finland would have shortened the delay in patients’ definitive treatment significantly.

Team Approach: Upper-Extremity Numbness.

* Upper-extremity numbness has a wide differential diagnosis and can arise from pathology in the cervical spine, brachial plexus, shoulder, elbow, and hand.* Physical examination must include evaluation of both nerve root and peripheral nerve function to aid in determining if symptoms are due to central or peripheral pathology.* Double-crush syndrome, with both spinal and peripheral etiology, is not uncommon and, if not recognized, may lead to treatment failure.* A team approach including orthopaedic surgeons, neurologists, physiatrists, radiologists, and occupational therapists can be crucial in making the diagnosis and designing the treatment plan.* Nonoperative treatment can include observation, physical and occupational therapy, functional bracing, and injections of corticosteroids and/or local anesthetics.* Operative treatment is appropriate after an appropriate course of nonoperative management has failed or with specific diagnoses in which a delay in definitive treatment may put a patient at risk for long-term functional deficits.

Soft Tissue Sarcoma of the Hand and Wrist: Epidemiology and Management Challenges.

Soft tissue sarcomas (STSs) of the hand and wrist are rare and confer a unique set of management challenges. We present a 15-year review and discussion of the epidemiology, tumor characteristics, treatment, and reconstructive strategies for such cases presenting to our regional sarcoma service. Three case examples are described. Of 218 STSs of the upper limb, 17 involved the hand or wrist. Alveolar rhabdomyosarcoma, synovial, and myxofibrosarcoma were the most common ones. Two patients required amputation for recurrence. Eight patients required flap reconstruction, of which five were free flaps with no failures or wound healing complications. Two-year overall survival rate was 92%. Local recurrence occurred in 12%. Limb-sparing surgery is possible in most patients, although there is often a degree of functional loss due to the surgical resection, and complex multistage reconstruction may be required. These lesions are still often incidental or unexpected findings when patients are treated for a presumed benign swelling. Clinicians treating localized swellings of the hand and wrist should maintain vigilance toward the possibility of a sarcoma diagnosis, to avoid delays in definitive treatment.

A Multifaceted Transfer Protocol Reduces the Door-in to Door-out Time for STEMI Patients Requiring Interhospital Helicopter Transfer

Introduction: For the half a million patients with ST-segment elevation myocardial infarction (STEMI) who present to Emergency Departments every year, timely percutaneous coronary intervention (PCI) is the preferred treatment. 1, 2 Current guidelines recommend that the time between first medical contact with Emergency Medical Services (EMS) and PCI should be less than 90 minutes, as this timeframe is associated with a significantly decreased rate of morbidity and mortality.1, 2 Because not every hospital is PCI capable, many patients require interfacility transfer, often via helicopter EMS (HEMS). 2-4 The need for transfer often causes delays in definitive treatment.

Use of Contrasted Computerized Tomography as a Surrogate for Nuclear Medicine Renogram to Categorize Renal Function in the Setting of Ureteropelvic Junction Obstruction

To use basic measurements on contrasted computerized tomography (CT) to reliably determine whether a kidney with ureteropelvic junction obstruction (UPJO) is definitively functional (≥30% differential renal function [DRF]) or nonfunctional (≤10% DRF), obviating the need for nuclear medicine renogram (RG) to determine DRF. This is a single institution, retrospective cohort of patients diagnosed with UPJO who underwent either pyeloplasty or nephrectomy between December 2004 and December 2014. Included patients had both preoperative mercaptoacetyltriglycine RG and contrasted CT within 180 days of each other. Patients with stents or nephrostomy tubes were excluded. A total of 49 patients were included. The strongest correlation between differential CT measurements and DRF on RG existed by multiplying the cortical area by the average cortical Hounsfield units (Pearson's r = 0.90, P < .001). Using an equation derived from linear regression and cutoff values generated by receiver operator curve (ROC) analysis, CT equation-estimated DRF values of ≥40% and ≤10% correlated with "definitively functional" RG values of ≥30% (100% specificity) and with "definitively nonfunctional" RG values of ≤10% (100% specificity), respectively. In 30 out of 49 cases, CT could have replaced RG. RG is the gold standard in determining quantitative DRF. However, the treatment algorithm for a kidney with symptomatic UPJO hinges on categorized function: "functional" (repair) or "nonfunctional" (remove). Appropriate measurements on contrasted CT can categorize definitively functional or nonfunctional kidneys with UPJO, negating the need for RG to obtain DRF in a majority of cases. This study design favors real-world application with potential to reduce medical expenditure and delay in definitive treatment.

Oesophageal injury

Oesophageal injury

Myocardial infarction in a patient with hereditary haemorrhagic telangiectasia in a remote location

Prompt reperfusion therapy in acute ST-segment elevation myocardial infarction (STEMI) improves outcomes and is therefore a key part of the management of affected patients. Primary percutaneous coronary intervention (PPCI) is preferred over thrombolysis; however, when PPCI is not available within an acceptable time frame, thrombolysis should be administered without delay. When thrombolysis is contraindicated, this can lead to delays in achieving coronary artery reperfusion, and making therapeutic decisions is more challenging. A 57-year-old woman with hereditary haemorrhagic telangiectasia (HHT) presented with chest pain to local medical services on a Scottish island. Initial assessment including 12-lead ECG was performed without delay and led to a diagnosis of infero-lateral STEMI. Initial treatment was with antiplatelets, nitrate and opiate analgesia. Immediate reperfusion therapy with thrombolysis was considered; however, this was contraindicated due to the diagnosis of HHT. Following discussion with the regional centre she was treated with heparin and urgently transferred to the nearest catheterisation laboratory for PPCI. Unfortunately delays in transfer were caused by inclement weather conditions, which precluded the use of an air ambulance. The patient reached a cardiac catheterisation laboratory by road. A total occlusion of a distal branch of the circumflex artery was found to be the culprit lesion and despite wiring and ballooning good blood flow was not restored. However, she made a good recovery and was discharged home on secondary prevention therapy, which was modified to take into account her increased bleeding risk associated with her pre-existing HHT. In this case, the patient presented early to medical services following the onset of symptoms and was immediately assessed, resulting in a prompt accurate diagnosis at first medical contact. Despite this, the presence of HHT, and the particularities of living in a remote area compounded by unfavourable weather conditions, resulted in a delay in definitive treatment that would have been available to a similar patient presenting in an urban setting. In remote regions where reperfusion therapy for acute STEMI relies more often on thrombolysis, an increased awareness of the issues around the contraindication of thrombolysis, together with early discussion with a regional cardiology service leads to the most efficient way of establishing the best treatment plan for individual patients. Despite this, rural patients may remain at a disadvantage.

The case against primary endoscopic realignment of pelvic fracture urethral injuries

ObjectivesTo review previous reports and present our experience on the outcomes after treating pelvic fracture urethral injuries (PFUIs) with primary endoscopic realignment (PER) vs. placing a suprapubic tube (SPT) with elective bulbomembranous anastomotic urethroplasty (BMAU). MethodsWe reviewed previous reports and identified articles that reported outcomes after PER vs. SPT and elective BMAU for patients who sustained PFUIs. We also present our institutional experience of treating patients who were referred after undergoing either form of treatment. ResultsThe success rates for PER after PFUI are wide-ranging (11–86%), with variable definitions for a successful outcome. At our institution, for patients treated by SPT/BMAU, the mean time to a definitive resolution of stenosis was dramatically shorter (6months, range 3–15) than for those treated with PER (122months, range 4–574; P<0.01). The vast majority of patients treated by PER required multiple endoscopic urethral interventions (median 4, range 1–36;P<0.01) and/or had various other adverse events that were rare among the SPT/BMAU group (14/17, 82%, vs. 2/23, 9%;P<0.05). ConclusionWhile PER occasionally results in urethral patency with no need for further intervention, the risk of delay in definitive treatment and the potential for adverse events have led to a preference for SPT and elective BMAU at our institution.

Con: bulbomembranous anastomotic urethroplasty for pelvic fracture urethral injuries.

Current literature remains controversial regarding whether to treat patients sustaining pelvic fracture urethral injuries (PFUIs) with primary endoscopic realignment (PER) versus suprapubic tube (SPT) placement alone with elective bulbomembranous anastomotic urethroplasty (BMAU). Success rates for PER following PFUI are wide-ranging, depending on various authors’ definitions of what defines a successful outcome. At our institution, for SPT/BMAU patients, the mean time to definitive resolution of stenosis was dramatically shorter compared to PER cases. The vast majority of PER patients required multiple endoscopic urethral interventions and/or experienced various other adverse events which were rarely noted among the SPT/BMAU group. While PER does occasionally result in urethral patency without the need for further intervention, the risk of delay in definitive treatment and potential for adverse events has led to a preference for SPT and elective BMAU at our institution.

Preoperative evaluation of penetrating esophageal trauma in the current era: An analysis of the National Trauma Data Bank.

Background:Preoperative diagnostic evaluation (PDE) of penetrating esophageal injury (PeEsIn) can delay treatment and increase morbidity. We sought to study the relationship among PDE, delay in definitive treatment, and patient mortality in PeEsIn.Materials and Methods:The 2008-2010 National Trauma Data Banks were queried for PeEsIn. Exclusion criteria were death within 1 day of injury, and missing data about survival to discharge or operative intervention. Data extracted included demographics, vital signs, injury severity, diagnostic procedures (endoscopy, computed tomography, and fluoroscopy), time to procedures and/or operation, hospital-free days, and mortality.Results:Of 280 patients, 75 underwent PDE and 205 did not. There were no significant differences in baseline demographics, vital signs or injury severity between the two groups. The median time to the first operation was shorter in the nonPDE cohort compared to the PDE cohort (2 vs. 3 h; P = 0.018). Median hospital-free days at day 60 were significantly less in nonPDE (42 days, interquartile range ([IQR] = [28, 50]) versus PDE patients (47 days, IQR = [38, 51]) (P = 0.007). Mortality was not statistically different.Conclusions:PDE in PeEsIn slightly delays the time to operation without worsening mortality, and is a predictor of more hospital-free days.

Laparoscopic/laparoscopic-assisted abdominal aortic aneurysm (AAA) repair is associated with less post-operative pain, fewer post-operative complications and a quicker return to normal function than open AAA repair

s / International Journal of Surgery 12 (2014) S13eS117 S110 for abdominal aortic aneurysm. 14.3% of patients had ankle-brachial pressure indexes (ABPI) carried out. 11.4% of GP were not confident of making the diagnosis, 20% of GPs were not able to or did not institute best medical treatment (BMT) in the community. 20% of patients referred had symptoms limiting lifestyle. Conclusions: We are not meeting the minimum requirements for clinical examination and ABPI measurements. This could be because GP’s often do not feel confident to diagnose IC and we can speculate as to whether education or increasing secondary care provisionwould be most appropriate. 0144: LAPAROSCOPIC/LAPAROSCOPIC-ASSISTED ABDOMINAL AORTIC ANEURYSM (AAA) REPAIR IS ASSOCIATED WITH LESS POST-OPERATIVE PAIN, FEWER POST-OPERATIVE COMPLICATIONS AND A QUICKER RETURN TO NORMAL FUNCTION THAN OPEN AAA REPAIR Philip C. Bennett *, Ijaz Ahmad, Sohail Choksy, Simon MacKenzie, Christopher Backhouse, Adam Q. Howard. Colchester Hospital University NHS Foundation Trust, Essex, UK. Introduction: To compare patient outcomes between laparoscopic/ laparoscopic assisted (LR) and open repair (OR) of AAA in subjects in whom endovascular repair was inappropriate. Methods: All patients undergoing either LR or OR since 2007 were included. Demographics, operative details and patient outcomes were prospectively recorded. Results: 104 patientswere investigated (51 LR; 53OR,median age 72[66-75] years, 92.3%male). The 2 groups had equivalent ages, sex distribution and VPOSSUM scores. LR procedures had longer aortic clamp times and longer operation times than OR ((90[63-120] vs. 76[57-105] minutes, p1⁄40.048) and (330[270-390] vs. 240[180-300] minutes, p 5(p 5 (OR:17.831, 95%CI 2.713117.193; P1⁄40.003) remained significant on multivariable analysis. Conclusions: Failure to respond to TNS devices may be predicted by greater calf circumference and neuropathy score of >5. Identifying such patients can save time and prove cost-effective. 0177: IMPROVING ACUTE VASCULAR ADMISSIONS AT A TERTIARY REFERRAL CENTRE BY IDENTIFYING AND QUANTIFYING DELAYS IN PATIENT CARE Simon Bellringer *, Jiten Patel, Benjamin Pettifer, Matthew Button, Lola Eid. Brighton University Hospital NHS Trust, Brighton, UK. Introduction: 1. To identify delays in surgical and interventional radiology (IR) procedures for acute vascular patients in a regional vascular centre. 2. To quantify these delays based on NCEPOD guidelines (NCEPOD recommendations http://www.ncepod.org.uk/pdf/NCEPODRecommendations. pdf) 3. To make appropriate recommendations to improve the care pathway of these patients Methods: The audit was carried out over a period of one calendar month. All acute vascular patients requiring a definitive radiological or surgical intervention were included. Time of decision to intervene and time of intervention were recorded for each patient. Results: 26 patients were included. Average time from decision to treat surgically to surgical intervention was 23 hours and 3 minutes and for IR was 52 hours and 33 minutes. The longest wait recorded was 116 hours and 12 minutes (for an IR procedure over a 4 day bank holiday weekend) Conclusions: This audit identified significant delays in definitive treatment for some patients due to shared CEPOD lists and limited availability of IR services. These findings highlight some of the challenges that regional centres face when an increase in service demand precedes the required expansion of services. Recommendation for additional IR sessions and a dedicated vascular CEPOD list were made. 0195: SYSTEMIC INFLAMMATORY RESPONSE SYNDROME SCORE MAY INDICATE INCREASED RISK OF MAJOR AMPUTATION IN PATIENTS WITH DIABETIC FOOT INFECTION Jon Griffin *, Rachel Williams , Chinonso Nwoguh , Perbinder Grewal . Perth Royal Infirmary, Perth, UK; Queen Alexandra Hospital, Portsmouth,

Reducing the time from diagnosis to treatment of patients with stage II/III rectal cancer at a large county hospital.

141 Background: The treatment of stage II/III rectal cancer is complex and requires multidisciplinary collaboration. Delays in definitive treatment may increase morbidity and compromise outcomes. The goal was to reduce the time from pathologic diagnosis to initiation of treatment by 30% for patients with stage II/III rectal cancer at Lyndon B. Johnson General Hospital (LBJGH), which provides care to uninsured and underinsured patients in Harris County, TX. Methods: The charts of 32 patients with rectal cancer diagnosed between July 2012 and December 2013 were reviewed. Baseline data regarding diagnostic and treatment time points were collected. Potential areas for improvement were identified through analysis of the baseline data, affinity sorting, and fishbone diagrams. A multidisciplinary rectal cancer working group with all relevant administrative and subspecialty stakeholders was created to discuss potential interventions and implementation strategies. The project was approved by the MD Anderson Quality Improvement Assessment Board. Results: Twenty-four of the thirty-two patients reviewed had stage II/III rectal cancer and were eligible for multimodality therapy with curative intent. The median time from pathologic diagnosis to treatment initiation was 62 days. The referral process was identified as the greatest source of delays. The median times from diagnosis to medical oncology and radiation oncology referral were 15 and 32 days, respectively. The median time for eligibility verification and clinical review by Case Management was 13 days. Conclusions: Based on these findings, two primary interventions have been instituted: (1) A synchronized referral process that will result in simultaneous consultation of all involved subspecialty services (surgery, medical oncology, and radiation oncology) was created for patients with rectal cancer; (2) Redundancy in the clinical review process was eliminated by coordination between Case Management and the Medical Oncology Chief Fellow. In tandem, these interventions are projected to reduce the time from diagnosis to treatment by approximately 50% (from 62 to 29 days).

Predictors of non-diagnostic cytology in surgeon-performed ultrasound guided fine needle aspiration of thyroid nodules.

BackgroundFine needle aspiration (FNA) is the standard of care for the diagnostic work-up of thyroid nodules but despite its proven utility, the non-diagnostic rate for thyroid FNA ranges from 6-36%. A non-diagnostic FNA is problematic for the clinician and patient because it can result in repeated procedures, multiple physician visits, and a delay in definitive treatment. Surgeon-performed FNA has been shown to be safe, cost-effective, as accurate as those performed by other clinicians, and has the added benefit of decreasing wait times to surgery. Several studies have examined rates and factors that may be predictive of a non-diagnostic cytology in non-surgeon FNA, but none have evaluated this in surgeon-performed thyroid FNA. If these factors are unique in surgeon-performed vs. non-surgeon performed thyroid FNA, then patients may be more appropriately triaged to FNA by alternate clinicians.ObjectivesThe purpose of this study was to determine the rate and factors predictive of a non-diagnostic FNA in surgeon performed ultrasound-guided FNA of thyroid nodules.MethodsWe conducted a retrospective review of all adult patients who underwent thyroid FNA by a staff, fellow, or resident Otolaryngologist at the University of Alberta between January 2011 and June 2013. Factors analyzed included patient factors, thyroid characteristics, nodule characteristics, and surgeon level of training and experience. Univariate and multivariate binary logistic regression analysis were performed.Results131 patients (180 nodules) were reviewed. The non-diagnostic rate was 23%. Nodules with predominant cystic component, those less than 1 cm, and resident-performed FNA were associated with non-diagnostic cytology (p = 0.001, p = 0.02, p = 0.04 respectively). A cystic nodule was the only independent predictor of non-diagnostic FNA on multivariate analysis (OR = 4.441, 95% CI [1.785-11.045], p = 0.001).ConclusionsThe rate of non-diagnostic thyroid FNA performed by a surgeon with ultrasound guidance is similar to other clinicians. A cystic nodule is a strong independent predictor of non-diagnostic cytology. Non-cystic nodules may particularly benefit from surgeon-performed thyroid FNA due to the high diagnostic rate and potential for earlier definitive management.

Mortality and Use of the Auxiliary Score in Extensive Toxic Epidermal Necrolysis Patients Admitted to an Adult Burns Referral Centre

Background: Toxic epidermal necrolysis (TEN) is a rare but fatal condition characterised by cutaneous exfoliation of the dermoepidermal layer and mucosal surfaces. Extensive TEN with epidermal detachment >30% of the total body surface area has been associated with a high mortality. Objective: This study aims to evaluate factors associated with mortality in extensive TEN. In the absence of data to qualify scoring systems such as SCORTEN, this study also aims to evaluate the use of the auxiliary score as a tool for calculating expected mortality. Methods: A retrospective chart review of all patients presenting to our burns service with extensive TEN was undertaken. Application and evaluation of the auxiliary score was also undertaken for this patient population. Results: In extensive TEN, age and delay in admission to a burns centre were factors associated with mortality. Applying the auxiliary score to our patient population, there were no significant differences between expected mortality and observed mortality. Conclusion: Mortality was associated with age and delay in definitive treatment in extensive TEN. Whilst SCORTEN is the gold standard prognostic tool for patients with TEN, in the absence of SCORTEN values, the auxiliary score provides an alternative scoring system to evaluate expected mortality.

The Sensitivity and Specificity of Frozen-Section Histopathology in the Management of Benign Oral and Maxillofacial Lesions

The management of odontogenic cysts and tumors involve treatment based on known biological behavior of the lesion and the recurrence rate. This typically requires an office biopsy which may present significant challenges when dealing with deep-seated lesions, pediatric patients, the medically compromised, or severely anxious patients, prompting an additional visit to the operating room for biopsy. These patients are thus exposed to morbidities including associated delay in definitive treatment, anesthesia, added cost, time away from work or school, and post-operative discomfort. A possible solution to the above scenario is the use of frozen sections. This would allow intra-operative diagnosis followed by definitive treatment under the same general anesthetic in many cases. The aim of this study is to determine the validity of frozen-section diagnosis in the management of benign oral and maxillofacial lesions.

Endobronchial lesion due to pulmonary Fusobacterium nucleatum infection in a child

Clinically significant infections due to the members of the genus Fusobacterium are rare. The clinical manifestations of pulmonary Fusobacterium nucleatum infections range from simple aspiration pneumonia to severe diseases as necrotizing pneumonia, lung abscess, and empyema. Endobronchial lesions and obstructions are rarely seen in children and are often a misdiagnosed result in delay of definitive treatment. Here, we report a case of endobronchial lesion due to pulmonary F. nucleatum infection in an entirely healthy child before illness. This is the first case reported in the literature of endobronchial lesion due to pulmonary F. nucleatum infection.

Anaphylaxis

Acute anaphylaxis has been described as ‘a serious allergic reaction that is rapid in onset and may cause death’. It is becoming more common and is underdiagnosed. Even when anaphylaxis is recognized, it tends to be undertreated. In view of these factors, all clinical staff should maintain awareness of it in order to recognize, assess and manage it optimally. In this article we have concentrated equally on treatment and recognition with assessment. The patient who exhibits the full range of manifestations of anaphylaxis may be readily diagnosed, but many present with only one or two of the features, thereby increasing diagnostic uncertainty and leading to delays in definitive treatment with adrenaline (epinephrine).