Edward Caruana

Chest wall invasion is seen in 5% to 8% of patients presenting with lung cancer. We report a case of complete resection of a 14 cm × 9 cm pT3N0M0 squamous cell carcinoma arising from the right lower lobe and invading the lower chest wall posteriorly, in a 75 years old male, via a hybrid thoracoscopic [video assisted thoracoscopic surgery (VATS)] approach. Following conventional VATS lobectomy, a targeted 10 cm
incision was performed to allow wide resection of the 7th to 10th ribs and 6th to 9th transverse processes, with the defect being subsequently reconstructed with a composite rigid prosthesis. The patient made an
uneventful recovery, and was discharged on the 3rd postoperative day; with later adjuvant chemotherapy. Thoracoscopic surgery is not currently widely adopted in patients with chest wall invasion, likely due to the technical difficulties. We briefly review the various techniques described in the current literature, whilst emphasising a role for such an approach in highly selected cases.

Background: Decortication for thoracic empyema is associated with significant blood loss and prolonged postoperative air leak. We sought to assess the potential application of an irrigated-tip radiofrequency (RF)
sealing device, in an attempt to reduce this morbidity.

Methods: Data for all patients undergoing open decortication (OD) for stage II thoracic empyema, using either conventional approach or facilitated by use of the Aquamantys® device, at a single thoracic surgical unit between April 2010 and July 2014, were retrospectively analysed. Unpaired t-test and Fisher’s exact test were used for statistical analysis.
Results: Thirty-three patients, aged 54±15 years (mean ± SD), and with a Charlson comorbidity index of 2.5±1.9 were included. Preoperative and intraoperative characteristics, including surgical time, were similar
in the conventional and Aquamantys® groups. Patients in the Aquamantys group were less likely to require red cell transfusion (9/22 vs. 10/11 patients, P=0.024) and received lower volume transfusions [0.0 (2.0) vs. 3.0 (1.6) units (median, IQR), P<0.0001]; chest drain duration was shorter [3.0 (1.0) vs. 6.5 (6.8) days, P=0.006], as was length of postoperative hospital stay [6.0 (8.7) vs. 10.0 (4.6) days, P=0.031]. There was no demonstrable difference in mortality.

Conclusions: Our data indicates that the use of irrigated tip RF ablation is safe and effective in improving pneumostasis and haemostasis in decortication for thoracic empyema; and that this translates to morbidity
and logistical benefit.

Aims: There is ongoing concern that procedures performed at weekends are associated with
worse outcomes than those undertaken on weekdays. We sought to evaluate the impact of
weekend operating at a UK-based specialist cardiac surgical centre, on length of stay of stay and
mortality.
Method: Prospectively-collected data was obtained for all patients who underwent cardiac
surgery at our institution between January and December 2013. Student t test and Pearson’s Chisquared
test were used for statistical analyses.
Results: A total of 139 of 1,941 (7.16%) procedures were performed at the weekend. The
weekend case mix was similar to that of weekdays in terms of clinical urgency (weekday vs
weekend, 71.2 vs 71.9% elective cases, p = 0.852). There was no difference in logistic
EuroSCORE (9.65±12.07 vs 10.79±15.56, p = 0.297) between cases undertaken on weekdays
and weekends respectively. Length of hospital stay (10.5±7.9 vs 9.6±7.3 days, p = 0.203),
hospital (2.4 vs 0.7%, p = 0.203), 90-day (4.4 vs 2.2%, p = 0.200) and one-year (6.9 vs 4.3%, p =
0.244) mortality was similar in both groups.
Conclusion: This study demonstrates that in our centre, weekend surgical outcomes are
equivalent to those of operations performed during the working week.

Aims: It has been previously demonstrated that the month of August is associated with adverse
patient outcomes, commonly attributed to trainee changeover and novice doctors. We sought to
re-evaluate this phenomenon at a UK-based specialist cardiac surgical centre with a focus on
long-term outcome.
Method: Prospectively-collected data was obtained for all patients who underwent cardiac
surgery at our institution between January and December 2013. Student t test and Pearson’s Chisquared
test were used for statistical analyses.
Results: 165 patients (8.5% of the annual cardiac surgery workload) had operations in August.
There was no difference in logistic EuroSCORE between August and the other months
collectively (9.1±11.4 vs 9.8±12.4, p = 0.496). Pre- operative (2.1±3.7 vs 2.5±4.6, p = 0.353) and
post-operative (10.2±6.0 vs 10.4±8.0) lengths of hospital stay were similar in both groups.
Hospital mortality was higher in August (4.8 vs 2.0%, p = 0.019). The difference at 90-days (6.1
vs 4.1%, p = 0.236) and at one-year (9.1 vs 6.5%, p = 0.199) was not statistically significant.
Conclusion: In-hospital mortality is higher for operations in the month of August.

Objectives: Conventional open decortication for thoracic empyema is associated with significant perioperative morbidity. We sought to assess the impact of use of an irrigated radiofrequency sealing system (Aquamantys®) for performing
this procedure.
Methods: Data for 33 patients with stage III thoracic empyema who underwent either (1) conventional open decortication or (2) open decortication using the Aquamantys® system at a thoracic surgical tertiary referral centre between April 2010 and July 2014 were retrospectively reviewed. Unpaired t test and
Fisher’s exact test were used for statistical analysis.
Results: Twenty-one of 33 patients (63.6%) underwent decortication with Aquamantys®. There was no significant difference in gender (conventional vs Aquamantys®: 50% vs 76.2%, P = 0.149) or age (52.2 ± 12.1 vs 55.3 ± 16.2 years,
P = 0.569) between the two groups, whilst preoperative haemoglobin was higher in the conventional group (11.2 ± 1.2 vs 10.4 ± 1.2 g/dl) but this did not reach statistical significance (P = 0.075). Patients in the Aquamantys® group suffered a lower perioperative drop in their haemoglobin (3.1 ± 1.5 vs 1.6 ± 0.7, P < 0.001), required less blood to be transfused (3.0 ± 1.3 vs 1.3 ± 1.8 units packed red cells, P = 0.007), and had their chest drains taken out earlier (9.1 ± 6.3 vs 4.0 ± 3.0 days, P = 0.004), whilst operative time was longer (119.6 ± 43.4 vs 177.1 ± 83.4, P = 0.034). Postoperative hospital stay was shorter in the Aquamantys® group (11.2 ± 4.5 vs 7.9 ± 5.7 days, P = 0.096) as
was the incidence of critical care admission (5 vs 2 admissions, P = 0.071), however, these did not achieve statistical significance.
Conclusions: Use of the Aquamantys® system in open decortication for thoracic empyema results in less blood loss, lower transfusion requirements, and shorter chest drain times; whilst contributing to reduced hospital length of stay.

ABSTRACT Purpose: Recognition and appropriate initial first aid of suspected myocardial infarction improves patient outcomes. This study seeks to identify current knowledge patterns with regards to identification and management of acute cardiac events, amongst members of the lay public in Malta. Methods: Volunteers, recruited according to a probability quota sample, submitted to a structured interview detailing demographics and relevant knowledge. Individual chi-squared tests were performed to relate knowledge to expected influences. Results: 599 individuals (49% male, n=291) were interviewed; of whom 36% (n=213) had previously attended formal first aid training, and 4% (n=23) reported having suffered a myocardial infarction (MI) in the past. An average of 6.8 (SD ±1.57) out of 9 common acute coronary syndrome (ACS) symptoms, were identified on prompting. Those symptoms least commonly identified were chest pain radiating to the right arm (33%, n=199) and that radiating to the neck, jaw or abdomen (54%, n=321); training failed to improve appreciation of the significance of these symptoms (p=0.38 and 0.51 respectively), as did history of previous MI (p=0.87 and 0.57 respectively). 98% (n=592) of patients would call an ambulance if suspecting a heart attack. 50% (n=300) would administer sublingual nitrate, and 48% (n=285) would administer aspirin if these were previously prescribed to and carried by the patient; training fails to confer benefit (p=0.46 and 0.09 respectively) as does previous ACS (p=0.53 and 0.38). 42% (n=253) of subjects said they would start cardiopulmonary resuscitation when presented with a patient experiencing chest pain and other symptoms suspicious of ACS; training was not associated with any improvement (p=0.486). Conclusions: The lay public is generally appropriately suspicious of ACS, except with less typical symptoms; however, knowledge of appropriate management is poor. This is not improved by current training, nor in patients who have previously suffered a heart attack.

ABSTRACT Introduction: There exists much uncertainty amongst members of the general public as to the actual site of the problem in a stroke. Objectives: This study aims to evaluate patient&amp;#39;s understanding of which organ has suffered insult in the case of stroke. Methodology: Volunteers, recruited according to a probability quota sample, underwent a structured interview detailing demographics, first aid training and basic facts about stroke. Individual chi-squared tests were performed to relate knowledge to expected influences. Results: 500 individuals (47% male, n = 233) were interviewed, of whom 34% (n = 169) had previously attended a formal training in first aid. 59% of subjects correctly indicated that it is the brain that has sustained damage in the case of a stroke; with a significant improvement noted amongst those who had previously attended training (68% vs 54%, p &amp;lt; 0.01). 25% of people questioned identified the problem to be in the limbs or face, and 10% in the heart. 90% of interviewees (n = 452) indicated the need to seek urgent medical attention even in the case transient symptomatology suggestive of stroke; whilst 98% (n = 488) correctly identified hospital as the appropriate first port of call. Conclusions: A significant proportion of the general public has a poor understanding of the nature of stroke; first aid training results in a significant increase in prevalence of this insight. There is almost universal appreciation of the urgency and seriousness of a “stroke”, rendering the onus on prompt recognition.

BACKGROUND Early appropriate intervention to control external haemorrhage reduces morbidity and mortality. Lay bystanders are often best placed to provide such first aid. This study evaluates the extent of and influences on knowledge of haemorrhage control amongst the general public in Malta. METHODS Voluntary subjects, recruited according to a probability quota sample, submitted to a structured interview detailing relevant demographics, training and experiences, and knowledge of first aid for bleeding. Individual chi-squared tests were performed to relate knowledge to expected influences. RESULTS 492 subjects (47% male) were interviewed. 50% of respondents spontaneously indicated that they would apply manual direct pressure in an initial attempt to stem severe haemorrhage; with those who had received formal first aid training (33%, n = 164) being more likely to do so (65.2% vs 42.2%, p &lt; 0.01). Respondents who had previously suffered a related injury (16%, n = 81) were similarly...

BACKGROUND Timely and appropriate first aid, as lay bystanders are often best positioned to deliver, positively impacts the long term outcome of injury and acute illness suffered outside of hospital. This study aims to evaluate the overall training rate, and the relative predominance of conventional versus modern pedagogical methods in Malta. METHODS Voluntary adult subjects, recruited according to a probability quota sample, responded to questions of demographics, formal and informal first aid training. Individual chi-squared tests were performed to relate knowledge to expected influences. RESULTS 528 subjects (44% male) were interviewed. 34% of study participants (n = 180) had previously attended conventional first aid training, with just over 13% (n = 70) having last received this training within the previous three years. Conversely, there was significantly less engagement in formal first aid training delivered at least in part via eLearning (p&lt;0.001), with only three particip...