Kayen Chan, MBBS, BSc, Prateush Singh, MBBChir, MA, MRCS, Shivani Dhar, MBBS, Tonderai Mutsago, MBBS, Tawfiq Elahi, MBBS, Afshin Mosahebi, MBBS, FRCS (Plast), P

Background: Tourniquet pressures used in upper limb surgery are commonly standardized at 250 mmHg. These higher tourniquet pressures have been associated with an increased risk of complications, such as neural compression injury and soft tissue damage. However, there has been limited consensus as to the use of lower tourniquet pressures and their efficacy. This systematic review and meta-analysis aims to examine the current evidence for the use of lower tourniquet pressures in upper limb surgery, comparing them to the standard tourniquet pressures of 250 mmHg and, in some cases, 300 mmHg. This study is registered on PROSPERO (CRD42024511501). The primary outcome was the adequacy and quality of the bloodless field achieved at lower pressures. Secondary outcomes were assessed when reported, including the operative time, pain, and complications. Methods: The databases Medline (via Ovid), Embase (via Ovid), Cochrane, Web of Science (Core Collection) and Scopus, ClinicalTrials.gov, EU Clinical Trials Register, and ISRCTN registry were searched from inception to January 2025. The inclusion criteria included patients undergoing upper limb surgery using regional or general anesthetic with the use of a pneumatic tourniquet. A total of 1994 studies were identified, of which 12 met the inclusion criteria for review and 8 studies were used in the meta-analysis. Risk of bias was assessed using the ROBINS-I and RoB-2 tools. Results: The sample size was 1427 patients with a mean age of 46.8 years. All studies showed a bloodless surgical field at lower tourniquet occlusion pressures. The meta-analysis showed the overall mean tourniquet inflation pressure, estimated using a random effects model, to be 169.3 mmHg with a 95% confidence interval of 144.9–193.6. However, the heterogeneity in the reported results is significant (p < 0.0001) and is a limitation to this review. Conclusions: This systematic review highlights the benefit of the use of a lower tourniquet pressure (below the standard 250 mmHg) to produce an adequate surgical field and influence procedural outcomes.

Background: Degenerative cervical myelopathy (DCM) is a progressive neurological condition, characterized by spinal cord injury secondary to degenerative changes in the spine. Misdiagnosis in primary care forms part of a complex picture leading to an average diagnostic delay of 2 years. This leads to potentially preventable and permanent disability. A lack of awareness secondary to deficits in postgraduate education may contribute to these delays. Objective: This study aims to assess the awareness of DCM in the setting of general practice. Methods: General practitioners completed a quantitative web-based cross-sectional questionnaire. The 17-item questionnaire captured data regarding demographics, subjective awareness, and objective knowledge. The questionnaire was disseminated via professional networks, including via practice managers and senior practice partners. Incentivization was provided via a bespoke DCM fact sheet for those that completed the survey. Results: A total of 54 general practitioners representing all 4 UK nations responded to the survey. General practitioners most commonly self-assessed that they had “limited awareness” of DCM (n=24, 51%). General practitioners felt most commonly “moderately able” to recognize a case of DCM (n=21, 46%). In total, 13% (n=6) of respondents reported that they would not be at all able to recognize a patient with DCM. Respondents most commonly reported that they were “moderately confident” in their ability to triage a patient with DCM (n=19, 41%). A quarter of respondents reported no prior introduction to DCM throughout their medical training (n=13, 25%). The mean score for knowledge-based questions was 42.6% (SD 3.96%) with the lowest performance observed in patient demographic and clinical recognition items. Conclusions: General practitioners lack confidence in the recognition and management of DCM. These findings are consistent with the diagnostic delays previously described in the literature at the primary care level. Further work to develop and implement educational interventions to general practitioner practices is a crucial step to improving patient outcomes in DCM.

Background: Facial reconstruction surgery is often a complex and staged process, leading to lengthy reconstructive journeys for patients. The integration of a clinical pathway can give patients a clearer understanding of what to expect at each stage of their reconstructive journey. Objectives: The authors demonstrate how the incorporation of multidisciplinary team clinics, three-dimensional (3D) photography, and 3D modeling into an integrated pathway can streamline the process for patients undergoing facial reconstructive surgeries and aid their understanding of their surgeries. Methods: A novel clinical pathway was developed for patients undergoing facial reconstructive surgery at a tertiary reconstructive unit in London. A case series was collated of 35 patients who had been through the integrated pathway. Patient-reported outcome measures (PROMs) were assessed using FACE-Q scales, Global Aesthetic Improvement Scale, Self-Perception of Age score, and Ordinal Rank change in facial aesthetic appearance, determined subjectively and objectively. Statistical analysis was performed to calculate mean averages for each scale and PROM. Results: High patient satisfaction with overall facial appearance, aging appearance, and the decision-making process was demonstrated. The average perceived improvement in age-related facial appearance was −7.7 years postreconstruction compared with prereconstruction. The Ordinal Rank improvement on facial aesthetic appearance showed considerable improvement, both subjectively and objectively. Conclusions: The authors advocate the implementation of an integrated clinical pathway for facial reconstruction, with positive impacts observed in terms of patient satisfaction and objective assessments of facial appearance. Similar principles can be extrapolated to other aspects of reconstructive surgery. Level of Evidence: 3:

Selective IgM deficiency is a rare immunological disorder, with patients presenting with recurrent infections and allergic manifestations. However, the association with early postoperative infection has not been widely reported in the literature. We describe a rare case of a patient who had an early wound infection 1 day after excision of a Merkel cell carcinoma from his right buttock and was later found to have decreased IgM levels. Selective IgM deficiency should therefore be considered in patients presenting with recurrent infections or in patients who have previously undergone surgery and subsequently developed early infection postoperatively. In this subset of patients, extra precautions may need to be taken pre‐ and postoperatively to reduce the risk of developing a postoperative infection.