A national survey of attitudes to research in Scottish General Surgery Trainees

INTRODUCTION

Given the importance placed on awareness and participation in research by Speciality and Training organisations, we sought to survey Scottish trainee attitudes to exposure to research practice during training and research in or out of programme.

METHODS

An online survey was distributed to core and specialist trainees in general surgery in Scotland.

RESULTS

Over a 4-month period, 108 trainees (75 ST/SPRs and 33 CTs) completed the survey. In their current post, most were aware of ongoing research projects (77%) and 55% were aware of trial recruitment. Only 47% attend regular journal clubs. Most believe that they are expected to present (89%) and publish (82%) during training. Most (59%) thought that participation in research is well supported. 57% were advised to undertake time out of programme research, mostly by consultants (48%) and training committee (36%). Of the 57 with time out of programme research experience, most did so in early training (37%) or between ST3-5 (47%). 28 out of the 36 (78%) without a national training number secured one after starting research. Most undertook research in a local academic unit (80%) funded by small grants (47%) or internally (33%). Most research (69%) was clinically orientated (13/55 clinical, 25/55 translational). 56% of those completing time out of programme research obtained an MD or PhD. About 91% thought that research was relevant to a surgical career.

CONCLUSIONS

Most trainees believe that research is an important part of training. Generally, most trainees are exposed to research practices including trial recruitment. However, <50% attend regular journal clubs, a pertinent point, given the current 'exit exam' includes the assessment of critical appraisal skills.

Meta-analysis of ischaemic preconditioning for liver resections

BACKGROUND

Vascular clamping reduces blood loss during liver resection but leads to ischaemia-reperfusion injury. Ischaemic preconditioning (IP) may reduce this. This study aimed to evaluate IP in liver resection under clamping.

METHODS

This was a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating IP in adults undergoing liver resection under either continuous clamping (CC) or intermittent clamping (IC). Primary outcomes were mortality, liver failure and morbidity. Secondary outcomes included duration of operation, blood loss, length of hospital stay, length of intensive therapy unit stay, transfusion requirements, prothrombin time, and bilirubin and aminotransferase levels. Weighted mean differences were calculated for continuous data, and pooled odds ratios (ORs) for dichotomous data. Results were produced with a random-effects model with 95 per cent confidence intervals (c.i.).

RESULTS

A total of 2960 records were identified and 11 RCTs included 669 patients (IP 331, control 338). No significant difference in mortality (6 RCTs; IP 186, control 190; OR 1·36, 95 per cent c.i. 0·13 to 13·68; P = 0·80) or morbidity (6 RCTs; IP 186, control 190; OR 0·58, 0·31 to 1·07; P = 0·08) was found for IP plus CC versus CC. Nor was there a significant difference in mortality (4 RCTs; IP 122, control 121; OR 1·33, 0·24 to 7·32; P = 0·74) or morbidity (4 RCTs; IP 122, control 121; OR 0·87, 0·52 to 1·47; P = 0·61) for IP plus (CC or IC) versus IC. No significant differences were found for secondary outcome measures.

CONCLUSION

This meta-analysis failed to find a significant benefit of IP in liver resection.

Systematic review and meta-analysis of continuous local anaesthetic wound infiltration versus epidural analgesia for postoperative pain following abdominal surgery

BACKGROUND

Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of local anaesthetic by continuous infusion. The aim was to compare these infiltration techniques with the current standard of epidural analgesia.

METHODS

A meta-analysis of randomized clinical trials (RCTs) evaluating wound infiltration versus epidural analgesia in abdominal surgery was performed. The primary outcome was pain score at rest after 24 h on a numerical rating scale. Secondary outcomes were pain scores at rest at 48 h, and on movement at 24 and 48 h, with subgroup analysis according to incision type and administration regimen(continuous versus bolus), opiate requirements, nausea and vomiting, urinary retention, catheter-related complications and treatment failure.

RESULTS

Nine RCTs with a total of 505 patients were included. No differences in pain scores at rest 24 h after surgery were detected between epidural and wound infiltration. There were no significant differences in pain score at rest after 48 h, or on movement at 24 or 48 h after surgery. Epidural analgesia demonstrated a non-significant a trend towards reduced pain scores on movement and reduced opiate requirements. There was a reduced incidence of urinary retention in the wound catheter group.

CONCLUSION

Within a heterogeneous group of RCTs, use of local anaesthetic wound infiltration was associated with pain scores comparable to those obtained with epidural analgesia. Further procedure-specific RCTs including broader measures of recovery are recommended to compare the overall efficacy of epidural and wound infiltration analgesic techniques.

Recurring pulmonary hamartomas: cause for concern?

We report the case of a well-controlled female asthmatic who developed 'multiple pulmonary hamartomas' on three separate occasions over a period of 25 years that necessitated surgical resection. To our knowledge, this is the first report of recurrent hamartomas in a single individual necessitating multiple thoracotomies.

Disordered vascular compliance in haemochromatosis

BACKGROUND

A relationship may exist between body iron stores, endothelial dysfunction and overall cardiovascular risk.

AIMS

To compare vascular compliance, biochemical endothelial function and antioxidant status between patients with homozygous hereditary haemochromatosis and healthy controls.

METHODS

Haemochromatosis patients and healthy controls were recruited. Measures of vascular compliance were assessed by applanation tonometry. Serological markers of endothelial function (plasma lipid hydroperoxides, cell adhesion molecules), antioxidant levels (ascorbate, lipid soluble antioxidants) and high-sensitivity C-reactive protein (CRP) were also measured.

RESULTS

Thirty-five hereditary haemochromatosis patients (ten females, mean age 54.6) and 36 controls (27 female, mean age 54.0) were recruited. Haemochromatosis patients had significantly higher systolic and diastolic blood pressures. Pulse wave velocity (PWV) was significantly higher in male haemochromatosis patients (9.90 vs. 8.65 m/s, p = 0.048). Following adjustment for age and blood pressure, male haemochromatosis patients continued to have a trend for higher PWVs (+1.37 m/s, p = 0.058). Haemochromatosis patients had significantly lower levels of ascorbate (46.11 vs. 72.68 μmol/L, p = 0.011), retinol (1.17 vs. 1.81 μmol/L, p = 0.001) and g-tocopherol (2.51 vs. 3.14 μmol/L, p = 0.011). However, there was no difference in lipid hydroperoxides (0.46 vs. 0.47 nmol/L, p = 0.94), cell adhesion molecule levels (ICAM: 348.12 vs. 308.03 ng/mL, p = 0.32 and VCAM: 472.78 vs. 461.31 ng/mL, p = 0.79) or high-sensitivity CRP (225.01 vs. 207.13 mg/L, p = 0.32).

CONCLUSIONS

Haemochromatosis is associated with higher PWVs in males and diminished antioxidants across the sexes but no evidence of endothelial dysfunction or increased lipid peroxidation.

Pulmonary sequelae of severe H1N1 infection treated with high frequency oscillatory ventilation

During the recent influenza A (H1N1) pandemic, due to severe respiratory failure many patients required treatment with alternative ventilator modalities including High Frequency Oscillatory Ventilation (HFOV). We present four such patients treated with HFOV at an academic, tertiary referral hospital in Ireland. We detail outcomes of clinical examination, pulmonary function testing, quality of life assessment and radiographic appearance on CT Thorax at follow-up at 6 months. Further clinical assessment and pulmonary function testing were performed at median 19 months (range 18-21 months) post-discharge. At initial review all patients were found to have reduced gas transfer (median predicted DLCO 74%) with preservation of lung volumes and normal spirometrical values at 6 months (median FVC 5.42L [101% predicted] and FEV14.5L [101.2% predicted] respectively), with improvements in gas transfer (median predicted DLCO 83%)at subsequent testing. Post-inflammatory changes on CT thorax at 6 months were seen in all 4 cases. To our knowledge this is the first report to document the long-term effects of severe H1N1 infection requiring high frequency oscillation on respiratory function. We conclude that the effects on respiratory function and pulmonary radiological appearance are similar to those observed following conventional treatment of Acute Respiratory Distress Syndrome [ARDS].

Systematic review of the management of ischaemic colitis

AIM

The study reviews the literature related to ischaemic colitis (IC) to establish an evidence base for its management and to identify factors predicting severity and mortality.

METHOD

A systematic review of the English language literature was conducted according to recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE, Embase and Cochrane Library databases were searched using the keyword search 'ischaemic colitis OR colon ischaemia OR colonic ischaemia OR management ischaemic colitis'. IC is often misdiagnosed so only studies where the diagnosis was supported by histopathology in every case were included. Critical appraisal was performed of included studies using predefined quality assessment checklists and narrative data synthesis.

RESULTS

In all, 2610 publications were identified. Of these, eight retrospective case series and three case controlled studies describing 1049 patients were included. Medical management was used in 80.3% patients of whom 6.2% died. Surgery was required in 19.6% of whom 39.3% died. The overall mortality of IC was 12.7%. Lack of rectal bleeding, peritonism and renal dysfunction were commonly quoted predictors of severity; however, right sided IC appeared to be the most significant predictor of outcome.

CONCLUSION

Most patients with IC can be managed conservatively. Right sided IC may be the most significant predictor of severity.

Effects of abdominal fat distribution parameters on severity of acute pancreatitis

BACKGROUND

Obesity is a well-established risk factor for acute pancreatitis. Increased visceral fat has been shown to exacerbate the pro-inflammatory milieu experienced by patients. This study aimed to investigate the relationship between the severity of acute pancreatitis and abdominal fat distribution parameters measured on computed tomography (CT) scan.

METHODS

Consecutive patients admitted to Cork University Hospital with acute pancreatitis between January 2005 and December 2010 were evaluated for inclusion in the study. An open source image analysis software (Osirix, v 3.9) was used to calculate individual abdominal fat distribution parameters from CT scans by segmentation of abdominal tissues.

RESULTS

A total of 214 patients were admitted with pancreatitis between January 2005 and December 2010. Sixty-two of these patients underwent a CT scan and were thus eligible for inclusion. Visceral fat volume was the volumetric fat parameter that had the most significant association with severe acute pancreatitis (P = 0.003). There was a significant association between visceral fat volume and subsequent development of systemic complications of severe acute pancreatitis (P = 0.003). There was a strong association between mortality and visceral fat volume (P = 0.019). Multivariate regression analysis, adjusted for gender, did not identify any individual abdominal fat distribution index as an independent risk factor for severe acute pancreatitis.

CONCLUSIONS

Overall, estimation of abdominal fat distribution parameters from CT scans performed on patients with acute pancreatitis indicates a strong association between visceral fat, severe acute pancreatitis, and the subsequent development of systemic complications. These data suggest that visceral fat volume should be incorporated into future predictive scoring systems.

Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis

AIM

Reduced opioid use in the immediate postoperative period is associated with decreased complications. This study aimed to determine the effect of transversus abdominis plane (TAP) block on morphine requirements 24 h after abdominal surgery. Secondary outcomes included the effect of TAP block on morphine use 48 h after surgery, incidence of postoperative nausea and vomiting (PONV) and impact on reported pain scores (visual analogue scale).

METHOD

A systematic review of the literature was conducted for randomised controlled trials (RCTs) evaluating the effects of TAP block in adults undergoing abdominal surgery. For continuous data, weighted mean differences (WMD) were formulated; for dichotomous data, odds ratios (OR) were calculated. Results were produced with a random effects model with 95% confidence intervals (CI).

RESULTS

Nine studies, including published and unpublished data, containing a total of 413 patients were included. Of these 205 received a TAP block and 208 a placebo. Cumulative morphine utilization was statistically significantly reduced at 24 h. [WMD=23.71mg (38.66-8.76); P=0.002] and 48h [WMD=38.08mg (18.97-57.19); P<0.0001] in patients who received a TAP block and the incidence of PONV was significantly reduced [OR=0.41(0.22-0.74); P=0.003]. There was a nonsignificant reduction in the visual analogue scales of postoperative pain [WMD=0.73cm (1.84-0.38), P=0.2]. There were no reported adverse events following TAP block.

CONCLUSION

Transversus abdominis plane block is safe, reduces postoperative morphine requirements, nausea and vomiting and possibly the severity of pain after abdominal surgery. It should be considered as part of a multimodal approach to anaesthesia and enhanced recovery in patients undergoing abdominal surgery.

Colorectal smartphone apps: opportunities and risks

AIM

The increased utilization of smartphones within the clinical environment together with connected applications (apps) provides opportunity for doctors, including coloproctologists, to integrate such technology into clinical practice. However, the reliability of unregulated medical apps has recently been called into question. Here, we review contemporary medical apps specifically themed towards colorectal diseases and assess levels of medical professional involvement in their design and content.

METHOD

The most popular smartphone app stores (iPhone, Android, Blackberry, Nokia, Windows and Samsung) were searched for colorectal disease themed apps, using the disease terms colorectal cancer, Crohn's disease, ulcerative colitis, diverticulitis, haemorrhoids, anal fissure, bowel incontinence and irritable bowel syndrome.

RESULTS

A total of 68 individual colorectal themed apps were identified, amongst which there were five duplicates. Only 29% of colorectal apps had had customer satisfaction ratings and 32% had named medical professional involvement in their development or content.

CONCLUSION

The benefits of apps are offset by lack of colorectal specification. There is little medical professional involvement in their design. Increased regulation is required to improve accountability of app content.

Comprehensive gene expression profiling and immunohistochemical studies support application of immunophenotypic algorithm for molecular subtype classification in diffuse large B-cell lymphoma: a report from the International DLBCL Rituximab-CHOP Consortium Program Study

Gene expression profiling (GEP) has stratified diffuse large B-cell lymphoma (DLBCL) into molecular subgroups that correspond to different stages of lymphocyte development-namely germinal center B-cell like and activated B-cell like. This classification has prognostic significance, but GEP is expensive and not readily applicable into daily practice, which has lead to immunohistochemical algorithms proposed as a surrogate for GEP analysis. We assembled tissue microarrays from 475 de novo DLBCL patients who were treated with rituximab-CHOP chemotherapy. All cases were successfully profiled by GEP on formalin-fixed, paraffin-embedded tissue samples. Sections were stained with antibodies reactive with CD10, GCET1, FOXP1, MUM1 and BCL6 and cases were classified following a rationale of sequential steps of differentiation of B cells. Cutoffs for each marker were obtained using receiver-operating characteristic curves, obviating the need for any arbitrary method. An algorithm based on the expression of CD10, FOXP1 and BCL6 was developed that had a simpler structure than other recently proposed algorithms and 92.6% concordance with GEP. In multivariate analysis, both the International Prognostic Index and our proposed algorithm were significant independent predictors of progression-free and overall survival. In conclusion, this algorithm effectively predicts prognosis of DLBCL patients matching GEP subgroups in the era of rituximab therapy.

A critical evaluation of HIPE data

Resource allocation and planning of future services is dependent on current volumes, making it imperative that procedural data is accurately recorded. We sought to evaluate the effectiveness of the information gathered by the Hospital Inpatient Enquiry (HIPE) system in recording such activity. Five index vascular procedures (open/endovascular abdominal aneurysm repair, carotid endarterectomy, lower limb angioplasty/bypass) were chosen to reflect activity. The Economic and Social Research Institute (ESRI), and HIPE databases were interrogated to obtain the regional and hospital specific figures for the years 2005, 2006 and 2009, and then compared with the prospective vascular database in St James's hospital. Data for 2006 (the most recent year available) shows significant discrepancies between the HIPE and vascular database figures for St James's hospital. The HIPE and database figures respectively for; open aneurysm 13/30 (-50%), endovascular aneurysm 39/31 (+25%), carotid 62/48 (+29%), angioplasty 242/111 (+100%) and bypass 24/10 (+100%) These inaccuracies are likely to be magnified on a regional and national level when pooling data.

Traumatic injury to the colon and rectum in Scotland: demographics and outcome

AIM

An analysis of a multi-centred database of trauma patients was performed.

METHOD

The study used data from a prospective multi-centre trauma database containing details of 52 887 trauma patients admitted to participating Scottish Hospitals over an 11-year period.

RESULTS

Three hundred and forty (0.64%) of 52 887 trauma patients (284 male) with colorectal injuries were identified; 43.9% of colorectal injuries occurred following blunt trauma and 56.1% following penetrating injury. Patients in the latter group were younger, had less haemodynamic compromise and were less likely to die than those with blunt trauma (P < 0.01). The overall mortality rate was 25.6% and after rectal injury it was 21.2% (P > 0.05). Female gender, increased age, road traffic accidents and those admitted as a result of a blunt traumatic injury were associated with increased mortality. Age > 65 years (P = 0.01), increasing injury severity score (ISS) at presentation (P < 0.001), haemodynamic compromise (P = 0.045) and decreased Glasgow Coma Score (GCS) (P < 0.001) had the strongest independent associations with mortality.

CONCLUSION

Colorectal injury after trauma has a high morbidity. Clinical features associated with death allow stratification of mortality risk.