Competency Assessment of General Surgery Trainees: A Perspective From the Global South, in a CBME-Naive Context

OBJECTIVE

Before proceeding with local implementation of competency-based medical education-related assessment practices designed and evaluated in the Global North, we sought to challenge the assumption that this would be perceived as both necessary and acceptable in our context where training and assessment is based on a traditional, knowledge-focused approach. The aim of this study was to determine the perspectives of general surgery trainees and consultants towards the assessment of competence, how this has been achieved previously, and how it should be performed in the future at the University of Cape Town (UCT), South Africa.

DESIGN

Semi-structured interviews were conducted with consultants and trainees. Interviews were transcribed and then analyzed using a Reflexive Thematic Analysis approach.

SETTING AND PARTICIPANTS

Ten consultants (5 senior and 5 junior) and 10 trainees (5 South African and 5 international) from the Division of General Surgery at UCT in August 2022.

RESULTS

Five unique themes were developed: (1) Assessment of competence is essential, (2) competence includes multiple domains of practice, (3) a surgeon must be able to operate, (4) previously used methods were inadequate to assess competence, and (5) frequent assessment with feedback is desired. The themes were considered in the context of Situated Learning Theory, particularly Communities of Practice and their role in the training for, and authentic assessment of, competence in general surgery trainees.

CONCLUSIONS

Participants described a need to develop and implement a new competency assessment program for general surgery training in this context, which is aligned with described competency-based medical education principles. Thoughtful integration of the formative and summative use of direct observation in the workplace, with a clear emphasis on procedural ability and the provision of high-quality feedback, may enhance the successful implementation of a strategy for competency-based assessment in general surgery training programs.

Trans-arterial therapy for Fibrolamellar carcinoma: A case report and literature review

Introduction

Fibrolamellar carcinoma (FLC) is a rare pathologically distinct primary liver cancer. Surgical resection is the only treatment associated with prolonged survival. Trans-arterial embolization (TAE), which is a recognised treatment for hepatocellular carcinoma has been used to treat FLC. We present a case and performed a literature review of patients with FLC treated with TAE.

Case presentation

We present a 19-year old female with a large potentially resectable FLC which was initially treated with trans-arterial chemo-embolization (TACE) with drug eluting beads. The TACE was followed by surgical resection. Histology confirmed tumour necrosis related to the previous TACE.

Discussion & literature review

We identified seven case reports and one case series of TAE for FLC. TAE was either used as a neo-adjuvant therapy to facilitate subsequent tumour resection or as a palliative treatment modality. We propose an algorithm for the treatment of FLC that includes TAE.

Conclusion

The rarity of FLC and the paucity of data precludes establishing clear evidence-based standards of care. We propose an algorithm for the treatment of FLC. The establishment of an international registry may facilitate the collection of better quality evidence.

•

Fibrolamellar carcinoma (FLC) is a rare primary liver tumour that predominantly occurs in young patients.

•

Surgical resection of the tumour and liver transplantation are the only potentially curative treatment modalities.

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Trans-arterial embolization has been used as neo-adjuvant and palliative treatment modalities.

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We propose a management algorithm which includes trans-arterial embolization for selected patients with FLC.

Translation and linguistic validation of the EORTC QLQ-PAN26 questionnaire for assessment of health-related quality of life in patients with pancreatic cancer and chronic pancreatitis into isiXhosa and Afrikaans

BACKGROUND

Health-related quality of life (HRQOL) parameters have become important components in the holistic management of pancreatic ductal adenocarcinoma (PDAC) and are now increasingly incorporated in treatment protocols. The European Organisation for Research and Treatment of Cancer (EORTC) pancreatic cancer specific questionnaire (QLQ-PAN26) has also been validated for chronic pancreatitis (CP). The objective was to translate the EORTC QLQPAN26 questionnaire into and validate it for isiXhosa and Afrikaans.

METHODS

Following the EORTC translation procedure, two forward translations of the English version into isiXhosa and Afrikaans were performed independently by two language practitioners for each language, followed by reconciliation of disagreements. A back translation of the reconciled version into English by a second pair of language practitioners was done. The results of all the steps were summarised with comments in a report for review by the EORTC translation unit. After proofreading by an external proof-reader chosen by the translation unit, pilot testing was performed on a cohort of ten isiXhosa patients and ten Afrikaans patients with PDAC or chronic pancreatitis. Results were summarised in a pilottesting report, and the final version approved by the translation unit.

RESULTS

Thirteen patients diagnosed with PDAC and seven with CP were included in the study. The questionnaire was completed electronically (n = 12) or on paper (n = 8). Median age in the isiXhosa group was 53.7 (range 41-63) and in the Afrikaans group 60.9 (range 35-79). Questions 31-54 had a 100% completion rate, while 35% of respondents did not complete Q55 and Q56. Internal consistency was satisfactory in isiXhosa (alpha = 0.88) and Afrikaans (alpha = 0.89).

CONCLUSION

The EORTC QLQ-PAN26 used in patients with PDAC and CP has been translated and linguistic validation performed in isiXhosa and Afrikaans. Availability of a questionnaire in patients' mother tongue should increase the validity of results.

Mentorship during undergraduate surgical training: comparing perceptions of medical students and faculty at two institutions in South Africa and Sweden

BACKGROUND

Having a mentor during undergraduate surgical training has been shown to positively influence medical students by increasing interest in surgery, improving confidence, and assisting in career planning. This study aimed to evaluate and compare medical student and faculty perceptions of mentorship during undergraduate surgical training and compare results between two teaching institutions in South Africa and Sweden.

METHODS

An electronic, online questionnaire was anonymously distributed to medical students and general surgical faculty at the University of Cape Town (UCT), South Africa, and Karolinska Institutet (KI), Stockholm, Sweden. The questionnaire consisted of multiple choice, true or false, and five-point Likert scale questions, exploring perceptions of mentorship and role models, as well as rating the most important mentor characteristics.

RESULTS

Approximately one third (34.2%) of students stated they had a mentor during their surgical training, with significant differences found between student cohorts (p < 0.001). The 'registrar' was most commonly reported as the best role model for medical students by faculty from both UCT (50.0%) and KI (69.4%), as well as UCT students (36.6%). Students rated the following mentor qualities significantly higher compared to faculty: student encouragement (p = 0.037), adequate supervision (p = 0.007), setting of fair expectations (p = 0.002), and teaching skills (p = 0.010).

CONCLUSION

With significant differences existing in the perceptions of medical students and faculty regarding mentorship and role models during undergraduate surgical training in both South African and Swedish institutions, reconciling and harmonising these differences will be crucial in fostering constructive mentoring relationships.

Mentorship during undergraduate surgical training: comparing perceptions of medical students and faculty at two institutions in South Africa and Sweden

ABSTRACT BACKGROUND: Having a mentor during undergraduate surgical training has been shown to positively influence medical students by increasing interest in surgery, improving confidence, and assisting in career planning. This study aimed to evaluate and compare medical student and faculty perceptions of mentorship during undergraduate surgical training and compare results between two teaching institutions in South Africa and Sweden METHODS: An electronic, online questionnaire was anonymously distributed to medical students and general surgical faculty at the University of Cape Town (UCT), South Africa, and Karolinska Institutet (KI), Stockholm, Sweden. The questionnaire consisted of multiple choice, true or false, and five-point Likert scale questions, exploring perceptions of mentorship and role models, as well as rating the most important mentor characteristics RESULTS: Approximately one third (34.2%) of students stated they had a mentor during their surgical training, with significant differences found between student cohorts (p < 0.001). The 'registrar' was most commonly reported as the best role model for medical students by faculty from both UCT (50.0%) and KI (69.4%), as well as UCT students (36.6%). Students rated the following mentor qualities significantly higher compared to faculty: student encouragement (p = 0.037), adequate supervision (p = 0.007), setting of fair expectations (p = 0.002), and teaching skills (p = 0.010 CONCLUSION: With significant differences existing in the perceptions of medical students and faculty regarding mentorship and role models during undergraduate surgical training in both South African and Swedish institutions, reconciling and harmonising these differences will be crucial in fostering constructive mentoring relationships Keywords: mentorship, role model, perception, surgical education

Translation and linguistic validation of the EORTC QLQ-PAN26 questionnaire for assessment of health-related quality of life in patients with pancreatic cancer and chronic pancreatitis into isiXhosa and Afrikaans

ABSTRACT BACKGROUND: Health-related quality of life (HRQOL) parameters have become important components in the holistic management of pancreatic ductal adenocarcinoma (PDAC) and are now increasingly incorporated in treatment protocols. The European Organisation for Research and Treatment of Cancer (EORTC) pancreatic cancer specific questionnaire (QLQ-PAN26) has also been validated for chronic pancreatitis (CP). The objective was to translate the EORTC QLQ-PAN26 questionnaire into and validate it for isiXhosa and Afrikaans METHODS: Following the EORTC translation procedure, two forward translations of the English version into isiXhosa and Afrikaans were performed independently by two language practitioners for each language, followed by reconciliation of disagreements. A back translation of the reconciled version into English by a second pair of language practitioners was done. The results of all the steps were summarised with comments in a report for review by the EORTC translation unit. After proofreading by an external proof-reader chosen by the translation unit, pilot testing was performed on a cohort of ten isiXhosa patients and ten Afrikaans patients with PDAC or chronic pancreatitis. Results were summarised in a pilot-testing report, and the final version approved by the translation unit RESULTS: Thirteen patients diagnosed with PDAC and seven with CP were included in the study. The questionnaire was completed electronically (n = 12) or on paper (n = 8). Median age in the isiXhosa group was 53.7 (range 41-63) and in the Afrikaans group 60.9 (range 35-79). Questions 31-54 had a 100% completion rate, while 35% of respondents did not complete Q55 and Q56. Internal consistency was satisfactory in isiXhosa (alpha = 0.88) and Afrikaans (alpha = 0.89 CONCLUSION: The EORTC QLQ-PAN26 used in patients with PDAC and CP has been translated and linguistic validation performed in isiXhosa and Afrikaans. Availability of a questionnaire in patients' mother tongue should increase the validity of results Keywords: health-related quality of life pancreatic ductal adenocarcinoma, questionnaire translation

Pancreas preserving duodenectomy for duodenal polyposis in familial adenomatous polyposis

Duodenal polyposis is common in familial adenomatous polyposis with a significant associated lifetime risk of cancer. Screening and regular surveillance is recommended, guided by the Spigelman stage. Pancreas preserving duodenectomy (PPD) is the preferred operation in patients needing removal of the whole duodenum. This presentation demonstrates the technique of PPD with particular emphasis on the resection and ampullary reconstruction. Initial early feeding tube placement through the cystic duct stump into the duodenum enables identification of the papilla and pancreatic duct as well as subsequent dissection. Separate trans-anastomotic pancreatic and biliary stents facilitate creation and patency of the pancreato-biliary anastomosis. The operation has similar outcomes compared to pancreaticoduodenectomy, however, the anatomical reconstruction allows for postoperative surveillance.

Mutations in ASIP and MC1R: dominant black and recessive black alleles segregate in native Swedish sheep populations

By studying genes associated with coat colour, we can understand the role of these genes in pigmentation but also gain insight into selection history. North European short-tailed sheep, including Swedish breeds, have variation in their coat colour, making them good models to expand current knowledge of mutations associated with coat colour in sheep. We studied ASIP and MC1R, two genes with known roles in pigmentation, and their association with black coat colour. We did this by sequencing the coding regions of ASIP in 149 animals and MC1R in 129 animals from seven native Swedish sheep breeds in individuals with black, white or grey fleece. Previously known mutations in ASIP [recessive black allele: g.100_105del (D₅ ) and/or g.5172T>A] were associated with black coat colour in Klövsjö and Roslag sheep breeds and mutations in both ASIP and MC1R (dominant black allele: c.218T>A and/or c.361G>A) were associated with black coat colour in Swedish Finewool. In Gotland, Gute, Värmland and Helsinge sheep breeds, coat colour inheritance was more complex: only 11 of 16 individuals with black fleece had genotypes that could explain their black colour. These breeds have grey individuals in their populations, and grey is believed to be a result of mutations and allelic copy number variation within the ASIP duplication, which could be a possible explanation for the lack of a clear inheritance pattern in these breeds. Finally, we found a novel missense mutation in MC1R (c.452G>A) in Gotland, Gute and Värmland sheep and evidence of a duplication of MC1R in Gotland sheep.

Disparity in oesophageal cancer management in South Africa: a comparison between two tertiary centres with special focus on the palliation of dysphagia

BACKGROUND

For most patients with oesophageal cancer worldwide, palliation of dysphagia is the goal which is most commonly achieved with self-expanding metal stents (SEMS). The aim of this study was to assess the profile and management of oesophageal cancer patients at Frere Hospital in the Eastern Cape, and compare this to a similar cohort from Groote Schuur Hospital (GSH) in the Western Cape Province.

METHOD

This study is a retrospective comparative cohort which reviewed all patients diagnosed with oesophageal cancer by the Frere Hospital and GSH endoscopy units from January to December 2015. Independent prospective electronic databases for the two hospitals were merged for comparative analysis.

RESULTS

During the study period, 346 and 108 patients were diagnosed with oesophageal cancer at Frere Hospital and GSH respectively. The rate of curative intended intervention was similarly low, with 3% of cases at Frere Hospital undergoing oesophagectomy or definitive radiotherapy as compared to 5% at GSH (p=0.48). In terms of palliation, significantly more patients received palliative oncological therapy at GSH as compared to Frere Hospital (21% vs 8%, p < 0.001). At Frere Hospital, 281 patients (81%) were treated primarily with serial dilatations. At GSH, 9 patients received a single dilatation, all as a bridge to radiotherapy or stenting. At Frere Hospital, 28 patients (8%) were stented, as compared to GHS where 69 patients (64%) were managed with a stent (p < 0.001).

CONCLUSION

This study shows significant differences in the oncological and endoscopic palliation of patients between the two institutions, highlighting a gross disparity in healthcare provision between them. The reasons for these disparities should be investigated and equipoise addressed by national health policy makers.

Hepatocellular carcinoma in sub-Saharan Africa - the way forward

Michael Kew's academic career spans five decades, representing the most proliferative and pioneering years of the expanded knowledge on all aspects of hepatocellular cancer (HCC). The preceding articles in this Festschrift bear testimony to his legacy, engagement, enthusiasm, dedication and ability to inspire others. His enormous contribution, mostly originating from research in sub-Saharan Africa (SSA), contributed immensely to the knowledge and evidence on which current understanding of the disease is based.

Resection of biliary mucinous cystic neoplasms of the liver: a prospective cohort series of 13 consecutive patients

BACKGROUND

Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation.

OBJECTIVE

To assess the outcome of surgical resection of BMCNs.

METHOD

A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome.

RESULTS

Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months.

CONCLUSION

BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit.

Distal malignant biliary obstruction: a prospective randomised trial comparing plastic and uncovered self-expanding metal stents in the palliation of symptomatic jaundice

BACKGROUND

The aim of this study was to determine the safety and clinical effectiveness of 10Fr plastic biliary stents compared to uncovered self-expanding metal stents (SEMS) for palliative treatment of patients with inoperable extra-hepatic malignant biliary obstruction in a public hospital in South Africa.

METHOD

From January 2009 to December 2013, 40 patients who were admitted to a tertiary academic centre because of distal malignant biliary obstruction were enrolled in a prospective randomized study. Patients were randomly assigned to receive an uncovered SEMS or a plastic stent deployed through the biliary stricture during endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Patient survival time in the two groups did not differ significantly (median: SEMS - 114 days; plastic - 107 days). Stent failure was more common in the plastic stent group (7/19 vs. 1/21). The results became significant after 6 months of follow-up. There was no significant difference between the two groups in the incidence of serious adverse events.

CONCLUSION

SEMS had a longer duration of patency than plastic stents, which recommends their use in the palliative treatment of patients with biliary obstruction due to distal malignant biliary obstruction.

Invited review: Breeding and ethical perspectives on genetically modified and genome edited cattle

The hot topic of genetic modification and genome editing is sometimes presented as a rapid solution to various problems in the field of animal breeding and genetics. These technologies hold potential for future use in agriculture but we need to be aware of difficulties in large-scale application and integration in breeding schemes. In this review, we discuss applications of both classical genetic modifications (GM) using vectors and genome editing in dairy cattle breeding. We use an interdisciplinary approach considering both ethical and animal breeding perspectives. Decisions on how to make use of these techniques need to be made based not only on what is possible, but on what is reasonable to do. Principles of animal integrity, naturalness, risk perception, and animal welfare issues are examples of ethically relevant factors to consider. These factors also influence public perception and decisions about regulations by authorities. We need to acknowledge that we lack complete understanding of the genetic background of complex traits. It may be difficult, therefore, to predict the full effect of certain modifications in large-scale breeding programs. We present 2 potential applications: genome editing to dispense with dehorning, and insertion of human genes in bovine genomes to improve udder health as an example of classical GM. Both of these cases could be seen as beneficial for animal welfare but they differ in other aspects. In the former case, a genetic variant already present within the species is introduced, whereas in the latter case, transgenic animals are generated-this difference may influence how society regards the applications. We underline that the use of GM, as well as genome editing, of farm animals such as cattle is not independent of the context, and should be considered as part of an entire process, including, for example, the assisted reproduction technology that needs to be used. We propose that breeding organizations and breeding companies should take an active role in ethical discussions about the use of these techniques and thereby signal to society that these questions are being responsibly addressed.

Resection of benign liver tumours: an analysis of 62 consecutive cases treated in an academic referral centre

BACKGROUND

Benign tumours of the liver are increasingly diagnosed and constitute a substantial proportion of all hepatic tumours evaluated and resected at tertiary referral centres. This study assessed the safety and outcome after resection of benign liver tumours at a major referral centre.

METHOD

All patients with symptomatic benign liver tumours who underwent resection were identified from a prospective departmental database of a total of 474 liver resections (LRs). Demographic data, operative management and morbidity and mortality using the Accordion classification were analysed.

RESULTS

Sixty-two patients (56 women, 6 men, median age 45 years, range 17-82) underwent resection of symptomatic haemangiomata n=23 (37.1%), focal nodular hyperplasia n=19 (30.6%), biliary cystadenoma n=16 (25.8%) and hepatic adenomas n=4 (6.5%). A major resection was required in 25 patients, 14 patients had 4 segments resected, 11 had 3 segments and 37 patients had 2 or fewer segments resected. Median operating time was 169 minutes (range 80-410). Median blood loss was 300 ml (range 50-4500 ml) and an intra-operative blood transfusion was required in 6 patients. Median length of post-operative hospital stay was 7 days (range 4-32). Complications occurred in 11 patients (Accordion grades 1 n=1, 2 n=4, 3 n=1, 4 n=4, 6 n=1). Four patients required re-operation (bleeding n=2, bile leak n=1, small bowel obstruction n=1). An elderly patient died in hospital on day 16 following a postoperative cerebrovascular accident.

CONCLUSION

Clinically relevant symptomatic benign liver tumours comprise a substantial proportion of LRs. Our data suggest that resections can be performed safely with minimal blood loss and transfusion requirements. We advocate selective resection according to established indications. Despite the low postoperative mortality rate, the risk of postoperative complications emphasizes the need for careful selection of patients for resection.

The management of pancreatic injuries

Pancreatic injuries are relatively uncommon, but considerable morbidity and mortality may result if associated vascular and duodenal injuries are present or if the extent of the injury is underestimated and appropriate intervention is delayed. Optimal management includes the need for early diagnosis and accurate definition of the site and extent of injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, the rapidity of resuscitation and the quality and appropriateness of surgical intervention. Early mortality results from uncontrolled or major bleeding due to associated injuries while late mortality is generally a consequence of infection or multiple organ failure. Initial management of pancreatic trauma is similar to that of any patient with a severe abdominal injury. Stable patients with a suspected pancreatic injury should have non-invasive imaging including a CT scan or MRI. Urgent laparotomy is required in patients with evidence of major intraperitoneal bleeding, associated visceral trauma, or peritonitis. Operative intervention is guided by the integrity of the main pancreatic duct. External drainage is adequate for parenchymal injuries with an intact duct, while duct injuries of the neck, body and tail require a distal pancreatectomy. Pancreatic head injuries are more complex. If the duodenum is reparable and the ampulla is intact, external drainage suffices. Rarely, complex injuries may require a pancreatoduodenectomy after damage control surgery if the patient has multiple injuries and is unstable. Postoperative pancreatic complications including fistula and pseudocysts are common but can usually be treated endoscopically.

Incidence and management of postoperative bile leaks: A prospective cohort analysis of 467 liver resections

BACKGROUND

Bile leaks from the parenchymal transection margin are a major cause of morbidity following major liver resections. The aim of this study was to benchmark the incidence and identify the risk factors for postoperative bile leakage after hepatic resection.

PATIENTS AND METHODS

A prospective database of 467 consecutive liver resections performed by the University of Cape Town HPB surgical unit between January 1990 and January 2016 was analysed. The relationship of demographic, clinical and perioperative factors to the development of bile leakage was determined. Bile leak and postoperative complications severity were graded using the International Study Group of Liver Surgery and Accordion classifications.

RESULTS

Overall morbidity was 24% (n = 112), with bile leaks occurring in 25 (5.4%) patients. Significantly more bile leaks occurred in patients who had major resections (≥ 3 segments) and longer total operative times (p < 0.05). There were 5 Grade A bile leaks which stopped spontaneously. Seventeen Grade B leaks required a combination of percutaneous drainage (n = 15), endoscopic biliary stenting (n = 8) and percutaneous transhepatic biliary drainage (n = 3). All 3 Grade C leaks required laparotomy for definitive drainage. Median hospital stay in the 442 patients without a bile leak was 8 days (IQR 1-98) compared with 12 days (IQR 6-30) for the 25 with bile leaks (p < 0.05) with no mortality. Major resections (≥ 3 segments) and total operative time (> 180mins) were significantly associated with bile leaks.

CONCLUSION

The incidence of bile leakage was 5.4% and occurred after major liver resections with longer operative times and resulted in significantly extended hospitalisation. Most were effectively treated nonoperatively by percutaneous drainage of the collection and/or endoscopic or percutaneous biliary drainage without mortality.

Instilling a culture of safety for laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred and most widely used method for removal of the gallbladder in patients with symptomatic cholelithiasis. Modern laparoscopic equipment provides better illumination and definition with the most recent generation processors and cameras offering the possibility of 3D visualization. The minimal access approach results in smaller wounds, less postoperative pain, faster recovery, shorter hospital stay and ultimately a better cosmetic result.1 The major disadvantage of LC, however, is the biliary complications associated with the procedure, the most serious of which is a major bile duct injury (BDI).2 Although the technique was introduced more than two decades ago, the incidence of BDIs has not decreased and still occurs in 0.4% of operations, a figure twice as high as recorded during the era of open cholecystectomy.3 A recent Swedish population-based study reporting a BDI rate of 1.5% suggests that the rates in the literature may be an underestimation, or more alarmingly, that BDI rates are increasing.

Severe post-pancreatoduodenectomy haemorrhage: An analytical review based on 118 consecutive pancreatoduodenectomy patients in a South African Academic Hospital

BACKGROUND

Bleeding after a major pancreatic resection, although uncommon, has serious implications and substantial mortality rates.

AIM

To analyse our experience with severe post-pancreatoduodenectomy haemorrhage (PPH) over the last 7 years to establish the incidence, causes, intervention required and outcome.

METHOD

All patients who underwent a pancreatoduodenectomy (PD) between January 2008 and December 2015 were identified from a prospectively maintained database. Data analysed included demographic information, operative details, anastomotic technique, histology, postoperative complications including pancreatic fistula and PPH, length of hospital stay, need for blood products and special investigations. Pancreatic fistula was classified according to the International Study Group of Pancreatic Surgery (ISGPS) classification. A modified ISGPS classification was used for PPH.

RESULTS

One hundred and eighteen patients underwent PD during the study period of whom 6 (5.0%) died perioperatively. Twenty patients (16.9%) developed a pancreatic fistula and 11 patients (9.3%) had a severe PPH of whom one (9.1%) died. No patients had a severe bleed during the first 24 hours postoperatively. Four patients bled within the first 5 days and the remaining 7 after five days. Six patients bled from the gastroduodenal artery and were all preceded by a pancreatic fistula. Three of the 7 patients who bled late presented with extraluminal bleeding, 3 presented with intraluminal bleeding and 1 with a combination of both. Patients presenting in the first 5 days were all successfully managed either endoscopically or surgically. Five patients who presented beyond 5 days postoperatively were managed primarily with interventional angiography, either with coiling or deployment of a covered stent. Three patients who had radiological intervention developed a liver abscess or necrosis.

CONCLUSION

Severe PPH is associated with substantial morbidity. Clinical factors including the onset of the bleeding, presentation with either extra and/or intraluminal haemorrhage, and the presence of a pancreatic fistula give an indication of the likely aetiology of the bleeding. A management algorithm based on these factors is presented.

Economic impact of suicidality in manic patients with depressive features

Introduction

There is limited information published on the specific financial costs of completed and/or attempted suicide in bipolar patients. In the last 15 years, only 6 studies were published. Their results vary considerably due to differences in methods used. Also, information on cost for pure manic versus mixed episodes is lacking. This is surprising, since studies have shown that suicidal behaviour is more common among patients with depressive symptoms than with pure mania, and this difference increases considerably when the mixed-features specifier is applied.

Objectives

We conducted a registry study with the aim to expand the epidemiological information on suicidal behaviour by episode type in bipolar disorder, and its associated costs.

Methods

Health data were retrieved from the Swedish Patient Register. Data covered the period 1990–2014 and included the number of discharged patients with bipolar diagnosis, hospital re-admissions, and attempted and/or completed suicides. Moreover, we retrieved data on suicide and cause of death from the Swedish Cause of Death register. Analyses were done for the whole sample and stratified by subtypes (mania, depression and mixed forms).

Results

First results will be presented at the EPA meeting.

Conclusions

This is a nation-wide Swedish study of completed and attempted suicide in bipolar patients. The hypothesis we will test is that there is a substantial variation between different bipolar disorder subtypes, and that most of the expenditures due to suicidal behaviour in bipolar disorder are linked to mixed forms, mania in combination with depression.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Fate of necrotic volume after microwave ablation of multiple liver metastases

BACKGROUND/AIMS

The aim of this study was to find the rate of shrinkage of necrosis and time of peak ablation volume after multiple microwave ablations in the treatment of multiple liver metastases of colorectal cancer. These factors are not known and are important in evaluation of treatment and identification of local recurrence, as microwave treatment is becoming more used thanks to improved technology in diagnostics and interventional therapy.

METHODOLOGY

A retrospective analysis of non-cirrhotic patients with multiple liver only metastases of colorectal cancer, not suited for resection for this reason. Patients were selected for palliative microwave treatment at a liver multidisciplinary team conference. 68 ablations were made in six patients. Ablation volume was analysed with repeated imaging and computer analyses.

RESULTS

The ablation volume peeks after 5-7 days where after reduction of the necrosis in the liver occurs logarithmically with a 60% reduction of ablation volume after 100 days and 80% after a year.

DISCUSSION

Liver regeneration after microwave ablations occurs at a constant logarithmic rate after an initial expansion of the ablation volume during the first five days. Evaluation of ablation volume in comparison to tumour volume must take this into account so that follow-up imaging is properly timed.

Randomized multicentre trial of gadoxetic acid-enhanced MRI versus conventional MRI or CT in the staging of colorectal cancer liver metastases

BACKGROUND

This multicentre international randomized trial compared the impact of gadoxetic acid-enhanced magnetic resonance imaging (MRI), MRI with extracellular contrast medium (ECCM-MRI) and contrast-enhanced computed tomography (CE-CT) as a first-line imaging method in patients with suspected colorectal cancer liver metastases (CRCLM).

METHODS

Between October 2008 and September 2010, patients with suspected CRCLM were randomized to one of the three imaging modalities. The primary endpoint was the proportion of patients for whom further imaging after initial imaging was required for a confident diagnosis. Secondary variables included confidence in the therapeutic decision, intraoperative deviations from the initial imaging-based surgical plan as a result of additional operative findings, and diagnostic efficacy of the imaging modalities versus intraoperative and pathological extent of the disease.

RESULTS

A total of 360 patients were enrolled. Efficacy was analysed in 342 patients (118, 112 and 112 with gadoxetic acid-enhanced MRI, ECCM-MRI and CE-CT respectively as the initial imaging procedure). Further imaging was required in 0 of 118, 19 (17.0 per cent) of 112 and 44 (39.3 per cent) of 112 patients respectively (P < 0.001). Diagnostic confidence was high or very high in 98.3 per cent of patients for gadoxetic acid-enhanced MRI, 85.7 per cent for ECCM-MRI and 65.2 per cent for CE-CT. Surgical plans were changed during surgery in 28, 32 and 47 per cent of patients in the respective groups.

CONCLUSION

The diagnostic performance of gadoxetic acid-enhanced MRI was better than that of CE-CT and ECCM-MRI as the initial imaging modality. No further imaging was needed in the gadoxetic acid-enhanced MRI group and comparison of diagnostic efficacy parameters demonstrated the diagnostic superiority of gadoxetic acid-enhanced MRI.

REGISTRATION NUMBER

NCT00764621(http://clinicaltrials.gov); EudraCT number: 2008-000583-16 (https://eudract.ema.europa.eu/).

QTL and association analysis for skin and fibre pigmentation in sheep provides evidence of a major causative mutation and epistatic effects

The pursuits of white features and white fleeces free of pigmented fibre have been important selection objectives for many sheep breeds. The cause and inheritance of non-white colour patterns in sheep has been studied since the early 19th century. Discovery of genetic causes, especially those which predispose pigmentation in white sheep, may lead to more accurate selection tools for improved apparel wool. This article describes an extended QTL study for 13 skin and fibre pigmentation traits in sheep. A total of 19 highly significant, 10 significant and seven suggestive QTL were identified in a QTL mapping experiment using an Awassi × Merino × Merino backcross sheep population. All QTL on chromosome 2 exceeded a LOD score of greater than 4 (range 4.4-30.1), giving very strong support for a major gene for pigmentation on this chromosome. Evidence of epistatic interactions was found for QTL for four traits on chromosomes 2 and 19. The ovine TYRP1 gene on OAR 2 was sequenced as a strong positional candidate gene. A highly significant association (P < 0.01) of grandparental haplotypes across nine segregating SNP/microsatellite markers including one non-synonymous SNP with pigmentation traits could be shown. Up to 47% of the observed variation in pigmentation was accounted for by models using TYRP1 haplotypes and 83% for models with interactions between two QTL probabilities, offering scope for marker-assisted selection for these traits.

Gd-EOB-DTPA-enhanced MRI for the assessment of liver function and volume in liver cirrhosis

OBJECTIVE

The aims of this study were to use dynamic hepatocyte-specific contrast-enhanced MRI to evaluate liver volume and function in liver cirrhosis, correlate the results with standard scoring models and explore the inhomogeneous distribution of liver function in cirrhotic livers.

METHODS

10 patients with liver cirrhosis and 20 healthy volunteers, serving as controls, were included. Hepatic extraction fraction (HEF), input relative blood flow and mean transit time were calculated on a voxel-by-voxel basis using deconvolutional analysis. Segmental and total liver volumes as well as segmental and total hepatic extraction capacity, expressed in HEFml, were calculated. An incongruence score (IS) was constructed to reflect the uneven distribution of liver function. The Mann-Whitney U-test was used for group comparison of the quantitative liver function parameters, liver volumes and ISs. Correlations between liver function parameters and clinical scores were assessed using Spearman rank correlation.

RESULTS

Patients had larger parenchymal liver volume, lower hepatocyte function and more inhomogeneous distribution of function compared with healthy controls.

CONCLUSION

The study demonstrates the non-homogeneous nature of liver cirrhosis and underlines the necessity of a liver function test able to compensate for the heterogeneous distribution of liver function in patients with diseased liver parenchyma.

ADVANCES IN KNOWLEDGE

The study describes a new way to quantitatively assess the hepatic uptake of gadoxetate or gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid in the liver as a whole as well as on a segmental level.

Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses

BACKGROUND

Diagnostic errors can have tremendous consequences because they can result in a fatal chain of wrong decisions. Experts assume that physicians' desire to confirm a preliminary diagnosis while failing to seek contradictory evidence is an important reason for wrong diagnoses. This tendency is called 'confirmation bias'.

METHOD

To study whether psychiatrists and medical students are prone to confirmation bias and whether confirmation bias leads to poor diagnostic accuracy in psychiatry, we presented an experimental decision task to 75 psychiatrists and 75 medical students.

RESULTS

A total of 13% of psychiatrists and 25% of students showed confirmation bias when searching for new information after having made a preliminary diagnosis. Participants conducting a confirmatory information search were significantly less likely to make the correct diagnosis compared to participants searching in a disconfirmatory or balanced way [multiple logistic regression: odds ratio (OR) 7.3, 95% confidence interval (CI) 2.53-21.22, p<0.001; OR 3.2, 95% CI 1.23-8.56, p=0.02]. Psychiatrists conducting a confirmatory search made a wrong diagnosis in 70% of the cases compared to 27% or 47% for a disconfirmatory or balanced information search (students: 63, 26 and 27%). Participants choosing the wrong diagnosis also prescribed different treatment options compared with participants choosing the correct diagnosis.

CONCLUSIONS

Confirmatory information search harbors the risk of wrong diagnostic decisions. Psychiatrists should be aware of confirmation bias and instructed in techniques to reduce bias.

Investigation into association and expression of PLCz and COX-2 as candidate genes for boar sperm quality and fertility

Phospholipase C zeta (PLCz) and cyclooxygenase isoenzyme type 2 (COX-2) are important in spermatogenesis, but their effect has not yet confirmed in pigs. Therefore, this study was aimed to analyse their association with sperm quality and fertility and to identify the mRNA and protein expression in boars reproductive tissues. DNA samples from 231 Pietrain (PI) and 109 Pietrain × Hampshire (PIHA) pigs with records of sperm quality [sperm concentration (SCON), motility, semen volume, plasma droplet and abnormal spermatozoa rate] and fertility (non-return rate and number of piglet born alive) traits were available. A SNP in non-coding region of PLCz g.158 A > C was associated with SCON (p < 0.05) in PIHA population while the polymorphism of COX-2 g.68 G > A in 3' UTR was not associated with any traits. For mRNA and protein expression study, a total of six boars were divided into two groups with G-I and G-II, where G-I was characterized for relatively better sperm quality. Both genes expressed higher in reproductive tissues compared with non-reproductive tissues. Phospholipase C zeta mRNA expressed higher in testis (p < 0.01), all parts of epididymis and spermatozoa from G-I, while COX-2 expressed higher in testis (p < 0.05), head and body of epididymis (p < 0.01), and spermatozoa from G-II boar. Both proteins were localized in Leydig cells and spermatozoa. These results might shed light on roles of these genes in spermatogenesis as candidate for boar sperm quality and fertility, but still the lack of association across populations should be considered.

Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986-2006 in Sweden

AIMS/HYPOTHESIS

Symptomatic hypoglycaemia with related confusion, syncope, epilepsy or seizures is a newly recognised complication of gastric bypass surgery for obesity. The incidence of these conditions is not known. We therefore studied the incidence of post-gastric bypass hypoglycaemia and related symptoms in patients who have undergone gastric bypass and a reference cohort from the general population of Sweden.

METHODS

This is a nationwide cohort study based on national registries with 5,040 persons who underwent gastric bypass, vertical banded gastroplasty or gastric banding for obesity in Sweden between 1 January 1986 and 31 December 2006 and a cohort of ten referents per patient matched for sex and age randomly sampled from the general population. The incidence rates of hospitalisation for hypoglycaemia, confusion, syncope, epilepsy or seizures before and after dates of surgery or inclusion in the reference cohort were studied.

RESULTS

Preoperative incidences of hospitalisation for hypoglycaemia were similar in the surgical and referent cohorts. After gastric bypass surgery, the adjusted hazard ratios were significantly elevated for hypoglycaemia (2.7 [95% CI 1.2-6.3]), confusion (2.8 [1.3-6.0]), syncope (4.9 [3.4-7.0]), epilepsy (3.0 [2.1-4.3]) and seizures (7.3 [5.0-10.8]). The proportions of gastric bypass patients and reference participants affected by hypoglycaemia were very low (0.2% and 0.04%, respectively). There was no increased risk of hypoglycaemia after vertical banded gastroplasty or gastric banding compared with the referent population.

CONCLUSIONS/INTERPRETATION

Obese persons who have undergone gastric bypass have an increased risk of hospitalisation for diagnoses associated with post-gastric bypass hypoglycaemia, although few patients are affected.

Health-economic evaluation of three imaging strategies in patients with suspected colorectal liver metastases: Gd-EOB-DTPA-enhanced MRI vs. extracellular contrast media-enhanced MRI and 3-phase MDCT in Germany, Italy and Sweden

The purpose of this study was to perform an economic evaluation of hepatocyte-specific Gd-EOB-DTPA enhanced MRI (PV-MRI) compared to extracellular contrast-media-enhanced MRI (ECCM-MRI) and three-phase-MDCT as initial modalities in the work-up of patients with metachronous colorectal liver metastases. The economic evaluation was performed with a decision-tree model designed to estimate all aggregated costs depending on the initial investigation. Probabilities on the need for further imaging to come to a treatment decision were collected through interviews with 13 pairs of each a radiologist and a liver surgeon in Germany, Italy and Sweden. The rate of further imaging needed was 8.6% after initial PV-MRI, 18.5% after ECCM-MRI and 23.5% after MDCT. Considering the cost of all diagnostic work-up, intra-operative treatment changes and unnecessary surgery, a strategy starting with PV-MRI with 959 Euro was cost-saving compared to ECCM-MRI (1,123 Euro) and MDCT (1,044 Euro) in Sweden. In Italy and Germany, PV-MRI was cost-saving compared to ECCM-MRI and had total costs similar to MDCT. In conclusion, our results indicate that PV-MRI can lead to cost savings by improving pre-operative planning and decreasing intra-operative changes. The higher cost of imaging with PV-MRI is offset in such a scenario by lower costs for additional imaging and less intra-operative changes.

How psychiatrists inform themselves and their patients about risks and benefits of antipsychotic treatment

OBJECTIVE

In order to choose the best treatment option, physicians have to inform themselves and their patients about both the benefits and risks of available treatment options equally. Our study aims to investigate whether psychiatrists actually do conduct such a balanced information search and presentation.

METHOD

Psychiatrists' information search and information presentation to a patient with schizophrenia were studied using two separate experiments. In both, participants were presented with hypothetical case vignettes and descriptions of fictitious antipsychotics.

RESULTS

When searching for information, psychiatrists looked more for risks than benefits of antipsychotic treatment options (t = -3.4, df = 74, P = 0.001). However, when informing a patient, they named more benefits than risks (t = 17.1, df = 224, P < 0.001).

CONCLUSION

The risk-biased information search presumably follows the principle of 'primum non nocere'. The benefit-biased information presentation might be motivated by the wish to persuade patients to accept the proposed therapy.

Evidence for association of lymphoid enhancer-binding factor-1 (LEF1) with the number of functional and inverted teats in pigs

The lymphoid enhancer-binding factor-1 (LEF1) belongs to a family of regulatory proteins that share homology with the high mobility group protein-1 (HMG1). The LEF1 gene is a mediator in the canonical Wnt-signalling pathway required for morphogenesis of early mammary gland during embryogenesis. Here we describe the molecular characterisation of the porcine LEF1 gene and its association with number of teats and inverted teats in experimental and commercial populations. The 2357-bp cDNA sequence contains an 1197-bp open reading frame encoding a protein of 398 amino acids. The porcine LEF1 protein shares high identity with LEF1 in other mammalian species. The LEF1 gene contains 12 exons and maps to pig chromosome 8 (SSC8). We identified two single nucleotide polymorphisms (SNPs), a T1351C transition and an A1666C transversion, in the 3' end of LEF1. Associations of the SNP A1666C with presence of inverted teats (P<or= 0.01), total number of teats (P <or= 0.01) and total number of inverted teats (P <or= 0.01) were highly significant; SNP T1351C showed near significance with total number of inverted teats (P <or= 0.1) in the experimental DUMI population. SNP T1351C was significantly associated with total number of inverted teats (P= 0.04) and close to significance with affected teats (P = 0.06) in commercial populations. Haplotype analysis confirmed the tendency towards association with affected teats (P = 0.06) in the experimental DUMI population. The function, position, and associations shown here promote LEF1 as a candidate gene for number of teats and in particular for presence and number of inverted teats.

SNP analysis, genotyping and mapping of the porcine <i>GPCR142</i> gene (Brief report)

Abstract. The RLN3 gene has been recently reported as a ligand for two related orphan G protein-coupled receptors, GPCR135 and GPCR142 (BATHGATE et al., 2002; LIU et al., 2003a; LIU et al., 2003b; CHEN et al., 2005). Pharmacological studies of the GPCR142 gene indicated that the RLN3 gene is the only member of the RLN family showing the ability to activate this gene (BATHGATE et al., 2002). The GPCR142 gene contains a single exon and is located on chromosome 1 (1q22) in human (FREDRIKSSON et al., 2003). It is expressed abundantly in the hypothalamus with discrete expression in the paraventricular nucleus of the hypothalamus and supraoptic nucleus; as well as in the cortex, septal nucleus and preoptical area (LIU et al., 2003b). The functional roles of the RLN3 gene and its receptors within the mammalian physiology are still unclear. The objectives of this study were to characterize the GPCR142 gene in pigs, to determine the chromosomal location and to analysis the expression profile in pigs.

Sterilized Mosquito Net versus Commercial Mesh for Hernia Repair

BACKGROUND

In industrialized countries alloplastic meshes are routinely used for hernia repair. However, in developing countries they are rarely available or affordable. This study compares textile properties and tissue response of commercial polypropylene mesh (PM) vs. sterilized nylon mosquito net (MN).

METHODS

Textile properties were examined in vitro. In 12 goats one MN and one PM (5.5 x 8 cm) were implanted onto the posterior layer of the rectus sheath. Wound healing was clinically assessed. Histology was assessed after 4 or 16 weeks.

RESULTS

MN was thinner and lighter, but weaker than PM. All wounds healed without complications. After 16 weeks foreign body granulomas in the MN group contained a higher proportion of inflammatory tissue (32.7 vs. 22.1%) and more giant cells (3.1 vs. 1.7/10 granulomas) with a significantly lower partial volume of foreign body (23.2 vs. 36.9%). Partial volume of fibrotic tissue was similar. MN was 1,000-fold cheaper than PM.

CONCLUSIONS

PM was superior concerning strength and extent of inflammatory response. However, the findings indicate that MN might serve as a cheap substitute if an alloplastic mesh is needed but no commercial one is available or affordable. Further studies are justified which should include mosquito nets of different materials and long-term outcome.

CT colonography versus colonoscopy in the follow-up of patients after diverticulitis - a prospective, comparative study

AIM

To assess whether computed tomography colonography (CTC) is a viable alternative to colonoscopy or double contrast barium enema in the follow-up of patients after diverticulitis.

MATERIAL AND METHODS

Fifty patients underwent CTC followed immediately by colonoscopy. Results were blinded to the examiners. Findings of diverticular disease and patient acceptance were evaluated.

RESULTS

Bowel preparation and distension were good in the majority of CTC and colonoscopy examinations. Diverticular disease was found in 96% of patients at CTC and in 90% at colonoscopy. The rate of agreement between CTC and colonoscopy for diverticular findings in the sigmoid colon was good (kappa=0.64). No complications were seen. Patients found colonoscopy more uncomfortable (p<0.03), more painful (p<0.001), and more difficult (p<0.01) than CTC. Of the patients favouring one examination, 74% preferred CTC.

CONCLUSION

CTC appears to have a better diagnostic potential for imaging of diverticular disease-specific findings, when compared with colonoscopy. Also, CTC was less uncomfortable and was preferred by a majority of patients. CTC seems to be a reasonable alternative in follow-up of patients with symptomatic diverticular disease.

Measurement of spin-correlation parameters ANN, ASS, and ASL at 2.1 GeV in proton-proton elastic scattering

At the Cooler Synchrotron COSY/Jülich spin-correlation parameters in elastic proton-proton (pp) scattering have been measured with a 2.11 GeV polarized proton beam and a polarized hydrogen atomic beam target. We report results for A(NN), A(SS), and A(SL) for c.m. scattering angles between 30 degrees and 90 degrees. Our data on A(SS)--the first measurement of this observable above 800 MeV--clearly disagrees with predictions of available pp scattering phase-shift solutions while A(NN) and A(SL) are reproduced reasonably well. We show that in the direct reconstruction of the scattering amplitudes from the body of available pp elastic scattering data at 2.1 GeV the number of possible solutions is considerably reduced.