The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) who have had a total colectomy remain with their rectum in situ, and are therefore at risk of rectal carcinoma. It is not clear how high the incidence of rectal cancer is in this cohort. The primary objective of this meta-analysis was to estimate the incidence of rectal cancer in patients with ulcerative colitis or Crohn's disease who have undergone colectomy but have a residual rectum, and to identify the risk factors for its development. In doing so, we explore the current recommendations for screening processes for these patients.

METHODS

A systematic review of the literature was performed. Five databases (Medline, Embase, Pubmed, Cochrane Library and Scopus) were searched from inception to 29 October 2021, to identify studies adhering to the population, intervention, control and outcomes (PICO) criteria. The included studies were critically appraised, and the relevant data was extracted. Cancer incidence was estimated from the reported information. Risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines.

RESULTS

Data from 23 of the 24 identified studies was suitable for analysis. The pooled incidence of rectal carcinoma was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a de-functioned rectal stump and ileorectal anastomosis, respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2, 95% CI 2.4-21.1). Patients with previous colorectal dysplasia were also at higher risk (RR 5.1, 95% CI 3.1-8.2). No universal standardised guidance regarding screening for this cohort could be identified in the available literature.

CONCLUSIONS

The overall risk of malignancy was estimated to be 1.3%, which is lower than previously reported. There is a need for clear and standardised screening guidance for this group of patients.

Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials

PURPOSE

Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques.

METHODS

We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool.

RESULTS

We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence.

CONCLUSION

Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

Using value chain and trade networks in the Eastern Cape Province of South Africa, as a basis for targeted rural chicken surveillance

Despite the benefits of rural chickens in the Eastern Cape Province (ECP) of South Africa, this sector is still underdeveloped and poorly surveyed for poultry diseases. The lack of a sustainable poultry disease surveillance system coupled with communities and practices where the interactions between birds are high, emphasize the need for targeted surveillance of chicken diseases in the province. However, to set up such a system requires knowledge of the value chain and trade networks. Consequently, a survey, which involved a rural chicken value chain analysis that also included an assessment of trading practices to identify biosecurity hotspots and an identification of barriers to market entry for rural farmers was conducted. Secondly, a social network analysis of chicken movements in the province was carried out to identify trade hubs that could be targeted for disease surveillance based on their centrality within the network and their size and influence within their ego networks. Traders and their transport vehicles were identified as biosecurity hotspots that could be targeted for disease surveillance within the chain. Social network analysis identified three municipalities viz. Umzimvubu, King Sabata Dalindyebo (KSD) and Enoch Mgijima as trade hubs where interaction between rural chickens occurs and resources can be focused. The movement of spent hens from commercial operations that are transported over long distances and distributed in the rural areas and townships were a major risk for spread of poultry diseases. This is the first study to formally describe chicken trade networks within the province and the surrounding region. Its findings provide a model for cost effective targeted surveillance in the ECP and similar resource poor regions of the world. The study also provides insight into the profitability of rural chickens and a possible contribution to job creation and poverty alleviation once the barriers to market entry are lifted.

A review of pig and poultry diseases in the Eastern Cape Province of South Africa, 2000-2020

The informal poultry and pig sector in the Eastern Cape Province (ECP) of South Africa is of significant socio-economic importance as it sustains livelihoods and ensures food security; yet little is known about the distribution and prevalence of infectious and zoonotic diseases in this region. This paper reviews data published for pig and poultry diseases in the province during the last 20 years (2000-2020). The review included relevant published papers identified by a computerised literature search from Web of Science; provincial animal health reports; the national database from the Department of Agriculture, Land Reform and Rural Development (DALRRD); animal health reports submitted by DALRRD to the World Organisation for Animal Health (OIE) via the World Animal Health Information Database (WAHID) interface and laboratory records. A publication was considered eligible if it included qualitative or quantitative information on any disease affecting pigs and poultry including zoonosis. The search retrieved 174 publications, of which 26 were relevant. The review found that Newcastle disease (ND), coccidiosis and fowl pox (FP) were the most reported avian diseases in the national database, whereas avian infectious bronchitis (AIB), ND and highly pathogenic avian influenza (HPAI) were the most reported diseases in the OIE database. Classical swine fever (CSF) was the most reported pig disease in both databases. The retrieved literature on pig and poultry diseases was scarce and no longer up to date, providing decision makers with little information. The review identified important zoonotic diseases that require further studies yet failed to find information on important neglected diseases like leptospirosis.

Improved outcomes for patients undergoing colectomy for acute severe inflammatory colitis by adopting a multi-disciplinary care bundle

PURPOSE

Severe inflammatory colitis as a consequence of inflammatory bowel disease (IBD) may not be amenable to medical management, and surgery is often required. The optimal timing of surgery and perioperative therapeutic care requires a formal link between surgical department and gastroenterology which is often lacking. In this study, we assess the impact of adopting a multidisciplinary care bundle on complication rates of subtotal colectomy in IBD patients.

METHODS

This is a single-centre retrospective observational study. Patients were identified through clinical discharge ICD10 codes. Clinical notes of patients who underwent subtotal colectomies from 1 January 2006 to 31 December 2019 were analysed. Socio-demographics, diagnosis, and medical and surgical management data were collected. A multimodule bundle, including weekly MDT discussions, was started in our unit on 1 April 2014. Multivariable logistic regression analysis was performed on these data.

RESULTS

A total of 296 patients were identified with 113 patients of these (38.2%) experiencing a complication post operation. The overall complication rate improved over time (p = 0.023). Those patients treated after the initiation of the MDT bundle had reduced complication rates (44.6% versus 33.7%, p = 0.045). On multivariate analysis, increasing age (1.023 OR; 95% CI 1.004, 1.041) and procedure performed before MDT bundle (3.1 OR; 95% CI 1.689, 5.723) were independent predictors for post-operative complications.

CONCLUSIONS

Closer links between gastroenterology and colorectal specialties have improved patient outcomes in our unit. Whilst IBD MDTs have previously been shown to improve outcomes for patients managed medically, we demonstrate that this interaction, implemented as a multidisciplinary care bundle, also improves surgical outcomes.

A study of rural chicken farmers, diseases and remedies in the Eastern Cape province of South Africa

The source of emerging diseases and antimicrobial resistance is of increasing interest to epidemiologists. This paper looks at village chickens as such a source. In addition, infectious diseases constitute a major challenge to the growth and profitability of the rural poultry sector in Sub-Saharan Africa. A serological survey was conducted to estimate the apparent seroprevalence of selected chicken diseases in the Eastern Cape Province of South Africa alongside a sociological survey of poultry farmers and the remedies most commonly used to prevent diseases in their flocks. Sera collected from village chickens (n = 1007) in the province were screened for specific antibodies against Newcastle disease (ND), avian influenza (AI), avian infectious bronchitis (IB) and Mycoplasma gallisepticum (MG). The overall seroprevalence of ND, AI, IB and MG in the province was found to be 69.2 % (95 % CI 51.9-86.5%); 1.8 % (95 % CI 0.2-3.4%); 78.5 % (95 % CI 74.9-82%) and 55.8 % (95 % CI 41.3-70.3%) respectively with clustering found at the District level. Cross hemagglutination inhibition (HI) tests indicated that the chickens were exposed to the ND vaccine. AI ELISA-positive samples were tested using HIs against the H5, H6 and H7-subtypes, but only H6-specific antibodies were detected. Avian influenza strains shared the common ancestor responsible for the 2002 chicken outbreak in KwaZulu-Natal Province. The majority of chicken farmers were females and pensioners (69 % and 66.1 % respectively) and had a primary school education (47.1 %). Traditional remedies were commonly used by farmers (47.15 %) and among the remedies, Aloe plant (Aloe ferox Mill.) or ikhala (Xhosa) was the most commonly used product (28.23 %) for preventing and reducing mortalities among village chickens. The findings stress the importance of village chickens as a substitute for social welfare and highlight the exposure of village chickens to important chicken pathogens. The economic impact of these pathogens on the development of this sub-sector needs further investigation. Village chickens are a potential source of virulent Newcastle disease virus (NDV) because of the lack of vaccination and biosecurity. They may serve as amplification hosts which increases the probability that virulent NDV could spill over into commercial poultry flocks due to large amounts of circulating virus. The zoonotic threat of circulating H6N2 viruses raise concern due to their mutation and reassortment among chickens and a potential movement of infected birds within the province. Finally, the use of antibiotics by untrained chicken farmers constitute another major concern as it could serve as a source of antimicrobial resistance (AMR).

Causes of death after emergency general surgical admission: population cohort study of mortality

Background

A substantial number of patients treated in emergency general surgery (EGS) services die within a year of discharge. The aim of this study was to analyse causes of death and their relationship to discharge diagnoses, in patients who died within 1 year of discharge from an EGS service in Scotland.

Methods

This was a population cohort study of all patients with an EGS admission in Scotland, UK, in the year before death. Patients admitted to EGS services between January 2008 and December 2017 were included. Data regarding patient admissions were obtained from the Information Services Division in Scotland, and cross-referenced to death certificate data, obtained from the National Records of Scotland.

Results

Of 507 308 patients admitted to EGS services, 7917 died while in hospital, and 52 094 within 1 year of discharge. For the latter, the median survival time was 67 (i.q.r. 21–168) days after EGS discharge. Malignancy accounted for 48 per cent of deaths and was the predominant cause of death in patients aged over 35 years. The cause of death was directly related to the discharge diagnosis in 56.5 per cent of patients. Symptom-based discharge diagnoses were often associated with a malignancy not diagnosed on admission.

Conclusion

When analysed by subsequent cause of death, EGS is a cancer-based specialty. Adequate follow-up and close links with oncology and palliative care services merit development.

International validation of a risk prediction algorithm for patients with malignant colorectal polyps

AIM

The optimal management strategy for patients with endoscopically resected malignant colorectal polyps (MCP) has yet to be defined. The aim of this study was to validate a published decision-making tool, termed the Scottish Polyp Cancer Study (SPOCS) algorithm, on a large international population.

METHODS

The SPOCS algorithm allocates patients to risk groups based on just two variables: the polyp resection margin and the presence of lymphovascular invasion (LVI). The risk groups are termed low (clear margin, LVI absent), medium (clear margin, LVI present) or high (involved/non-assessable margin). The International Polyp Cancer Collaborative was formed to validate the algorithm on data from Australia, Denmark, UK and New Zealand.

RESULTS

In total, 1423 patients were included in the final dataset. 680/1423 (47.8%) underwent surgical resection and 108/680 (15.9%) had residual disease (luminal disease 8.8%, lymph node metastases 8.8%). The SPOCS algorithm classified 602 patients as low risk (in which 1.5% had residual disease), 198 patients as medium risk (in which 7.1% had residual disease) and 484 as high risk (in which 14.5% had residual disease) (P < 0.001, χ² test). Receiver operating characteristic curve analysis demonstrated good accuracy of the algorithm in predicting residual disease (area under the curve 0.732, 95% CI 0.687-0.778, P < 0.001). When patients were designated as low risk, the negative predictive value was 98.5%.

CONCLUSION

The SPOCS algorithm can be used to predict the risk of residual disease in patients with endoscopically resected MCPs. Surgery can be safely avoided in patients who have a clear margin of excision and no evidence of LVI.

Video consultation for new colorectal patients

AIM

For patients, an outpatient review can lead to a stressful journey to hospital with the resultant risks associated with breaching social distancing. Despite this, video consultations (VCs) have not been frequently used in colorectal practice. We assessed outcomes, including the economic and environmental impact, of a VC clinic for new colorectal referrals.

METHOD

This was a prospective observational study. Fifty consecutive patients attending a VC colorectal appointment were reviewed between March 2019 and February 2020. Face-to-face appointments during the same time period were also assessed. The distance, time, cost and carbon emissions of journeys were estimated using web-based resources. Estimated loss of earnings used data from the Office for National Statistics. The subsequent management plans were also recorded.

RESULTS

Of 50 patients using VC, 40 used home devices and 10 used equipment in their local medical facility. Three patients had difficulties with the technology and converted to telephone review. Failure to attend VC appointments was less than for face-to-face appointments (4% vs 6.1%). VC appointments saved 6685 miles of travel (range 2-364 miles), 148 h travelling time and £1767 costs. Additional savings for loss of earnings were approximately £33.56 per patient. The carbon emissions saved was 4659 lb CO₂ equivalent, corresponding to over 250 000 charges of a smartphone.

CONCLUSION

The use of VC resulted in significant savings related to travel and reduced time and costs for patients who chose to use the service, in addition to the environmental benefits. In this current climate VC clinics have a central role in outpatient care for both new patients and follow-ups.

Colon capsule endoscopy

There are multiple indications for luminal imaging of the colon. From assessment of known disease, to diagnosing new pathology; intra-luminal visualisation is the mainstay of gastrointestinal diagnosis. Colonoscopy and radiological imaging are currently the most frequently deployed diagnostic methods. However, both have an associated risk profile, have significant resource pressures and are not universally tolerated. Colon capsule endoscopy (CCE) offers an adjunct to these diagnostic options. In this narrative review the utility of CCE is described. Its current uses, potential benefits and future developments are also discussed.

Twenty-year study of in-hospital and postdischarge mortality following emergency general surgical admission

Background

Emergency general surgery (EGS) patients have a higher mortality than those having elective surgery. Few studies have investigated changes in EGS-associated mortality over time or explored mortality rates after discharge. The aim of this study was to conduct a comprehensive, population-based analysis of mortality in EGS patients over a 20-year time frame.

Methods

This was a cross-sectional study of all adult EGS admissions in Scotland between 1996 and 2015. Data were obtained from national records. Co-morbidities were defined by Charlson Co-morbidity Index, and operations were coded by OPCS-4 classifications. Linear and multivariable logistic regression models were used to evaluate changes over time.

Results

Among 1 450 296 patients, the overall inpatient, 30-day, 90-day and 1-year mortality rates were 1·8, 3·8, 6·4 and 12·5 per cent respectively. Mortality was influenced by age at admission, co-morbidity, operation performed and date of admission (all P < 0·001), and improved with time on subgroup analysis by age, co-morbidity and operation status. Medium-term mortality was high: the 1-year mortality rate in patients aged over 75 years was 35·6 per cent. The 1-year mortality rate in highly co-morbid patients decreased from 75·1 to 57·1 per cent over the time frame of the study (P < 0·001).

Conclusion

Mortality after EGS in Scotland has reduced significantly over the past 20 years. This analysis of medium-term mortality after EGS admission demonstrates strikingly high rates, and postdischarge death rates are higher than is currently appreciated.

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist

Background

The WHO Surgical Safety Checklist has been implemented widely since its launch in 2008. It was introduced in Scotland as part of the Scottish Patient Safety Programme (SPSP) between 2008 and 2010, and is now integral to surgical practice. Its influence on outcomes, when analysed at a population level, remains unclear.

Methods

This was a population cohort study. All admissions to any acute hospital in Scotland between 2000 and 2014 were included. Standardized differences were used to estimate the balance of demographics over time, after which interrupted time-series (segmented regression) analyses were performed. Data were obtained from the Information Services Division, Scotland.

Results

There were 12 667 926 hospital admissions, of which 6 839 736 had a surgical procedure. Amongst the surgical cohort, the inpatient mortality rate in 2000 was 0·76 (95 per cent c.i. 0·68 to 0·84) per cent, and in 2014 it was 0·46 (0·42 to 0·50) per cent. The checklist was associated with a 36·6 (95 per cent c.i. –55·2 to –17·9) per cent relative reduction in mortality (P &lt; 0·001). Mortality rates before implementation were decreasing by 0·003 (95 per cent c.i. –0·017 to +0·012) per cent per year; annual decreases of 0·069 (–0·092 to –0·046) per cent were seen during, and 0·019 (–0·038 to +0·001) per cent after, implementation. No such improvement trends were seen in the non-surgical cohort over this time frame.

Conclusion

Since the implementation of the checklist, as part of an overall national safety strategy, there has been a reduction in perioperative mortality.

Meta-analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis

Background

It is not clear whether laparoscopic transcystic exploration (LTCE) laparoscopic choledochotomy (LCD) is superior in the management of choledocholithiasis. In this meta‐analysis, the success of LTCE versus LCD was evaluated.

Methods

Cochrane Central Register of Controlled Trials, Web of Science, Trip, PubMed, Ovid and Embase databases were searched systematically for relevant literature up to May 2017. Studies that compared the success rate of LTCE and LCD in patients with choledocholithiasis were included. PRISMA guidelines were followed. Multiple independent reviewers contributed on a cloud‐based platform. Random‐effects model was used to calculate odds ratios (ORs) or standardized mean differences (MDs) with 95 per cent confidence intervals. An a priori hypothesis was generated based on clinical experience that LTCE is as successful as LCD.

Results

Of 3533 screened articles, 25 studies comprising 4224 patients were included. LTCE achieved a lower duct clearance rate than LCD (OR 0.38, 95 per cent c.i. 0·24 to 0·59). It was associated with a shorter duration of surgery (MD −0·86, 95 per cent c.i. −0·97 to −0·77), lower bile leak (OR 0·46, 0·23 to 0·93) and shorter hospital stay (MD −0·78, −1·14 to −0·42) than LCD. There was no statistically significant difference in conversion, stricture formation or reintervention rate.

Conclusion

LCD has a higher rate of successful duct clearance, but is associated with a longer duration of surgery and hospital stay, and a higher bile leak rate.

Prognostic value of tumour regression grade in locally advanced rectal cancer: a systematic review and meta-analysis

AIM

The current standard of care for locally advanced rectal cancer involves neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision. There is a spectrum of response to neoadjuvant therapy; however, the prognostic value of tumour regression grade (TRG) in predicting disease-free survival (DFS) or overall survival (OS) is inconsistent in the literature.

METHOD

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was undertaken using Ovid MEDLINE, Embase and Google Scholar. Inclusion criteria were Stage II and III locally advanced rectal cancer treated with long-course CRT followed by radical surgery. The aim of the meta-analysis was to assess the prognostic implication of each TRG for rectal cancer following neoadjuvant CRT. Long-term prognosis was assessed. The main outcome measures were DFS and OS. A random effects model was performed to pool the hazard ratio (HR) from all included studies.

RESULTS

There were 4875 patients from 17 studies, with 775 (15.9%) attaining a pathological complete response (pCR) and 719 (29.9%) with no response. A significant association with OS was identified from a pooled-estimated HR for pCR (HR = 0.47, P = 0.002) and nonresponding tumours (HR = 2.97; P < 0.001). Previously known tumour characteristics, such as ypN, lymphovascular invasion and perineural invasion, were also significantly associated with DFS and OS, with estimated pooled HRs of 2.2, 1.4 and 2.3, respectively.

CONCLUSION

In conclusion, the degree of TRG was of prognostic value in predicting long-term outcomes. The current challenge is the development of a high-validity tests to predict pCR.

An evidence-based treatment algorithm for colorectal polyp cancers: results from the Scottish Screen-detected Polyp Cancer Study (SSPoCS)

OBJECTIVES

Colorectal polyp cancers present clinicians with a treatment dilemma. Decisions regarding whether to offer segmental resection or endoscopic surveillance are often taken without reference to good quality evidence. The aim of this study was to develop a treatment algorithm for patients with screen-detected polyp cancers.

DESIGN

This national cohort study included all patients with a polyp cancer identified through the Scottish Bowel Screening Programme between 2000 and 2012. Multivariate regression analysis was used to assess the impact of clinical, endoscopic and pathological variables on the rate of adverse events (residual tumour in patients undergoing segmental resection or cancer-related death or disease recurrence in any patient). These data were used to develop a clinically relevant treatment algorithm.

RESULTS

485 patients with polyp cancers were included. 186/485 (38%) underwent segmental resection and residual tumour was identified in 41/186 (22%). The only factor associated with an increased risk of residual tumour in the bowel wall was incomplete excision of the original polyp (OR 5.61, p=0.001), while only lymphovascular invasion was associated with an increased risk of lymph node metastases (OR 5.95, p=0.002). When patients undergoing segmental resection or endoscopic surveillance were considered together, the risk of adverse events was significantly higher in patients with incomplete excision (OR 10.23, p<0.001) or lymphovascular invasion (OR 2.65, p=0.023).

CONCLUSION

A policy of surveillance is adequate for the majority of patients with screen-detected colorectal polyp cancers. Consideration of segmental resection should be reserved for those with incomplete excision or evidence of lymphovascular invasion.

Variability in the prescribing of intravenous fluids: A cross sectional multicentre analysis of clinical practice

AIMS

Intravenous (IV) fluid administration continues to be a mainstay of care in General Surgery. Yet if they are prescribed incorrectly significant morbidity including electrolyte abnormalities, renal impairment and cardiac failure can develop. Despite this, it is frequently the responsibility of the most junior staff to prescribe IV fluids. We aim to analyse the understanding of IV fluid prescribing amongst junior doctors and to describe variability in clinical practice.

METHODS

We undertook a multicentre questionnaire study. Foundation doctors and specialty trainees were invited to undertake a two part paper-based questionnaire. Part one analysed baseline knowledge of the concentration of commonly prescribed fluids. Part two consisted of four clinical vignettes requiring a IV fluid prescribing decision by the surveyed doctor.

RESULTS

A total of 143 Doctors working in 8 hospitals were recruited. 65 (45.5%) doctors correctly stated the daily maintenance fluid requirements of water for an adult (25-30 mls/kg/day), while only 54 (37.8%) knew the sodium concentration of 0.9% NaCl. Lack of postgraduate experience (p = 0.011), qualifying from a medical school outside the United Kingdom (p < 0.0001) and working in one of the eight hospitals in this study (p < 0.0001) were associated with a lower knowledge level. There was limited consensus in prescribing in the responses to the 4 clinical scenarios, with 69 unique combinations of fluid choice, rate and volume prescribed.

CONCLUSIONS

Knowledge of the constituents of common IV fluids and routine requirement for fluid and common electrolytes is poor across junior doctors of all grades, driving large variation in clinical practice.

A retrospective study and predictive modelling of Newcastle Disease trends among rural poultry of eastern Zambia

Newcastle Disease (ND) is a highly infectious disease of poultry that seriously impacts on food security and livelihoods of livestock farmers and communities in tropical regions of the world. ND is a constant problem in the eastern province of Zambia which has more than 740 000 rural poultry. Very few studies give a situational analysis of the disease that can be used for disease control planning in the region. With this background in mind, a retrospective epidemiological study was conducted using Newcastle Disease data submitted to the eastern province headquarters for the period from 1989 to 2014. The study found that Newcastle Disease cases in eastern Zambia followed a seasonal and cyclic pattern with peaks in the hot dry season (Overall Seasonal Index 1.1) as well as cycles every three years with an estimated provincial incidence range of 0.16 to 1.7% per year. Annual trends were compared with major intervention policies implemented by the Zambian government, which often received donor support from the international community during the study period. Aid delivered through government programmes appeared to have no major impact on ND trends between 1989 and 2014 and reasons for this are discussed. There were apparent spatial shifts in districts with outbreaks over time which could be as a result of veterinary interventions chasing outbreaks rather than implementing uniform control. Data was also fitted to a predictive time series model for ND which could be used to plan for future ND control. Time series modelling showed an increasing trend in ND annual incidence over 25 years if existing interventions continue. A different approach to controlling the disease is needed if this trend is to be halted. Conversely, the positive trend may be a function of improved reporting by farmers as a result of more awareness of the disease.

Reduction of the intestinal endotoxin pool by three different SDD regimens in human volunteers

Aerobic Gram-negative bacilli (AGNB) carried in the gut by healthy individuals generate 1 mg of 'physiological' endotoxin per g of faeces. Successful eradication of AGNB from the gut would be expected to lead to a lowering of the intestinal endotoxin pool. This prompted us to evaluate the reduction of intestinal endotoxin in 6 healthy volunteers who each received 3 different oral antibiotic regimens. Regimen 1 was polymyxin E (600 mg/day), regimen 2 polymyxin E (400 mg/day) combined with tobramycin (320 mg/day) and regimen 3 pefloxacin (800 mg/day). Each regimen was separated by an antibiotic free period of 3 months. A faecal sample (minimally 2 g) was obtained from each volunteer, before treatment began and afterwards 3 times a week on alternating days (Monday, Wednesday, Friday) for 3 weeks. Each volunteer produced 30 samples, 10 each per oral antibiotic. The samples were serially diluted in nutrient broth for the colony count of AGNB, whilst endotoxin was measured using the classical Limulus amoebocyte lysate micro-assay. The base-line value of faecal AGNB was 10 3-4 colony forming units/g of faeces. All samples obtained on day 3 following antibiotic intake were negative for AGNB, and remained negative during antibiotic intake. The AGNB free carrier state was associated with a reduction in gut endotoxin. The reduction was approximately 10 ng (1 log) for polymyxin E and pefloxacin, whilst the combination of polymyxin/tobramycin significantly reduced the intestinal endotoxin concentrations from 1 mg to 100 ng in the gut; a reduction of 104. Although AGNB were killed by the three regimens, the 'free' endotoxin left in the gut was effectively neutralised by the combination polymyxin/tobramycin only. From a clinical point of view, gut-derived endotoxaemia may play a role in the systemic inflammatory response syndrome and hence the outcome, in critically ill intensive care patients. This study supports other work which indicates that mortality is significantly reduced in only those intensive care patients who received oral polymyxin/tobramycin.

Prognostic value of lymph node ratio and extramural vascular invasion on survival for patients undergoing curative colon cancer resection

Background:

Increasing lymph node ratio (LNR) (ratio of metastatic lymph nodes to the total number of harvested lymph nodes) and extramural vascular invasion (EMVI) have been proposed as adverse prognostic indicators in colorectal cancer, although their use remains variable and controversial. The aim of the present study was to assess the prognostic value of LNR and EMVI in predicting survival for patients undergoing curative colon cancer resection.

Methods:

Between 2006 and 2012, 922 patients underwent curative colon cancer resection. Surgical technique and pathological assessment did not change during the study period. Clinical and pathological data were collected from a prospectively maintained database. The primary outcome measure was overall survival and disease-free survival. LNR was separated into five categories based on three previously calculated cutoff values: LNR 0 (no lymph nodes involved), LNR 1 (ratio 0.01<0.17), LNR 2 (ratio 0.18–0.41), LNR 3 (ratio 0.42–0.69), and LNR 4 (ratio >0.70).

Results:

Nine hundred and twenty-two patients underwent colon cancer resection. The median follow-up for survivors was 52.8 months (IQR 34.6–77.6). The median total number of lymph nodes harvested was 16 (IQR13-22). On multivariate analysis, both pN and LNR were strongly associated with overall and disease-free survival. Using the Akaike information criterion (AIC), LNR had greater prognostic value compared with pN. For overall survival, compared with patients in LNR category 0, hazard ratios (95% CI) for those in categories 1, 2, 3 and 4 were 1.37 (1.03,1.82), 2.37 (1.70,3.30), 2.40 (1.57,3.65) and 5.51 (3.16,9.58), respectively. For disease-free survival, patients had hazard ratios (95% CI) of 1.78 (1.25,2.52), 3.79 (2.56,5.61), 2.60 (1.50,4.48) and 4.76 (2.21,10.27), respectively. The presence of EMVI was a significant predictor of decreased overall and disease-free survival (P<0.001).

Conclusions:

This study demonstrated, in the presence of high surgical, oncology and pathological standards, EMVI and increasing LNR were independent predictors of decreased overall and disease-free survival for patients undergoing curative colon cancer resection. LNR was superior to pN stage in predicting overall and disease-free survival.

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.

Complications after laparoscopic and open subtotal colectomy for inflammatory colitis: a case-matched comparison

AIM

The aim of this study was to compare the early postoperative outcome of patients undergoing laparoscopic subtotal colectomy with those undergoing open subtotal colectomy for colitis refractory to medical treatment.

METHOD

A retrospective observational study was carried out of patients who underwent subtotal colectomy for refractory colitis, at a single centre, between 2006 and 2012. Patients were matched for age, gender, American Society of Anesthesiology (ASA) grade, urgency of operation and immunosuppressant/modulator treatment. The primary outcome measure was the number of postoperative complications, classified using the Clavien-Dindo scale. Secondary end-points included procedure duration, laparoscopic conversion rates, blood loss, 30-day readmission rates and length of hospital stay.

RESULTS

Ninety-six patients were included, 39 of whom had laparoscopic surgery. Thirty-two of these were matched to similar patients who underwent an open procedure. The overall duration of the procedure was longer for laparoscopic surgery than for open surgery (median: 240 vs 150 min, P < 0.005) but estimated blood loss was less (median: 75 vs 400 ml, P < 0.005). In the laparoscopic group, 23 patients experienced 27 complications, and in the open surgery group, 23 patients experienced 30 complications. Most complications were minor (Grade I/II), and the distribution of complications, by grade, was similar between the two groups. There was no statistically significant difference in 30-day readmission rates between the laparoscopic and open groups (five readmissions vs eight readmissions, P = 0.536). Length of hospital stay was 4 days shorter for laparoscopic surgery, but this difference was not statistically significant (median: 7 vs 11 days, P = 0.159).

CONCLUSION

In patients requiring colectomy for acute severe colitis, laparoscopic surgery reduced blood loss but increased operating time and was not associated with a reduction in early postoperative complications, length of hospital stay or readmission rates.

Does the location of colorectal carcinoma differ between screened and unscreened populations?

AIM

Screening for colorectal malignancy using faecal occult blood testing is established across the UK. In NHS Grampian the programme was introduced in 2007. Previous studies have reported no difference in anatomical locations of cancers detected by screening programmes compared with those in unscreened populations. This study aims to review the location of tumours detected in an established screening programme compared with those diagnosed through symptomatic presentation within the same population.

METHOD

All patients discussed at the regional multidisciplinary meeting between June 2007 and August 2011 were included. Data were collated prospectively from multidisciplinary team records while site of tumour was documented from radiology, endoscopy, operative and pathology reports. Comparative statistics (χ(2) ) were performed using spss 19.

RESULTS

Of 1487 patients included 255 were detected via the screening programme and 1232 from symptomatic presentation. More left sided tumours (splenic flexure to rectosigmoid) were detected via screening (P=0.005). Of non-screened patients (n=1232), 456 (37%) tumours were right sided (caecum to distal transverse colon), 419 (34%) were left sided and 357 (29%) were in the rectum. This compares with the screened group (n=255): right sided 74 (29%), left sided 113 (44%) and rectal 68 (27%).

CONCLUSION

More left sided tumours appear to be detected in screened patients compared with symptomatic presentation, contrary to previously published work. These results may be worthy of further consideration given the ongoing debate on the optimal means of screening.

Urgency of referral and its impact on outcome in patients with colorectal cancer

AIM

Primary care referral for patients with bowel symptoms is triaged by general practitioners to urgent or routine based on the clinical suspicion of malignancy. Triage directly influences time to assessment and investigation. This study aimed to establish whether urgency of referral of patients with large bowel malignancy has any effect on management.

METHOD

An analysis was undertaken of all patients with colorectal cancer referred by primary care and discussed at the regional colorectal multi-disciplinary team (MDT) meetings from January 2009 to December 2010. Demographics and tumour data were collated prospectively from MDT records, and operation and investigation reports.

RESULTS

Of 369 primary case referrals with colorectal cancer, 303 (82.1%) were urgent and 66 (17.9%) routine. Patient characteristics (age, sex, American Society of Anesthesiologists grade) and resection rates were similar in both groups and no significant difference in tumour location was observed. The time from referral to diagnosis was significantly longer in the routine group (mean 73.7 days vs 30.2 days; P = 0.001). Dukes stage was less advanced for the routine referral group, (P = 0.002).

CONCLUSION

Urgency of referral decreased the time to diagnosis. This did not influence resection rates. Dukes stage was higher for urgent referrals. Long-term follow-up is required to determine any impact on survival.

End-of-life care is still a challenge for Italy

The aim of this paper was to review current end of life (EOL) practice in Italy. The authors have made an appraisal of the existing literature in order to understand current end of life care practice in Italy. This manuscript focuses on analyzing the dying process, the transoceanic similarities and differences in the end of life decision-making practice, and the family involvement. The authors acknowledge the importance of the recent Englaro court case verdict on current practice in Italy. Dying has changed as a process over the last century in term of causes of death, costs, communication of the prognosis, and needs of the patient's family. Regardless of national and international guidelines, there is no agreement among Italian doctors regarding the gold standards of daily clinical practice at the EOL.

The impact and recovery of asteroid 2008 TC(3)

In the absence of a firm link between individual meteorites and their asteroidal parent bodies, asteroids are typically characterized only by their light reflection properties, and grouped accordingly into classes. On 6 October 2008, a small asteroid was discovered with a flat reflectance spectrum in the 554-995 nm wavelength range, and designated 2008 TC(3) (refs 4-6). It subsequently hit the Earth. Because it exploded at 37 km altitude, no macroscopic fragments were expected to survive. Here we report that a dedicated search along the approach trajectory recovered 47 meteorites, fragments of a single body named Almahata Sitta, with a total mass of 3.95 kg. Analysis of one of these meteorites shows it to be an achondrite, a polymict ureilite, anomalous in its class: ultra-fine-grained and porous, with large carbonaceous grains. The combined asteroid and meteorite reflectance spectra identify the asteroid as F class, now firmly linked to dark carbon-rich anomalous ureilites, a material so fragile it was not previously represented in meteorite collections.

Completed Audit Cycle on Lithium Monitoring on Older Adults in Northumbria Healthcare NHS Trust, UK

Aims:

The aim of this study was to audit the practise of Lithium monitoring on all patients over the age of 65 years, over a one-year period in North Tyneside General Hospital, against the recommended standards, and re-auditing the following year.

Methods:

During the audit; data was collected from the medical notes of all patients prescribed Lithium, over 65 years in North Tyneside General Hospital. This was from January 2004 - January 2005. The standards used were the recommendations of The British National Formulary. The monitoring of urea, electrolytes, TSH and Lithium were recorded. The presence of an ECG, documentation of side effects, information leaflets’ distribution and patients lost to follow up were noted. Following the audit, recommendations were made and prescribing Consultants were informed. A re-audit was conducted on all patients on Lithium the next year from January 2006 - June 2006, using the same designed tool.

Results:

22 patient's notes were audited and 29 notes re-audited. 41% were males and 59% females in the audit, with similar distribution in the re-audit. 54% were between 65-75 years and 45% over the age of 75years in the audit. 41% and 59% respectively in the re-audit. Blood monitoring followed the standards in 86% in the audit and 95% in the re-audit. 32% had documentation of side effects in the audit, increasing to 72% in the re-audit. While 23% patients were lost to follow up in the audit, all were followed up in the re-audit.

Conclusions:

The re-audit encouragingly showed significant improvement in practise.

[Less ventilator-associated pneumonia after oral decontamination with chlorhexidine; a randomised trial]

OBJECTIVE

To determine the effect of oral decontamination with either chlorhexidine (CHX, 2%) or the combination chlorhexidine-colistin (CHX-COL, 2%-2%) on the frequency and the time to onset of ventilator-associated pneumonia in Intensive Care patients.

DESIGN

Double blind, placebo-controlled, multicentre, randomised trial.

METHODS

Consecutive ICU patients needing at least 48 h of mechanical ventilation were enrolled in a randomized trial with 3 arms: CHX, CHX-COL, and placebo (PLAC). The trial medication was administered in the oral cavity every 6 h. Oropharyngeal swabs were obtained daily and analysed quantitatively for Gram-positive and Gram-negative microorganisms. Endotracheal colonisation was monitored twice weekly. Ventilator-associated pneumonia was diagnosed on the basis of a combination of clinical, radiological and microbiological criteria.

RESULTS

Of 385 patients included, 130 received PLAC, 127 CHX and 128 CHX-COL. Baseline characteristics in the three groups were comparable. The daily risk of ventilator-associated pneumonia was reduced in both treatment groups compared to PLAC: 65% (HR= 0.352; 95% CI: 0.160-0.791; p = 0.012) for CHX and 55% (HR= 0.454; 95%/ CI: 0.224-0.925; p = 0.030) for CHX-COL. CHX-COL provided a significant reduction in oropharyngeal colonisation with both Gram-negative and Gram-positive microorganisms, whereas CHX significantly affected only colonisation with Gram-positive microorganisms. There were no differences in the duration of mechanical ventilation, ICU-stay or ICU-survival.

CONCLUSION

Oral decontamination of the oropharyngeal cavity with chlorhexidine or the combination chlorhexidine-colistin reduced the incidence and the time to onset ofventilator-associated pneumonia.

Risk prediction in patients presenting with suspected cardiac pain: the GRACE and TIMI risk scores versus clinical evaluation

BACKGROUND

Identifying which patients presenting with undifferentiated chest pain are at risk of major cardiac events is a major clinical challenge. Clinical evaluation may lack sufficient precision, leading to unnecessary admission or inappropriate discharge. It is uncertain whether risk scores derived from ACS populations apply to unselected patients with chest pain.

AIM

To determine the predictive accuracies of the GRACE risk score, the TIMI risk score and clinical evaluation in unselected patients with suspected cardiac pain.

DESIGN

Prospective observational study.

METHODS

We recruited 347 sequential patients with suspected cardiac pain presenting to a large teaching hospital. The main outcome measures were death, non-fatal myocardial infarction and emergency revascularization, in hospital and at 3 months. Receiver operating characteristic (ROC) curves were plotted for TIMI and GRACE risk scores and clinical evaluation.

RESULTS

Overall 54 patients (15.6%) experienced a major cardiac event (16 deaths, seven myocardial infarctions (MIs), one emergency revascularization) or emergency re-admission (n=30) within 3 months. Both GRACE (p<0.001) and TIMI scores (p<0.001) predicted death/MI/revascularization (and the composite including re-admission), but the GRACE score was superior to the TIMI score for predicting major cardiac events (z=2.05), and both scores were superior to clinical evaluation (ROC areas 0.82, 0.74 and 0.55 respectively). The GRACE score predicted an ACS discharge diagnosis (p<0.001) and duration of hospital stay (p<0.001).

DISCUSSION

In unselected patients presenting with suspected cardiac pain, the GRACE risk score is superior to the TIMI risk score in predicting major cardiac events, and both risk scores are superior to using ECG and troponin findings at presentation.

Transgenic peas (Pisum sativum) expressing polygalacturonase inhibiting protein from raspberry (Rubus idaeus) and stilbene synthase from grape (Vitis vinifera)

The pea (Pisum sativum L.) varieties Baroness (United Kingdome) and Baccara (France) were transformed via Agrobacterium tumefaciens-mediated gene transfer with pGPTV binary vectors containing the bar gene in combination with two different antifungal genes coding for polygalacturonase-inhibiting protein (PGIP) from raspberry (Rubus idaeus L.) driven by a double 35S promoter, or the stilbene synthase (Vst1) from grape (Vitis vinifera L.) driven by its own elicitor-inducible promoter. Transgenic lines were established and transgenes combined via conventional crossing. Resveratrol, produced by Vst1 transgenic plants, was detected using HPLC and the PGIP expression was determined in functional inhibition assays against fungal polygalacturonases. Stable inheritance of the antifungal genes in the transgenic plants was demonstrated.

An efficient transformation system for chickpea (Cicer arietinum L.)

A reproducible and efficient transformation method was developed for Desi and Kabuli chickpeas (Cicer arietinum L.) using germinated seedlings as sources of explants. Slices derived from plumules were the most efficient at generating transformed shoots. The AGL1 Agrobacterium-treated explants were first incubated on thidiazuron-containing media, then selected using phosphinothricin. Resistant shoots were successfully transferred to soil either by grafting or in vitro rooting. In experiments each taking 4-9 months, a total of 41 confirmed transformed lines were created using embryo axis slices as source explants, giving a transformation frequency of 5.1%. Southern analysis and histochemical and leaf painting assays demonstrated integration and expression of the transgenes in the initial transformants and two generations of progeny.

An efficient transformation system for chickpea (Cicer arietinum L.)

A reproducible and efficient transformation method was developed for Desi and Kabuli chickpeas (Cicer arietinum L.) using germinated seedlings as sources of explants. Slices derived from plumules were the most efficient at generating transformed shoots. The AGL1 Agrobacterium-treated explants were first incubated on thidiazuron-containing media, then selected using phosphinothricin. Resistant shoots were successfully transferred to soil either by grafting or in vitro rooting. In experiments each taking 4-9 months, a total of 41 confirmed transformed lines were created using embryo axis slices as source explants, giving a transformation frequency of 5.1%. Southern analysis and histochemical and leaf painting assays demonstrated integration and expression of the transgenes in the initial transformants and two generations of progeny.

Successful treatment of severe bleeding with recombinant factor VIIa after kidney transplantation

Recombinant factor VIIa (rFVIIa, NovoSeven) has been registered for the treatment of bleeding episodes in patients with inherited or acquired hemophilia A or B with inhibitors. Furthermore, rFVIIa has been used successfully for the treatment of bleeding in patients with thrombocytopenia, and acquired and congenital platelet dysfunction. The definite spectrum of indications for rFVIIa has not yet been established. We describe a case of severe intra-abdominal bleeding 3 days after non-heart beating kidney transplantation in a patient with severe coronary artery disease in which rFVIIa (a single intravenous bolus injection 70 microg/kg bodyweight) was successfully used. No thrombotic complications occurred. This report demonstrates that rFVIIa might be safe and effective after recent renal transplantation.

PACT: An ESICM Multidisciplinary Distance Learning Programme for Intensive Care Training

Intensive Care Medicine (ICM) is a medical specialty where doctors from a variety of disciplinary backgrounds manage the medical care of critically ill patients. Training and continuing education for these doctors involves the acquisition and maintenance of the knowledge, skills and attitudes which allow them to manage the most severely ill. In order to improve and harmonise the quality of intensive care medicine, the European Society of Intensive Care Medicine (ESICM) is producing a distance learning programme: Patient-Centred Acute Care Training (PACT) for the training of doctors working in intensive care and acute medicine.