Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Educational impact and recommendations from implementation of student-led clinical trial recruitment: a mixed-methods study

Medical students have an essential role in medical research, yet often lack opportunities for involvement within randomised trials. This study aimed to understand the educational impact of clinical trial recruitment for medical students. Tracking wound infection with smartphone technology (TWIST) was a randomised controlled trial that included adult patients undergoing emergency abdominal surgery across two university teaching hospitals. All recruiters underwent prerecruitment training based on 'Generating Student Recruiters for Randomised Trials' principles, and completed prerecruitment and postrecruitment surveys. Respondent agreement with statements were assessed using 5-point Likert scales (from 1 ('strongly disagree') to 5 ('strongly agree')). Quantitative data were analysed using paired t-tests to compare differences pre-involvement and post-involvement. Thematic content analysis was performed on free-text data to generate recommendations for future student research involvement. Of 492 patients recruited to TWIST between 26 July 2016 and 4 March 2020, 86.0% (n=423) were recruited by medical students. Following introduction of student co-investigators (n=31), the overall monthly recruitment rate tripled (4.8-15.7 patients). 96.8% of recruiters (n=30/31) completed both surveys, and all respondents reported significant improvement in clinical and academic competencies. Three higher-level thematic domains emerged from the qualitative analysis: (1) engagement, (2) preparation and (3) ongoing support. Student recruitment in clinical trials is feasible and accelerates recruitment to clinical trials. Students demonstrated novel clinical research competencies and increased their likelihood of future involvement. Adequate training, support and selection of suitable trials are essential for future student involvement in randomised trials.

Evaluation of remote digital postoperative wound monitoring in routine surgical practice

Remote digital postoperative wound monitoring provides an opportunity to strengthen postoperative community care and minimise the burden of surgical-site infection (SSI). This study aimed to pilot a remote digital postoperative wound monitoring service and evaluate the readiness for implementation in routine clinical practice. This was a single-arm pilot implementational study of remote digital postoperative wound monitoring across two tertiary care hospitals in the UK (IDEAL stage 2b, clinicaltrials.gov: NCT05069103). Adults undergoing abdominal surgery were recruited and received a smartphone-delivered wound assessment tool for 30-days postoperatively. Patients received 30-day postoperative follow-up, including the Telehealth Usability Questionnaire (TUQ). A thematic mixed-methods approach was used, according to the WHO framework for monitoring and evaluating digital health interventions. 200 patients were enroled, of whom 115 (57.5%) underwent emergency surgical procedures. Overall, the 30-day SSI rate was 16.5% (n = 33/200), with 72.7% (n = 24) diagnosed post-discharge. Usage of the intervention was 83.0% (n = 166/200), with subsequently 74.1% (n = 123/166) TUQ completion. There were no issues reported with feasibility of the technology, with the reliability (3.87, 95% CI: 3.73-4.00) and quality of the interface rated highly (4.18, 95%: 4.06-4.30). Patient acceptance was similarly high with regards to ease of use (4.51, 95% CI: 4.41-4.62), satisfaction (4.27, 95% CI: 4.13-4.41), and usefulness (4.07, 95% CI: 3.92-4.23). Despite the desire for more frequent and personalised interactions, the majority viewed the intervention as providing meaningful benefit over routine postoperative care. Remote digital postoperative wound monitoring successfully demonstrated readiness for implementation with regards to the technology, usability, and healthcare process improvement.

Readiness for implementation of novel digital health interventions for postoperative monitoring: a systematic review and clinical innovation network analysis

An increasing number of digital health interventions (DHIs) for remote postoperative monitoring have been developed and evaluated. This systematic review identifies DHIs for postoperative monitoring and evaluates their readiness for implementation into routine health care. Studies were defined according to idea, development, exploration, assessment, and long-term follow-up (IDEAL) stages of innovation. A novel clinical innovation network analysis used coauthorship and citations to examine collaboration and progression within the field. 126 DHIs were identified, with 101 (80%) being early stage innovations (IDEAL stage 1 and 2a). None of the DHIs identified had large-scale routine implementation. There is little evidence of collaboration, and there are clear omissions in the evaluation of feasibility, accessibility, and the health-care impact. Use of DHIs for postoperative monitoring remains at an early stage of innovation, with promising but generally low-quality supporting evidence. Comprehensive evaluation within high-quality, large-scale trials and real-world data are required to definitively establish readiness for routine implementation.

The apparent metabolisable energy and ileal amino digestibility of black soldier fly (Hermetia illucens) larvae meal for broiler chickens

1. Two experiments were conducted to determine the apparent metabolisable energy (AME) and standardised amino acid digestibility coefficients (SIDC) of black soldier fly larvae (BSFL) for broiler chickens.2. The BSFL contained, on a g/kg dry matter basis: crude protein, 486; crude fat, 320; ash, 58.5; neutral detergent fibre, 181; calcium, 6.8 and phosphorus, 9.1.3. In Experiment 1, an AME assay was performed wherein broilers were fed two experimental diets (a maize-soy basal diet and a test diet containing 250 g/kg BSFL) for 4 d from d 18 posthatch. The AME of BSFL was calculated based on the difference between the AME values of basal and test diets. The AME and nitrogen-corrected AME were determined to be 19.1and 18.0 MJ/kg of dry matter, respectively.4. In Experiment 2, the ileal amino acid (AA) digestibility of BSFL was determined using 22-d-old broilers by the direct method and the digesta was collected on d 25. The ratios between the AA and titanium in the diet and digesta were used to calculate the apparent digestibility and then standardised using previously published endogenous losses to estimate the SIDC of AA. The SIDC of Lys, Met, Thr, Val and average SIDC of AA in our BSFL sample were 0.85, 0.90, 0.91, 0.87 and 0.84, respectively.5. The findings showed that the BSFL meal is a good source of available energy and digestible AA, and could be a potential substitute for soybean meal in broiler diets.

Educational impact and recommendations from implementation of student-led clinical trial recruitment: a mixed-methods study

Medical students have an essential role in medical research, yet often lack opportunities for involvement within randomised trials. This study aimed to understand the educational impact of clinical trial recruitment for medical students. Tracking wound infection with smartphone technology (TWIST) was a randomised controlled trial that included adult patients undergoing emergency abdominal surgery across two university teaching hospitals. All recruiters underwent prerecruitment training based on 'Generating Student Recruiters for Randomised Trials' principles, and completed prerecruitment and postrecruitment surveys. Respondent agreement with statements were assessed using 5-point Likert scales (from 1 ('strongly disagree') to 5 ('strongly agree')). Quantitative data were analysed using paired t-tests to compare differences pre-involvement and post-involvement. Thematic content analysis was performed on free-text data to generate recommendations for future student research involvement. Of 492 patients recruited to TWIST between 26 July 2016 and 4 March 2020, 86.0% (n=423) were recruited by medical students. Following introduction of student co-investigators (n=31), the overall monthly recruitment rate tripled (4.8-15.7 patients). 96.8% of recruiters (n=30/31) completed both surveys, and all respondents reported significant improvement in clinical and academic competencies. Three higher-level thematic domains emerged from the qualitative analysis: (1) engagement, (2) preparation and (3) ongoing support. Student recruitment in clinical trials is feasible and accelerates recruitment to clinical trials. Students demonstrated novel clinical research competencies and increased their likelihood of future involvement. Adequate training, support and selection of suitable trials are essential for future student involvement in randomised trials.

Oncological and clinical outcomes after conventional right hemicolectomy

PURPOSE

Complete mesocolic excision (CME) has been proposed for better local control of colon cancer and to improve cancer-specific survival (CSS). However, CME may be associated with increased morbidity from bleeding during central vascular ligation. This study aimed to investigate the outcome of conventional right hemicolectomy, a traditional anatomical dissection along anatomical planes with radical excision of the central lymph nodes at the level of the origin of colic artery but without exposure of superior mesenteric vein and artery (SMV/SMA).

METHOD

This was a retrospective review of a cohort of all elective right hemicolectomies performed at a specialist tertiary unit during a five-year period (2011-2015).

RESULTS

Five-hundred-nineteen patients (271 female, a median age of 73.0 years (interquartile range (IQR) 65.0-80.0)) were included (Stage I disease: 2.7%, stage II: 53.2%, stage III: 33.3%, stage IV: 10.8%). At the latest follow-up (a median 47 months (IQR 29-67)), local recurrence occurred in 34 patients (6.6%). Three-year overall survival was 74.4% and 3-year CSS was 85.9%. Subgroup analysis for stage I-III showed local recurrence in 6.0%, sole distant recurrence in 7.6% while 19 patients (4.1%) suffered concomitant local and distant recurrence. The anastomotic leak rate was 1.0% and perioperative bleeding occurred in 1.2%.

CONCLUSIONS

Oncological outcomes comparable to those of CME can be achieved by conventional surgery but with low rates of bleeding complications and anastomotic leakage. The proposed advantages of CME should be carefully considered and balanced against patients' co-morbidities and potential complications.

O8 Tracking wound infection with smartphone technology (twist): a randomised controlled trial in emergency surgery patients

Introduction

Surgical site infections (SSI) complicate 2%–10% of general surgery cases, and represent a significant burden on acute healthcare services. We aim to investigate if a smartphone-delivered wound assessment tool results in earlier treatment.

Method

This parallel, single-blinded randomised control trial enrolled adult emergency abdominal surgery patients in two tertiary hospitals (ClinicalTrials.gov number, NCT02704897). Patients were randomised (1:1 ratio) between standard postoperative care and additional access to a smartphone-delivered wound assessment tool for 30-days postoperatively. Patients routinely submitted wound questionnaires and photos for surgical review at postoperative days 3, 7, and 15. The primary outcome measure was time-to-diagnosis of SSI (CDC definition) within 30 postoperative days.

Result

492 patients undergoing emergency surgery were randomised (smartphone intervention = 223; standard care = 269). There was no significant difference (P = 0.513) in the 30-day SSI rate between trial arms: 21 (9.4%) in smartphone vs 20 (7.4%) in standard care. While the mean time-to-diagnosis of SSI was 9.3 days (SD = 6.3) in the smartphone group, and 11.8 days (SD = 6.7) in the control group, this did not demonstrate a significant difference for the primary outcome (P = 0.255). However, patients in the smartphone group had 3.7-fold higher odds to be diagnosed in first 7 postoperative days (95% CI: 1.02 to 13.51, P = 0.043).

Conclusion

Digital patient-driven postoperative wound follow-up can be feasibly delivered in a broad cohort of emergency surgery patients. This can facilitate triage of patients to the appropriate level of assessment required, allowing diagnosis of SSI earlier in the postoperative period.

Take-home Message

Digital patient-driven postoperative wound follow-up can be feasibly delivered in a broad cohort of emergency surgery patients. This can facilitate triage of patients to the appropriate level of assessment required, allowing diagnosis of SSI earlier in the postoperative period.

Post-Operative Monitoring of Intestinal Tissue Oxygenation Using an Implantable Microfabricated Oxygen Sensor

Anastomotic leakage (AL) is a common and dangerous post-operative complication following intestinal resection, causing substantial morbidity and mortality. Ischaemia in the tissue surrounding the anastomosis is a major risk-factor for AL development. Continuous tissue oxygenation monitoring during the post-operative recovery period would provide early and accurate early identification of AL risk. We describe the construction and testing of a miniature implantable electrochemical oxygen sensor that addresses this need. It consisted of an array of platinum microelectrodes, microfabricated on a silicon substrate, with a poly(2-hydroxyethyl methacrylate) hydrogel membrane to protect the sensor surface. The sensor was encapsulated in a biocompatible package with a wired connection to external instrumentation. It gave a sensitive and highly linear response to variations in oxygen partial pressure in vitro, although over time its sensitivity was partially decreased by protein biofouling. Using a pre-clinical in vivo pig model, acute intestinal ischaemia was robustly and accurately detected by the sensor. Graded changes in tissue oxygenation were also measurable, with relative differences detected more accurately than absolute differences. Finally, we demonstrated its suitability for continuous monitoring of tissue oxygenation at a colorectal anastomosis over a period of at least 45 h. This study provides evidence to support the development and use of implantable electrochemical oxygen sensors for post-operative monitoring of anastomosis oxygenation.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.

Can a smartphone-delivered tool facilitate the assessment of surgical site infection and result in earlier treatment? Tracking wound infection with smartphone technology (TWIST): protocol for a randomised controlled trial in emergency surgery patients

INTRODUCTION

National data suggest that surgical site infection (SSI) complicates 2%-10% of general surgery cases, although the patient-reported incidence is much higher. SSIs cause significant patient morbidity and represent a significant burden on acute healthcare services, in a cohort predominantly suitable for outpatient management. Over three-quarters of UK adults now own smartphones, which could be harnessed to improve access to care. We aim to investigate if a smartphone-delivered wound assessment tool results in earlier treatment.

METHODS AND ANALYSIS

This is a randomised controlled trial aiming to recruit 500 patients across National Health Service (NHS) hospitals. All emergency abdominal surgery patients over the age of 16 who own smartphones will be considered eligible, with the exclusion of those with significant visual impairment. Participants will be randomised in a 1:1 ratio between standard postoperative care and the intervention - use of the smartphone tool in addition to standard postoperative care. The main outcome measure will be time-to-diagnosis of SSI with secondary outcome measures considering use of emergency department and general practitioner services and patient experience. Follow-up will be conducted by clinicians blinded to group allocation. Analysis of time-to-diagnosis will be by comparison of means using an independent two sample t-test.

ETHICS AND DISSEMINATION

This is the first randomised controlled trial on the use of a smartphone-delivered wound assessment tool to facilitate the assessment of SSI and the impact on time-to-diagnosis. The intervention is being used in addition to standard postoperative care. The study design and protocol were reviewed and approved by Southeast Scotland Research and Ethics Committee (REC Ref: 16/SS/0072 24/05/2016). Study findings will be presented at academic conferences, published in peer-reviewed journals and are expected in 2020. A written lay summary will be available to study participants on request.

TRIAL REGISTRATION NUMBER

NCT02704897; Pre-results.

In vivo validation of a miniaturized electrochemical oxygen sensor for measuring intestinal oxygen tension

Recent advances in the fields of electronics and microfabrication techniques have led to the development of implantable medical devices for use within the field of precision medicine. Monitoring visceral surface tissue O₂ tension (PTo2) by means of an implantable sensor is potentially useful in many clinical situations, including the perioperative management of patients undergoing intestinal resection and anastomosis. This concept could provide a means by which treatment could be tailored to individual patients. This study describes the in vivo validation of a novel, miniaturized electrochemical O₂ sensor to provide real-time data on intestinal PTo2. A single O₂ sensor was placed onto the serosal surface of the small intestine of anesthetized rats that were exposed to ischemic (superior mesenteric artery occlusion) and hypoxemic (alterations in inspired fractional O₂ concentrations) insults. Control experiments demonstrated that the sensors can function and remain stable in an in vivo environment. Intestinal PTo2 decreased following superior mesenteric artery occlusion and with reductions in inspired O₂ concentrations. These results were reversible after reinstating blood flow or by increasing inspired O₂ concentrations. We have successfully developed an anesthetized rat intestinal ischemic and hypoxic model for validation of a miniaturized O₂ sensor to provide real-time measurement of intestinal PTo2. Our results support further validation of the sensors in physiological conditions using a large animal model to provide evidence of their use in clinical applications where monitoring visceral surface tissue O₂ tension is important.NEW & NOTEWORTHY This is the first report of real-time continuous measurements of intestinal oxygen tension made using a microfabricated O₂ sensor. Using a developed rodent model, we have validated this sensor's ability to accurately measure dynamic and reversible changes in intestinal oxygenation that occur through ischemic and hypoxemic insults. Continuous monitoring of local intestinal oxygenation could have value in the postoperative monitoring of patients having undergone intestinal surgery.

Molecular detection of Bartonella coopersplainsensis and B. henselae in rats from New Zealand

AIM To identify Bartonella spp. in rats from New Zealand using molecular methods. METHODS DNA was extracted from the spleens of 143 black rats (Rattus rattus) captured in the Tongariro National Park, New Zealand. PCR was performed using Bartonella genus-specific primers amplifying segments of the 16S-23S rRNA internal transcribed spacer and citrate synthase (gltA) and beta subunit of the RNA polymerase (rpoB) genes. PCR products were sequenced and compared online with sequences stored in the database of the National Center for Biotechnology Information of the United States of America. RESULTS DNA sequences matching Bartonella coopersplainsensis and B. henselae were detected in samples from 22/143 (15.4%) and 3/143 (2.1%) rats, respectively. Co-occurrence of B. coopersplainsensis and B. henselae sequences was observed in the sample from one rat. CONCLUSIONS AND CLINICAL RELEVANCE Gram-negative fastidious bacteria belonging to the genus Bartonella are associated with a range of human diseases. Rodents play an important role as reservoirs of a broad range of Bartonella species. To our knowledge, this is the first report of a molecular detection of Bartonella spp. DNA in rodents from New Zealand, and the first identification of B. henselae DNA in rats, worldwide. Whereas the public health significance of B. coopersplainsensis remains undefined, B. henselae is the agent of cat scratch disease, and the presence of this bacterium in rats may have public health implications. Our results are preliminary and additional analyses of larger samples, preferably by bacterial culture, would provide more information on the prevalence and diversity of Bartonella spp., in particular B. henselae, in rats.

The economic burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA)

The economic impact of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) remains unclear. We developed an economic simulation model to quantify the costs associated with CA-MRSA infection from the societal and third-party payer perspectives. A single CA-MRSA case costs third-party payers $2277-$3200 and society $7070-$20 489, depending on patient age. In the United States (US), CA-MRSA imposes an annual burden of $478 million to 2.2 billion on third-party payers and $1.4-13.8 billion on society, depending on the CA-MRSA definitions and incidences. The US jail system and Army may be experiencing annual total costs of $7-11 million ($6-10 million direct medical costs) and $15-36 million ($14-32 million direct costs), respectively. Hospitalization rates and mortality are important cost drivers. CA-MRSA confers a substantial economic burden on third-party payers and society, with CA-MRSA-attributable productivity losses being major contributors to the total societal economic burden. Although decreasing transmission and infection incidence would decrease costs, even if transmission were to continue at present levels, early identification and appropriate treatment of CA-MRSA infections before they progress could save considerable costs.

Improving covalent cell encapsulation with temporarily reactive polyelectrolytes

Calcium alginate/poly-L-lysine beads were coated with either 50% hydrolyzed poly(methyl vinyl ether-alt-maleic anhydride) (PMM(50)), or with poly(vinyl dimethyl azlactone-co-methacrylic acid) (50:50, PMV(50)), to form covalently shell-crosslinked capsules, and compared with analogous capsules coated with sodium alginate. All capsule types were prepared with and without C2C12 murine myoblast cells, and implanted into mice for up to 6 weeks. Cell viability, capsule integrity, fibrotic overgrowth, and mechanical strength of the capsules were assessed, and correlated with inflammatory cytokine marker levels in tail vein blood samples taken at different time points. AP-PMM(50) capsules displayed the least amount of fibrotic overgrowth, were found to be the strongest, and showed the lowest levels of TNF-α in tail vein serum samples taken at 4 h, 24 h, 1 and 6 weeks post transplantation. The results for APA and AP-PMV(50) capsules were more variable and depended on the presence or absence of encapsulated cells.

Acceptance by stoats(Mustela erminea)of 1080 (sodium monofluoroacetate) in small-volume baits and its effect on behaviour and time to death

AIMS

To assess whether stoats (Mustela erminea) would eat small baits containing 0.1% sodium monofluoroacetate (1080); whether they would die from it; how long it would take to kill them; and to document the behaviour of 1080-intoxicated stoats.

METHODS

Stoats were offered 1-g baits of two semi-fluid formulations containing 0.1% 1080, presented in open dishes, and their subsequent behaviour was monitored by video and direct observation. Muscle samples from stoats that died were analysed for 1080 residues.

RESULTS

There was no significant difference between two types of bait with regard to acceptance, mortality, and time to death, and behavioural effects were similar; consequently, results from the two types of bait were combined. Twelve of 14 stoats offered the baits ate them voluntarily, and a 13th licked bait off its fur; all 13 died between 1 h 15 min and 4 h 7 min (mean 2 h 38 min) later. At first (range 29 min - 2 h 7 min, mean 1 h 1 min), their behaviour appeared to be normal. Ataxia and hyperactivity were the first behavioural signs of poisoning, and lasted 2 min - 1 h 40 min (mean 26 min). This was followed by recumbency with convulsions and rapid breathing (range 16 min to 2 h, mean 58 min), then recumbency with limited activity and progressively shallow breathing prior to death (range 1-51 min, mean 33 min). Stoats became non-responsive to a light being turned on, or to touch once recumbency became sustained. Residues of 1080 were found in muscle tissue of all 13 dead stoats, at concentrations ranging from 0.075 microg/g in a 287-g male that died 4 h 7 min after eating only 0.74 g of bait, to 2.5 microg/g in a 254-g female that died 2 h 42 min after taking a whole 1-g bait.

CONCLUSION

Stoats will voluntarily take small (1-g) baits containing a lethal dose of 1080 at 0.1%, and die from it comparatively rapidly for a mammalian carnivore.

Quantitative risk assessment for the annual risk of exposure to Trichinella spiralis in imported chilled pork meat from New Zealand to Singapore

AIMS

To determine the annual likelihood of exposure to an infectious dose of Trichinella spiralis from consuming imported pork meat from New Zealand to Singapore.

METHODS

Input values specific for chilled pork meat imported into Singapore from New Zealand were used in a quantitative risk-assessment model. The model, designed to allow any combination of importing and exporting countries, was divided into two components, viz the release assessment, and the exposure assessment that assessed the annual risk of exposure to the consumer (ARC). The former estimated the likelihood that a contaminated fresh meat product from New Zealand would arrive at Singapore's border, and took into consideration the prevalence of disease on different types of farms. The latter determined the likelihood over a year that a person in Singapore would consume one or more servings of imported fresh meat from New Zealand that contained a burden of greater than or equal to one larva(e) of T. spiralis per gram after preparation for consumption.

RESULTS

The ARC for offal was 2.41 x 10(-7), which was below the pre-selected safety threshold of 1.00 x 10(-6). The ARC for lean meat was 2.39 x 10(-5), which was above the acceptable safety threshold.

CONCLUSIONS

The study demonstrated that continued routine testing at slaughter is unnecessary for pig offal produced commercially, and provided a model with which to further assess management of the risk of exposure to T. spiralis in lean meat.

CLINICAL RELEVANCE

The potential of Trichinella species to cause disease in humans is a public health concern, and has created adverse effects on the international trade of fresh lean meat without regard to the surveillance measures employed by particular pork-producing countries.

Mechanically enhanced microcapsules for cellular gene therapy

Microcapsules bearing a covalently cross-linked coating have been developed for cellular gene therapy as an improvement on alginate-poly(L-lysine)-alginate (APA) microcapsules that only have ionic cross-linking. In this study, two mutually reactive polyelectrolytes, a polycation (designated C70), poly([2-(methacryloyloxy)ethyl]trimethylammonium chloride-co-2-aminoethyl methacrylate hydrochloride) and a polyanion (designated A70), poly(sodium methacrylate-co-2-(methacryloyloxy)ethyl acetoacetate), were used during the microcapsule fabrication. Ca-alginate beads were sequentially laminated with C70, A70, poly(L-lysine) (PLL), and alginate. The A70 reacts with both C70 and PLL to form a approximately 30 microm thick covalently cross-linked interpenetrating polymer network on the surface of the capsules. Confocal images confirmed the location of the C70/A70/PLL network and the stability of the network after 4 weeks implantation in mice. The mechanical and chemical resistance of the capsules was tested with a "stress test" where microcapsules were gently shaken in 0.003% EDTA for 15 min. APA capsules disappeared during this treatment, whereas the modified capsules, even those that had been retrieved from mice after 4-weeks implantation, remained intact. Analysis of solutions passing through model flat membranes showed that the molecular weight cut-off of alginate-C70-A70-PLL-alginate is similar to that of alginate-PLL-alginate. Recombinant cells encapsulated in APA and modified capsules were able to secrete luciferase into culture media. The modified capsules were found to capture some components of regular culture media used during preparation, causing an immune reaction in implanted mice, but use of UltraCulture serum-free medium was found to prevent this immune reaction. In vivo biocompatibility of the new capsules was similar to the APA capsules, with no sign of clinical toxicity on complete blood counts and liver function tests. The increased stability of the covalently modified microcapsules coupled with the acceptable biocompatibility and permeability demonstrated their potential for use as immunoisolation devices in gene therapy.

Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection

OBJECTIVE

Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP.

METHOD

One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively.

RESULTS

One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both.

CONCLUSION

Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

Retrospective review of laser therapy for palliation of colorectal tumours

Patients with inoperable colorectal tumours will often require symptomatic relief due to the nature of extensive disease spread or existing co-morbidities. The use of laser treatment for palliation of tumours in the lower gastrointestinal tract has become an attractive treatment option for such patients. This paper presents the results of a retrospective review of 58 case notes in order to determine the effectiveness of laser therapy in palliating symptoms of colorectal tumours. In addition, the paper aims to identify which colorectal symptoms laser is best used to palliate. The study was conducted in a regional coloproctology unit at the Western General Hospital in Edinburgh. The main findings show that 52% (n=30) of patients had successful (complete/good) resolution of symptoms, 36% (n=21) had a poor response and 12% (n=7) had no resolution of symptoms from laser therapy. Of all documented symptoms, this study found that laser is most effective at palliating obstructive symptoms. It also has beneficial application in the palliation of bleeding and mucous discharge. It is less effective for the anal symptoms of tenesmus and pain and for stool related symptoms such as diarrhoea, constipation, frequency and incontinence.

A retrospective evaluation of rectal irrigation in the treatment of disorders of faecal continence

OBJECTIVES

The aim of this study was, firstly, to evaluate the efficacy and acceptability of rectal irrigation in the treatment of patients with disorders of faecal continence that have not responded to other treatment modalities. Secondly, to see if standard anorectal physiology measures can identify patients who might have successful treatment with rectal irrigation.

PATIENTS AND METHODS

All patients who had been treated with rectal irrigation, between 1998 and 2000, were sent a postal questionnaire. Patients were asked to quantify their symptoms (before and after rectal irrigation) using a visual analogue scale to determine the efficacy of rectal irrigation. An increase of 10 (10 mm) in this score was regarded as successful treatment and incontinence scores obtained. The acceptability of rectal irrigation was determined using a Quality of Life questionnaire. Data regarding presenting symptoms, previous therapies, pretreatment anorectal physiology measurements were obtained from a retrospective case note and database review.

RESULTS

Completed questionnaires were obtained from 48 (52%) of 92 patients, 39 patients had had previous medical and/or surgical treatment before trying rectal irrigation. At the time of the questionnaire 44 of 48 patients were still using rectal irrigation. Using the linear analogue scores 24 of 48 (50%) reported an improvement in their symptoms using rectal irrigation. Most patients found the treatment acceptable. Incontinence scores and anorectal physiology measures did not predict those patients who responded successfully to rectal irrigation.

CONCLUSION

Rectal irrigation can offer symptomatic improvement to patients with faecal evacuatory disorders where other therapies have failed. Most patients find the treatment acceptable. Standard anorectal physiology measures and incontinence scores do not predict those patients likely to have successful treatment.

Treatment of hemophilia B in mice with nonautologous somatic gene therapeutics

The implantation of nonautologous cells encapsulated in immunoprotective microcapsules provides an alternative nonviral method for gene therapy. This strategy was successful in reversing the disease phenotypes of dwarfism and a lysosomal storage disease, mucopolysaccharidosis VII, in murine models. In this article we implanted transgenic hemophilic B mice with microcapsules enclosing factor IX-secreting C2C12 myoblasts to study the clinical potential of this approach in the treatment of hemophilia. Treated mice showed increased plasma factor IX levels as high as 28 ng of human factor IX per milliliter of plasma and decreased activated thromboplastin times (reduced by 20% to 29%). However, the level of factor IX decreased to baseline levels by day 7, coinciding with emergence of anti-human factor IX antibody, the titer of which increased greater than 10-fold by day 28. Monoclonal anti-CD4 antibodies were used to deplete CD4+ T cells to suppress the immune response against the recombinant factor IX. In the treated hemophilic mice, the anti-factor IX antibody response was totally suppressed to beyond day 28 accompanied by a significant decrease in activated thromboplastin time compared with that seen in untreated hemophilic mice. When the microcapsules were recovered from the intraperitoneal cavity after 38 days of implantation, the encapsulated cells continued to secrete factor IX at preimplantation levels, but both cell viability and microcapsule mechanical stability were reduced. Hence although the polymer chemistry of the microcapsules and cell viability may need to be improved for long-term delivery, nonautologous gene therapy with microencapsulated cells has been shown to be effective, at least for the short-term, in alleviating the hemophilic hemostatic anomaly. Coadministration of an immunosuppressant is effective in inhibiting antibody development against the delivered factor IX and should be considered for recipients at risk of inhibitor development.

Proctalgia fugax

Proctalgia fugax is a benign, self-limiting pain experienced in the perineum. It is common, but most sufferers do not seek medical advice. The aetiology is unclear, but a variation of irritable bowel syndrome, pelvic floor myalgia, and internal anal sphincter spasm have all been suggested. A careful history can elicit the characteristic history, and simple reassurance is often all that is necessary. For persistent symptoms, therapies that induce internal anal sphincter relaxation are of value.

Training readiness of public health agencies: a framework for assessment

The Healthy People 2010 Objectives and the Taskforce on Public Health Workforce Development both have recognized the important roles of state and local agencies in the education and training of their employees. This article describes an initial step in the development of a tool to assess agencies' training readiness using five factors derived from learning organization theory. These factors (resources, policies, learning culture, programs, and leadership) offer a useful framework for further development of a tool to assess training program readiness.

Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long-term outcomes

OBJECTIVES

This randomized trial compared a strategy of predischarge coronary angiography (CA) with exercise treadmill testing (ETT) in low-risk patients in the chest pain unit (CPU) to reduce repeat emergency department (ED) visits and to identify additional coronary artery disease (CAD).

BACKGROUND

Patients with chest pain and normal electrocardiograms (ECGs) have a low likelihood of CAD and a favorable prognosis, but they often seek repeat evaluations in EDs. Remaining uncertainty regarding their symptoms and diagnosis may cause much of this recidivism.

METHODS

A total of 248 patients with no ischemic ECG changes triaged to a CPU were randomized to CA (n = 123) or ETT (n = 125). All patients had a probability of myocardial infarction < or =7% according to the Goldman algorithm, no biochemical evidence of infarction, the ability to exercise and no previous documented CAD. Patients were followed up for > or =1 year and surveyed regarding their chest pain self-perception and utility of the index evaluation.

RESULTS

Coronary angiography showed disease (> or =50% stenosis) in 19% and ETT was positive in 7% of the patients (p = 0.01). During follow-up (374+/-61 days), patients with a negative CA had fewer returns to the ED (10% vs. 30%, p = 0.0008) and hospital admissions (3% vs. 16%, p = 0.003), compared with patients with a negative/nondiagnostic ETT. The latter group was more likely to consider their pain as cardiac-related (15% vs. 7%), to be unsure about its etiology (38% vs. 26%) and to judge their evaluation as not useful (39% vs. 15%) (p < 0.01 for all comparisons).

CONCLUSIONS

In low-risk patients in the CPU, a strategy of CA detects more CAD than ETT, reduces long-term ED and hospital utilization and yields better patient satisfaction and understanding of their condition.

Needs assessment and a model agenda for training the public health workforce

OBJECTIVES

A training needs assessment project tested the use of "universal" competencies for establishing a model training agenda for the public health workforce.

METHODS

Agency supervisors selected competencies for training priorities. Regional and national public health leaders used these selections to design the model training agenda.

RESULTS

The competencies given high priority by supervisors varied among state and local agencies and included some not within the universal set. The model training agenda reflected supervisors' priorities as well as leaders' perspectives.

CONCLUSIONS

The universal competencies provide a useful starting point, but not necessarily an exclusive framework, for assessing and meeting the training needs of the public health workforce.

Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes

OBJECTIVES

We prospectively evaluated the relation between cardiac troponin T (cTnT) level, the presence and severity of coronary artery disease (CAD) and long-term prognosis in patients with chest pain but no ischemic electrocardiographic (ECG) changes who had short-term observation.

BACKGROUND

Cardiac TnT is a powerful predictor of future myocardial infarction (MI) and death in patients with ECG evidence of an acute coronary syndrome. However, for patients with chest pain with normal ECGs, it has not been determined whether cTnT elevation is predictive of CAD and a poor long-term prognosis.

METHODS

In 414 consecutive patients with no ischemic ECG changes who were triaged to a chest pain unit, cTnT and creatine kinase, MB fraction (CK-MB) were evaluated > or = 10 h after symptom onset. Patients with adverse cardiac events, including death, MI, unstable angina and heart failure were followed for as long as one year.

RESULTS

A positive (>0.1 ng/ml) cTnT test was detected in 37 patients (8.9%). Coronary artery disease was found in 90% of 30 cTnT-positive patients versus 23% of 144 cTnT-negative patients who underwent angiography (p < 0.001), with multivessel disease in 63% versus 13% (p < 0.001). The cTnT-positive patients had a significantly (p < 0.05) higher percent diameter stenosis and a greater frequency of calcified, complex and occlusive lesions. Follow-up was available in 405 patients (98%). By one year, 59 patients (14.6%) had adverse cardiac events. The cumulative adverse event rate was 32.4% in cTnT-positive patients versus 12.8% in cTnT-negative patients (p = 0.001). After adjustment for baseline clinical characteristics, positive cTnT was a stronger predictor of events (chi-square = 23.56, p = 0.0003) than positive CK-MB (>5 ng/ml) (chi-square = 21.08, p = 0.0008). In a model including both biochemical markers, CK-MB added no predictive information as compared with cTnT alone (chi-square = 23.57, p = 0.0006).

CONCLUSIONS

In a group of patients with chest pain anticipated to have a low prevalence of CAD and a good prognosis, cTnT identifies a subgroup with a high prevalence of extensive and complex CAD and increased risk for long-term adverse outcomes.

Cooperative coevolution: an architecture for evolving coadapted subcomponents

To successfully apply evolutionary algorithms to the solution of increasingly complex problems, we must develop effective techniques for evolving solutions in the form of interacting coadapted subcomponents. One of the major difficulties is finding computational extensions to our current evolutionary paradigms that will enable such subcomponents to "emerge" rather than being hand designed. In this paper, we describe an architecture for evolving such subcomponents as a collection of cooperating species. Given a simple string-matching task, we show that evolutionary pressure to increase the overall fitness of the ecosystem can provide the needed stimulus for the emergence of an appropriate number of interdependent subcomponents that cover multiple niches, evolve to an appropriate level of generality, and adapt as the number and roles of their fellow subcomponents change over time. We then explore these issues within the context of a more complicated domain through a case study involving the evolution of artificial neural networks.

Diagnostic delay in colorectal cancer

Recent guidelines recommend early diagnosis of colorectal cancer. Little data exists for comparison or to set standards. The aims of this study were to calculate the time to diagnosis for colorectal cancer from first hospital attendance and to identify any remedial factors felt to contribute to an undue delay in diagnosis. A one year retrospective audit was undertaken in a specialist teaching hospital. There were 59 patients and the median time to diagnosis was 17 days after first hospital consultation (mean 52 days). Some 34% had to wait more than one month for diagnosis. Incomplete examination or initial referral to a non-surgical specialty appeared to contribute to delay. Greater awareness of guidelines across the breadth of hospital specialties may reduce time to diagnosis.

Review--the use of immunosuppressive agents to prevent neutralizing antibodies against a transgene product

A potential obstacle to successful gene therapy for some patients is the in vivo production of neutralizing antibodies against the recombinant therapeutic product delivered. This is a problem inherent to all gene therapy methods, regardless of the vector used to deliver the protein. This clinical situation can be mimicked in animal models by delivering a foreign protein (i.e., a human protein) to the animal to provoke anti-human protein antibody production. The efficacy of different immunosuppressive treatments to inhibit the development of neutralizing antibodies can then be investigated. The immunosuppressive agents examined here include drugs (e.g., cyclophosphamide, FK506), cytokines (e.g., interferon-gamma, interleukin-12), and monoclonal antibodies (e.g., anti-CD4, anti-gp39, CTLA4-Ig). It has been found that a high level of antibody suppression is necessary to allow prolonged delivery of a foreign protein. Immunosuppressive agents capable of this high level of suppression will be important adjuncts to prevent treatment failures in situations where patients are at risk of developing neutralizing antibodies.

Prealbumin measurement as a screening tool for protein calorie malnutrition in emergency hospital admissions: a pilot study

OBJECTIVE

To examine the effectiveness of prealbumin measurement as a routine diagnostic test for protein calorie malnutrition (PCM) in emergency admissions.

DESIGN

Cohort study.

SETTING

Canadian tertiary care hospital.

PATIENTS

A total of 147 consecutive patients admitted through the emergency department, excluding psychiatric admissions, for whom a serum sample was sent to the chemistry laboratory.

OUTCOME MEASURES

(1) Albumin and prealbumin levels to diagnose PCM; (2) length of stay (LOS), in-hospital mortality, and nutritional supplementation in patients with PCM; and (3) cost analysis of using prealbumin level as an admission screening test for PCM.

RESULTS

Twenty-four per cent of the patients had at least mild PCM (prealbumin level < 160 mg/L). Albumin level (< 35 g/L) had a sensitivity of 50% and specificity of 95% in identifying PCM. The mean LOS in the patients with PCM was 16 (standard deviation 18) days, compared with 8 (SD 12) days in the patients without PCM (p < 0.0002). The in-hospital mortality rate was 17% in patients with PCM compared with 4% in patients without PCM (p < 0.02). Only 42% of patients with PCM received nutritional supplementation. Cost analysis of screening with prealbumin level projected a saving of $414 per patient screened.

CONCLUSIONS

PCM is underdiagnosed in current clinical practice and is associated with an increased LOS and mortality rate. Prealbumin is a biochemical marker that could be used as a cost-effective screening test to identify patients with PCM who may benefit from nutritional supplementation.

Diagnostic accuracy, angiographic correlates and long-term risk stratification with the troponin T ultra sensitive Rapid Assay in chest pain patients at low risk for acute myocardial infarction

AIMS

This prospective study of acute chest pain patients clinically at low risk for a myocardial infarction was designed to: determine the diagnostic accuracy of a cardiac troponin T (cTnT) ultra sensitive Rapid Assay (RAII) compared with the quantitative cTnT assay; evaluate the association of a positive RAII with the presence and severity of coronary artery disease (CAD); and determine the ability of the RAII result to predict adverse events during long-term follow-up.

METHODS AND RESULTS

A total of 199 patients referred for chest pain, without ST segment elevation on presenting ECG, underwent RAII, quantitative cTnT, CK and CK-MB tests drawn simultaneously > or = 10 h after symptom onset. An abnormal value for cTnT was defined as >0.1 ng.mL(-1). The presence and extent of CAD was recorded in patients undergoing angiography. Adverse events, including cardiac death, non-fatal infarction, and readmission for unstable angina or heart failure, were assessed long-term. An abnormal RAII was found in 41 (20-6%) patients. The RAII sensitivity for detecting abnormal quantitative cTnT levels was 100%, specificity 96.3% (158/164) and overall concordance 97.5%. Although the presenting ECG was normal or non-specific in 95%, ST depression or T wave inversion occurred in 17% of RAII-positive versus 2%, RAII-negative patients (P=0.004). Of RAII-positive patients who underwent angiography (79%), 87% had CAD and 60% had multivessel disease. Kaplan Meier event-free survival curves showed early separation and continued to modestly diverge for patients with positive and negative RAII (69% versus 90% one-year event-free survival, P=0.002).

CONCLUSION

In a chest pain population anticipated to have a low prevalence of acute coronary syndromes and a good prognosis, the RAII is a quick and reliable test. It provides an important initial opportunity to identify patients with a high prevalence of CAD and increased incidence of future cardiac events.

Suppression of immunological response against a transgene product delivered from microencapsulated cells

A potential obstacle to successful gene therapy for some patients is the in vivo production of neutralizing antibodies against the recombinant therapeutic product delivered. To mimic this clinical situation, we implanted microencapsulated recombinant cells producing human growth hormone into C57B1/6 mice to provoke antihuman growth hormone antibody production. We then investigated the efficacy of different immunosuppressive treatments to inhibit the development of neutralizing antibodies. The experimental mice were treated with either an immunosuppressive drug (FK506 or cyclophosphamide), a cytokine (interferon-gamma [IFN-gamma] or interleukin-12 [IL-12], or a monoclonal antibody (anti-CD4, anti-gp39, or CTLA4-Ig). Serum human growth hormone and mouse anti-human growth hormone antibody levels were measured by enzyme-linked immunosorbent assay (ELISA) for 4 weeks. There were three patterns of response noted among the seven treatment groups. First, the mice receiving IFN-gamma, IL-12, anti-gp39, or CTLA4-Ig were similar to the untreated controls-no suppression of anti-hGH antibodies and no improvement in delivery of hGH. Next, the mice receiving FK506 or cyclosphosphamide showed > or = 90% suppression of antibodies but also no improvement in product delivery. Last, the mice receiving anti-CD4 showed almost complete antibody suppression over 1 month postimplantation. Furthermore, only anti-CD4 permitted a sustained level of human growth hormone delivery to day 28, in contrast to the controls whose human growth hormone delivery was undetectable by day 14 postimplantation. Hence, the use of anti-CD4 inhibited formation of neutralizing antibodies against a recombinant gene product delivered in vivo, and allowed prolonged delivery of a foreign protein. Its role as adjunct treatment for appropriate patients receiving gene therapy should be examined further.

A prospective controlled study of the association of Streptococcus bovis with colorectal carcinoma

AIM

To investigate the ability of Streptococcus bovis to colonise colorectal cancers.

PATIENTS

19 patients with colorectal cancer and 23 controls without malignancy.

SETTING

University teaching hospital.

METHODS

Prospective study comparing unselected patients with known colorectal cancer with age and sex matched controls. Carcinoma tissue from patients with colorectal cancer and normal colonic mucosa, stool, and blood from both patients and control subjects were cultured.

RESULTS

In contrast to published data, the faecal carriage rate was similar in cancer (11%) and control groups (13%).

CONCLUSIONS

Faecal colonisation by Str bovis in colorectal cancer patients is lower than previously reported and does not differ significantly from controls.

Gene therapy in pediatrics

There has been a rapid proliferation of gene therapy trials in humans in the last few years. Gene therapy in pediatric patients has included treatment of classical genetic diseases as well as cancer and AIDS. Despite hundreds of trials involving thousands of patients, to date no disease has been cured with gene therapy. Setbacks in these trials have led to the development of new vectors for gene transfer, more specific targeting of therapy and increased efforts to understand the pathophysiology of diseases.

Written discharge advice sheets reduce visits to the general practitioner

A prospective audit of early post-operative morbidity in patients who would not normally receive routine outpatient review was undertaken. One-hundred-and forty-seven (92 per cent) of 162 patients invited returned for assessment. Thirty-five patients (24 per cent) had complications. These were of a minor nature with infected wounds being most numerous. Much of this morbidity appeared avoidable if the patients had received appropriate advice whilst in hospital. Also noted was the surprising frequency with which patients required to consult their general practitioner (GP) for guidance regarding an otherwise uncomplicated convalescence. Written advice sheets for the patients were drawn up and the study repeated. One-hundred-and-fifty (93 per cent) of 162 patients attended including 11 (7.3 per cent) who did not receive an advice sheet. Twenty-five (16.7 per cent) had complications. Although the overall complication rate was not significantly different there were significantly fewer wound infections in the second group (6 (4 per cent) versus 15 (10 per cent); p < 0.05). The number of GP visits was also reduced (24 (16.3 per cent) versus 13 (8.7 per cent); p < 0.05). Written post-operative advice sheets should be given to all patients following minor surgery.

Open diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) plays an important part in the assessment of patients with blunt abdominal trauma. For reasons of safety the open technique is recommended by the Advanced Trauma Life Support (ATLS) Course for Physicians1. In the absence of good lighting and with limited assistance in the trauma suite this method can be time-consuming and often contaminated with blood especially in the obese patient. For similar reasons of safety open techniques for insertion of laparoscopic ports have been developed. The open technique for port insertion2 provides a quick, virtually blood-free access to the peritoneum whatever the ambient conditions and equipment available. This technique is described below.

An objective assessment of surgical training

The aim of this study was to determine the feasibility of assessing surgical training from routine, prospectively collected data and to establish whether weighted workload assessed surgical training more objectively than caseload (case counting). The surgeons in this surgical unit prospectively documented details of all operations and endoscopic procedures (caseload) on a database. Over a six-month period the workload was calculated by weighting the caseload using Intermediate Equivalent (IE) values. Some 1827 procedures were documented. The three consultants performed 796 (44 per cent) procedures, the senior registrar (SR) 137 (7.5 per cent), the registrar 241 (13 per cent) and the three senior house officers (SHO) 644 (35 per cent). The consultant was first assistant in 185 (66 per cent) procedures performed by the SHOs, in 52 (61 per cent) by the registrar in 9 (13 per cent) by the SR. When assessed by caseload one SHO (as a representative example) performed 224 procedures compared to 137 by the SR. The IE workloads were 156 and 166 respectively. This better reflected the greater complexity of the operations performed by the SR. This study has shown that details of surgical training can be easily retrieved from existing administrative databases. This can be used to document the number and type of operations performed by a trainee and the degree of consultant supervision. The degree of surgical training is better assessed by weighted workload rather than caseload.