Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy.

BACKGROUND: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored. METHODS: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. RESULTS: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. CONCLUSION: Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Intravenous Local Anesthetic Compared With Intraperitoneal Local Anesthetic in Laparoscopic Colectomy: A Double-blind Randomized Controlled Trial.

INTRODUCTION: Controlling perioperative pain is essential to improving patient experience and satisfaction following surgery. Traditionally opioids have been frequently utilized for postoperative analgesia. Although they are effective at controlling pain, they are associated with adverse effects, including postoperative nausea, vomiting, ileus, and long-term opioid dependency.Following laparoscopic colectomy, the use of intravenous or intraperitoneal infusions of lidocaine (IVL, IPL) are promising emerging analgesic options. Although both techniques are promising, there have been no direct, prospective randomized comparisons in patients undergoing laparoscopic colon resection. The purpose of this study was to compare IPL with IVL. METHODS: Double-blinded, randomized controlled trial of patients undergoing laparoscopic colonic resection. The 2 groups received equal doses of either IPL or IVL which commenced intra-operatively with a bolus followed by a continuous infusion for 3 days postoperatively. Patients were cared for through a standardized enhanced recovery after surgery program. The primary outcome was total postoperative opioid consumption over the first 3 postoperative days. Patients were followed for 60 days. RESULTS: Fifty-six patients were randomized in a 1:1 fashion to the IVL or IPL groups. Total opioid consumption over the first 3 postoperative days was significantly lower in the IPL group (70.9 mg vs 157.8 mg P < 0.05) and overall opioid consumption during the total length of stay was also significantly lower (80.3 mg vs 187.36 mg P < 0.05. Pain scores were significantly lower at 2 hours postoperatively in the IPL group, however, all other time points were not significant. There were no differences in complications between the 2 groups. CONCLUSION: Perioperative use of IPL results in a significant reduction in opioid consumption following laparoscopic colon surgery when compared to IVL. This suggests that the peritoneal cavity/compartment is a strategic target for local anesthetic administration. Future enhanced recovery after surgery recommendations should consider IPL as an important component of a multimodal pain strategy following colectomy.

Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Both topical and oral metronidazole have been shown to reduce pain after excisional hemorrhoidectomy. Although recent meta-analyses have demonstrated efficacy against placebo, there has been no comparison between the 2 routes. OBJECTIVE: This study aims to investigate whether topical or oral metronidazole provides the most analgesic properties after excisional hemorrhoidectomy. DESIGN: A prospective, double-blind, randomized controlled trial was performed. SETTING: This trial was conducted at 2 hospitals in New Zealand between March 2019 and February 2020. PATIENTS: Adults undergoing elective excisional hemorrhoidectomy for grade III/IV hemorrhoids were randomized. INTERVENTIONS: Participants were randomized to receive either topical metronidazole ointment and an oral placebo versus oral metronidazole with a placebo ointment for 7 days. MAIN OUTCOME MEASURES: The primary outcome was daily pain scores for 7 days, estimated using a generalized linear mixed model fitted with time and treatment arm and tested for interaction with time and treatment arm. Secondary outcomes included additional analgesia, return to normal activity, recovery scores, and adverse effects. RESULTS: A total of 120 participants were included, with 60 in each group. A unimodal peak of pain was recorded with the maximum at days 3 and 4, but there was no significant difference in resting pain scores, with a mean difference at day 3 of 0.47 (-0.48, 1.42). There were no significant differences for secondary outcomes. Fourteen (11.7%) participants were readmitted, without significant difference between groups. Fifty-nine percent of participants preferred topical analgesic compared with 31% who preferred oral and 9.7% who had no preference. LIMITATIONS: This was a pragmatic study in which we could not have stopped participants seeking other analgesics and with less than perfect complete compliance. CONCLUSION: Postoperative oral and topical metronidazole provide similar analgesia after excisional hemorrhoidectomy. The route should depend on patient preference, with topical administration potentially benefiting from improved antimicrobial stewardship and having less effect on the gut microbiome. See Video Abstract at http:/links.lww.com/DCR/B853 .METRONIDAZOL TÓPICO VERSUS ORAL DESPUÉS DE UNA HEMORROIDECTOMÍA POR ESCISIÓN: UN ENSAYO CONTROLADO ALEATORIO DOBLE CIEGO. ANTECEDENTES: Se ha demostrado que tanto el metronidazol tópico como el oral reducen el dolor después de una hemorroidectomía por escisión. Aunque los metaanálisis más recientes han demostrado eficacia frente al placebo, no ha habido comparación entre las dos vías. OBJETIVO: Este estudio tiene como objetivo investigar si el metronidazol tópico u oral proporciona las propiedades más analgésicas después de una hemorroidectomía por escisión. DISEO: Se realizó un ensayo prospectivo, controlado, aleatorio, a doble ciego. AJUSTE: Este ensayo fue realizado en dos hospitales de Nueva Zelanda entre marzo de 2019 y febrero de 2020. PACIENTES: Se asignaron al azar pacientes adultos sometidos a hemorroidectomía por escisión electiva por hemorroides de grado III / IV. INTERVENCIONES: Los participantes fueron asignados al azar para recibir un ungüento de metronidazol tópico y un placebo oral versus metronidazol oral con un ungüento de placebo durante siete días. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fueron las puntuaciones diarias de dolor durante siete días, estimadas mediante un modelo lineal mixto generalizado ajustado tanto con el tiempo y el brazo de tratamiento y probado para la interacción con el tiempo y el brazo de tratamiento. Los resultados secundarios incluyen analgesia adicional, retorno a la actividad normal, puntuaciones de recuperación y efectos adversos. RESULTADOS: Se incluyó un total de 120 participantes, 60 en cada grupo. Se registró un pico de dolor unimodal con el máximo en los días 3 y 4, pero no hubo diferencias significativas en las puntuaciones de dolor en reposo, con una diferencia media en el día 3 de 0,47 (-0,48, 1,42). No hubo diferencias significativas para los resultados secundarios. Catorce (11,7%) participantes fueron readmitidos, sin diferencias significativas entre los grupos. El cincuenta y nueve por ciento de los participantes prefirió el tópico, en comparación con el 31% por vía oral y el 9,7% sin preferencia. LIMITACIONES: Este fue un estudio pragmático en el que no pudimos haber impedido que los participantes buscaran otros analgésicos, con un cumplimiento completo menos que perfecto. CONCLUSINES: El metronidazol posoperatorio por vía oral o tópica proporciona una analgesia similar después de una hemorroidectomía por escisión. La vía debe depender de la preferencia del paciente, y la administración tópica se beneficia potencialmente por una mejor protección de los antimicrobianos y un menor efecto sobre el microbioma intestinal. Consulte Video Resumen en http://links.lww.com/DCR/B853 . (Traducción-Dr Osvaldo Gauto).

Detection of Anastomotic Leakage Following Elective Colonic Surgery: Results of the Prospective Biomarkers and Anastomotic Leakage (BALL) Study.

BACKGROUND: Anastomotic leakage (AL) is an infrequent but life-threatening surgical complication following colorectal surgery. Early diagnosis remains clinically difficult but is a necessity to reduce associated morbidity and mortality. Clinical review and radiological modalities for the diagnosis of leakage remain non-specific and often only detect AL once it is well developed. Inflammatory biomarkers however have shown promise in early pre-clinical detection of leakage following colorectal surgery. METHODS: A multi-center, prospective observational study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were initially recruited over a 3-y period. Perioperative blood samples were collected to measure interleukin (IL)-6, IL-1ß, tumor necrosis factor α, IL-10, C-reactive protein (CRP), leukocyte and neutrophil counts. Statistical analysis was performed to compare patients with an uncomplicated recovery with patients with AL. RESULTS: Sixteen patients developed AL (5.7%), diagnosed at a median post-operative (POD) day 7. CRP and IL-6 were consistently elevated in the early post-operative period in patients with AL, and had the best diagnostic accuracy on POD 3 (area under the curve 0.70; P = 0.02) and POD 1 (area under the curve 0.69; P = 0.02), respectively. IL-10, once adjusted for body mass index and surgical approach, was the sole biomarker significantly elevated in patients with AL on POD 4. CONCLUSIONS: Early post-operative elevations of CRP and IL-6 provide utility for early detection of AL after elective colectomy. Application of these inflammatory biomarkers and their combinations in daily practice warrants further investigation.

A systematic review and meta-analysis of the efficacy of topical sphincterotomy treatments for anal fissure.

BACKGROUND: Anal fissure is a common condition that can be treated medically or surgically. Chemical sphincterotomy is often used before surgical intervention. This study aims to evaluate the effectiveness of topical agents for chemical sphincterotomy on healing of anal fissures and side-effects. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant systematic review was performed using MEDLINE, EMBASE, Scopus, and CENTRAL databases. Eligible studies included randomized controlled trials which compared topical sphincterotomy agents with topical placebo agents or each other. Studies that included surgical treatments were excluded. Overall evidence was synthesized according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: Thirty-seven studies met the study selection criteria. Seventeen studies show that glyceryl trinitrate (GTN) was significantly more likely to heal anal fissure than placebo (relative risk (RR) = 1.96, 95% confidence interval (95%CI) = 1.35-2.84, I2 = 80%). Eleven studies showed a marginally significant difference between healing rates for diltiazem vs GTN, RR = 1.16, (1.01-1.33) I2 = 48%. There was no significant difference in healing between diltiazem and placebo, RR = 1.65, (0.64-4.23), I2 = 92%. GTN significantly reduced pain on the visual analog scale compared to the placebo group, MD-0.97 (-1.64 to -0.29) I2 = 92%. There was high certainty of evidence that GTN was significantly more likely to cause headache than placebo (RR = 2.73 (1.82-4.10) I2 = 58%) and diltiazem RR = 6.88 (2.19-21.63) I2 = 17%. CONCLUSION: There is low certainty evidence topical nitrates are an effective treatment for anal fissure healing and pain reduction compared to placebo. Despite widespread use of topical diltiazem, more evidence is required to establish the effectiveness of calcium channel blockers compared to placebo.

Epidemiology of haemorrhoids and publicly funded excisional haemorrhoidectomies in New Zealand (2007-2016): a population-based cross-sectional study.

AIM: Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. METHOD: This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. RESULTS: A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. CONCLUSION: There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

Patient Experiences of the Emergency Laparotomy Pathway: A Qualitative Study.

INTRODUCTION: Emergency laparotomy (EL) is a commonly performed operation with high rates of morbidity and mortality. Despite a growing body of literature on outcomes from EL, there is sparse literature on the patient experience. The aim of this study is to capture the perspective of patients on their EL experience. Qualitative methodology is used as a platform to allow patients to express their personal experiences and ideas around the EL process. MATERIALS AND METHOD: Participants were consented as a part of a large observational study, established across the three public teaching hospitals in Auckland, New Zealand. Patients who had an EL within the past 4 months were recruited. A recorded interview was conducted either face-to-face or over the telephone, using questions formulated from a previous systematic review on EL outcomes. Transcripts were transported to NVivo and thematically analysed by two reviewers. RESULTS: Fifteen participants were interviewed. The majority of participants were female, New Zealand European and 65 or older. Five important themes were identified. Overall, participants expressed satisfaction with their interactions with hospital staff. However, they wanted more information about their condition, operation and what outcomes might occur. Participants also described post-operative priorities in the acute setting, as well as long-standing physical and emotional impacts. CONCLUSION: This study provides a better understanding of what is important to patients during the EL process. This information is important when considering ways to improve care and communication with patients undergoing EL.

Intraperitoneal Tramadol in Abdominal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesic regimes are required to treat pain. Intraperitoneal (IP) agents, such as local anesthetics (LAs), have been shown to reduce pain after abdominal surgery. Other IP analgesics have been tested in several randomized control trials (RCTs), but no reviews or guidelines have evaluated their use. Tramadol is an effective oral and intravenous analgesia with recent evidence supporting the use of IP tramadol (IPT). We aimed to review the efficacy of IPT as an adjunct to intraperitoneal local anesthetics (IPLAs) for pain relief after abdominal surgery. MATERIALS AND METHODS: Relevant articles were identified by two independent reviewers from MEDLINE, EMBASE and PubMed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines up to January 2019. Only RCT comparing IPT + IPLA with IPLA alone were included. Outcomes recorded were the postoperative analgesic requirement, pain scores at 4 h and 24 h and adverse events. Data were analyzed with Review Manager, version 5.3. RESULTS: A total of five RCTs (4× laparoscopic cholecystectomy and 1× abdominal hysterectomy) were included in this review from 419 studies screened. All doses were given as a single bolus. Pain relief requirements over the first 24 h weres less in the IPT + IPLA groups when compared with those in IPLA alone. Pain scores were less for IPT + IPLA groups at 4 h and 24 h. There were no significant differences in adverse events between groups. CONCLUSIONS: In summary, IPT, in combination with IPLA, is effective in the management of acute postoperative pain and reduces the total amount of pain relief consumed in the first 24 h after surgery. Studies reporting the use of IPT + IPLA reported no toxicity or systemic adverse events. Further research into standardizing the dosing of IPT to optimize its effectiveness and further reduce the additional analgesic requirement is indicated.

Topical analgesia following excisional haemorrhoidectomy: a systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Post-operative pain following excisional haemorrhoidectomy poses a particular challenge for patient recovery, as well as a burden on hospital resources. There appears to be an increasing role for topical agents to improve this pain, but their efficacy and safety have not been fully assessed. This systematic review aims to assess all topical agents used for pain following excisional haemorrhoidectomy. METHODS: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors independently assessed MEDLINE, EMBASE, and CENTRAL databases to 27 June 2019. All randomised controlled trials (RCTs) in English that investigated topical agents following excisional haemorrhoidectomy were included. Meta-analysis was performed using Review Manager, version 5.3. RESULTS: A total of 3639 records were identified. A final 32 RCTs were included in the qualitative analysis. Meta-analysis was performed on 9 RCTs that investigated glyceryl trinitrate (GTN) (5 for diltiazem, 2 for metronidazole and 2 for sucralfate). There were mixed significant changes in pain for GTN compared with placebo. Diltiazem resulted in significant reduction of pain on post-operative days 1, 2, 3 and 7 (p < 0.00001). Metronidazole resulted in significant reduction of pain on days 1 (p = 0.009), 7 (p = 0.002) and 14 (p < 0.00001). Sucralfate resulted in signification reduction of pain on days 7 and 14 (both p < 0.00001). CONCLUSION: Topical diltiazem, metronidazole and sucralfate appear to significantly reduce pain at various timepoints following excisional haemorrhoidectomy. GTN had mixed evidence. Several single trials identified other promising topical analgesics.

Local Anaesthesia Alone Versus Regional or General Anaesthesia in Excisional Haemorrhoidectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Excisional haemorrhoidectomy has been traditionally performed under general or regional anaesthesia. However, these modes are associated with complications such as nausea, urinary retention and motor blockade. Local anaesthesia (LA) alone has been proposed to reduce side effects as well as to expedite ambulatory surgery. This systematic review aims to assess LA versus regional or general anaesthesia for excisional haemorrhoidectomy. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE and CENTRAL databases were searched to 13 January 2020. All randomised controlled trials comparing LA only versus regional or general anaesthesia in patients who received excisional haemorrhoidectomy were included. The main outcomes included pain, adverse effects and length of stay. RESULTS: Nine trials, consisting of six studies comparing local versus regional anaesthesia and three comparing LA versus general anaesthesia, were included. Meta-analysis showed a significantly lower relative risk for need of rescue analgesia (RR 0.32 [95% CI 0.16-0.62]), intra-operative hypotension (RR 0.17 [95% CI 0.04-0.76]), headache (RR 0.13 [0.02-0.67]) and urinary retention (RR 0.17 [95% CI 0.09-0.29]) for LA when compared with regional anaesthesia. There was mixed evidence for both regional and general anaesthesia in regard to post-operative pain. CONCLUSIONS: LA alone may be considered as an alternative to regional anaesthesia for excisional haemorrhoidectomy with reduced complications and reduction in the amount of post-operative analgesia required. The evidence for LA compared to general anaesthesia for haemorrhoidectomy is low grade and mixed.

An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group.

BACKGROUND: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training. METHODS: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries. RESULTS: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country's need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries. CONCLUSIONS: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Comparison of Feather Damage Associated With the Application of Pressure-sensitive Adhesive Tapes.

Pressure-sensitive adhesive tapes are commonly used for the positioning of birds for radiography and securing bandages. The effect of 5 common tapes on feather structure was investigated with before-and-after comparisons. Each tape demonstrated a characteristic pattern of damage to the feather vane that involved separation of barbules and/or tearing of barbs. Tapes with rigid backing materials and strong adhesives were more likely to cause tearing and barbule separation, respectively, whereas flexible tapes with limited adhesion to feathers were more successful in securing feathers without causing irreparable damage. Consideration should be given to the appropriate selection of tape applied to the feathers of birds to prevent iatrogenic damage to their plumage.

Laparoscopic Ventral Hernia Repair in South Auckland, New Zealand-A Retrospective Review.

BACKGROUND: Ethnic disparities in surgical care and outcomes have been previously reported in studies for other surgical procedures. In addition, it has been reported that ethnic differences in postoperative analgesia exist. We aimed to determine ethnic disparities in postoperative outcomes, total opioid analgesia use, and complication rates of all patients who underwent a laparoscopic ventral hernia repair (LVHR) at our institution over a 3-y period. METHODS: A retrospective review of all patients who underwent an LVHR at Counties Manukau Health from January 1, 2013, to December 31, 2015, was performed in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement. RESULTS: A total of 267 ventral hernias were repaired in 254 patients at Counties Manukau Health over the study period, of which most were primary umbilical ventral hernias. The majority of patients in our cohort were New Zealand European and male. Major complications, as per the Clavien-Dindo classification grade 3 and above, were observed in six patients with no deaths (2.4%). There were no statistically significant ethnic disparities in length of stay, receipt of opioid analgesia, and rates of complication observed after linear regression modeling after adjustment for confounding factors. CONCLUSIONS: Our study showed that the majority of patients who had a ventral hernia repaired at our institution were mostly New Zealand European and male. Although significant ethnic disparities in patient characteristics were observed, these were not associated with ethnic disparities in postoperative outcomes after an LVHR.

MYCOTIC DERMATITIS IN JUVENILE FRESHWATER CROCODILES (CROCODYLUS JOHNSTONI) CAUSED BY NANNIZZIOPSIS CROCODILI.

Nannizziopsis crocodili, a contagious, keratinophilic fungus, was identified from biopsied tissue in a captive juvenile freshwater crocodile during an outbreak of severe multifocal dermatitis affecting four of five crocodiles. Lesions progressed from superficial, well-demarcated ulceration of scales, to black pigmentation, localized edema, erythema, and flattening of the scales. Treatment with topical enilconazole provided clinical improvement in three of four crocodiles but all developed terminal gout. One crocodile did not develop clinical disease despite long-term exposure. This is the first report of N. crocodili in freshwater crocodiles and in a location remote to the index Australian case.

Paediatric Osteomyelitis in Fiji.

INTRODUCTION: Osteomyelitis can lead to significant morbidity and long-term disability if early treatment is not initiated in a timely manner. For developing countries this can lead to a significant burden on the healthcare system. This study aims to describe the demographic variables, aetiology and outcomes of treatment and to calculate the incidence of paediatric osteomyelitis in Fiji. The micro-organism profile and the outcomes for treatment were analysed. METHODS: This is a retrospective review of medical records of all paediatric patients presenting to hospitals in Fiji over a 5-year period (2006-2010) with a diagnosis of osteomyelitis. Data were collected from the three divisional hospitals in Fiji (Colonial War Memorial Hospital, Lautoka Hospital and Labasa Hospital). RESULTS: Two hundred and twenty patients were identified. An annual incidence of 18.1 cases/100,000 paediatric population was identified. The highest incidence was in the itaukei (ethnic Fijian) population (21 cases/100,000). Males were at a higher risk of developing osteomyelitis (20.8/105 vs. 10.7/105). Staphylococcus Aureus was identified in 86% of all positive blood and 81% of all positive pus cultures, and it was sensitive to cloxacillin in 100% of cases. The most common factor identified preceding the development of osteomyelitis was trauma (55%) followed by skin sepsis (32%). Fifty-four per cent of the cases had chronic osteomyelitis, and the most common mode of presentation was in the form of an abscess (48%) followed by sinus/sequestrum (24%). The age group most commonly affected was between 5 and 9 years of age (19.6/105). Children with chronic osteomyelitis were more likely to require operative intervention in addition to antibiotics as compared to acute osteomyelitis (85 vs. 24%). The success rate of treating acute osteomyelitis was 92% compared to 61% for chronic osteomyelitis. CONCLUSION: Paediatric osteomyelitis poses a significant problem in Fiji, especially in the male, ethnic Fijian population between 5 and 9 years of age. The chance of complete resolution after treatment of acute osteomyelitis is very good. Therefore, interventions aimed at early diagnosis and treatments are required.

Intravenous Local Anaesthetic Compared with Intraperitoneal Local Anaesthetic in Abdominal Surgery: A Systematic Review.

INTRODUCTION: Modern perioperative care strategies aim to optimise perioperative care by reducing the body's stress response to surgery. A major facet of optimising an abdominal surgery analgesia programme is using a multimodal opioid sparing approach. Local anaesthetics have shown promise and there has been considerable research into the most effective route for their administration. This review aims to determine if there is a difference in analgesic efficacy between intraperitoneal local anaesthetic (IPLA) and intravenous local anaesthetic (IVLA). MATERIALS AND METHODOLOGY: In concordance with the PRISMA statement, a literature search was conducted to identify randomised control trials that compared IVLA with IPLA in abdominal surgery. The primary outcomes of interest were opioid analgesia requirements and pain score assessed by visual analogue score. Data were extracted and entered into pre-designed electronic spreadsheets. RESULTS: This review has identified six papers that compared intravenous lignocaine to intraperitoneal lignocaine. This review showed significantly lower morphine consumption at 4 and 24 h in the intraperitoneal group. There was no significant difference in pain scores. CONCLUSION: From the analysis of these studies, intraperitoneal local anaesthetic had an analgesic benefit over intravenous lignocaine with regard to decreased opioid consumption for abdominal surgery. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

A Retrospective Study of Horner Syndrome in Australian Wild Birds, 2010-2016.

Horner syndrome was identified in 25 of 30 777 avian admissions to Currumbin Wildlife Hospital during 2010-2016. Unilateral ptosis and erection of facial feathers were distinct findings on physical examination and consistent across 9 species. Affected birds were biased toward adults (64%) suffering traumatic injuries (88%). Concurrent injuries requiring treatment were present in 38% of cases, and 76% had additional neurologic deficits. Prognosis for release was poor, with an overall success rate of 32%. Resolution of clinical signs increased to 44% with higher doses of meloxicam and required an average hospitalization of 22 days (range, 3-78 days). Further investigation of the underlying causes of Horner syndrome in birds to provide treatment and prognostic guidelines is warranted.

Standard-dose pembrolizumab in combination with reduced-dose ipilimumab for patients with advanced melanoma (KEYNOTE-029): an open-label, phase 1b trial.

BACKGROUND: Reduced-dose nivolumab in combination with standard-dose ipilimumab improves objective response and progression-free survival compared with standard-dose ipilimumab alone, but increases toxicity. We assessed the safety and anti-tumour activity of standard-dose pembrolizumab in combination with reduced-dose ipilimumab. METHODS: In this open-label, phase 1b trial, we recruited patients from 12 medical centres in Australia, New Zealand, and the USA. Eligible patients were aged at least 18 years, had advanced melanoma, had an Eastern Coooperative Oncology Group performance status of 0 or 1, had measurable disease according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, had adequate organ function, had resolution of toxic effects of the most recent previous chemotherapy to grade 1 or less, had no active autoimmune disease requiring systemic steroids or immunosuppressive agents, had no active non-infectious pneumonitis, had no uncontrolled thyroid dysfunction or diabetes, had no active brain metastases, and had not received previous immune checkpoint inhibitor therapy. Patients received intravenous pembrolizumab 2 mg/kg plus intravenous ipilimumab 1 mg/kg every 3 weeks for four doses, followed by intravenous pembrolizumab 2 mg/kg every 3 weeks for up to 2 years or disease progression, intolerable toxicity, withdrawal of consent, or investigator decision. The primary endpoint was safety and tolerability. The proportion of patients achieving an objective response assessed per RECIST version 1.1 by independent central review and overall survival were secondary endpoints. We also assessed progression-free survival. The primary endpoint was assessed in all patients who received at least one dose of combination therapy. Activity was assessed in all enrolled patients. This trial is registered with ClinicalTrials.gov, number NCT02089685. Enrolment into this cohort is closed, but patients are still being monitored for safety and anti-tumour activity. FINDINGS: Between Jan 13, 2015, and Sept 17, 2015, we enrolled and treated 153 patients. As of the Oct 17, 2016, cutoff date, median follow-up was 17·0 months (IQR 14·8-18·8). 110 (72%) of 153 patients received all four pembrolizumab plus ipilimumab doses; 64 (42%) remained on pembrolizumab monotherapy. 110 grade 3-4 treatment-related adverse events occurred in 69 (45%) patients. No treatment-related deaths occurred. Treatment-related adverse events led to discontinuation of pembrolizumab and ipilimumab in 22 (14%) patients, including 17 (11%) who discontinued both treatments for the same event and five (3%) who discontinued ipilimumab for one event and later discontinued pembrolizumab for another. 12 (8%) patients discontinued ipilimumab only and 14 (9%) discontinued pembrolizumab only because of treatment-related adverse events. 158 immune-mediated adverse events of any grade occurred in 92 (60%) patients, and 50 immune-mediated adverse events of grade 3-4 occurred in 42 (27%) patients; the most common immune-mediated adverse events were hypothyroidism (25 [16%]) and hyperthyroidism (17 [11%]). 93 (61% [95% CI 53-69]) patients achieved an objective response. Estimated 1 year progression-free survival was 69% (95% CI 60-75), and estimated 1 year overall survival was 89% (95% CI 83-93). INTERPRETATION: Standard-dose pembrolizumab given in combination with four doses of reduced-dose ipilimumab followed by standard-dose pembrolizumab has a manageable toxicity profile and provides robust anti-tumour activity in patients with advanced melanoma. These data suggest that standard-dose pembrolizumab plus reduced-dose ipilimumab might be a tolerable, efficacious treatment option for patients with advanced melanoma. A randomised phase 2 trial of alternative dosing strategies of this combination is underway. FUNDING: Merck & Co, Inc.

Intraperitoneal Local Anesthetic for Laparoscopic Appendectomy in Children: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to investigate the efficacy of intraperitoneal local anesthetic (IPLA) on pain after acute laparoscopic appendectomy in children. SUMMARY OF BACKGROUND: IPLA reduces pain in adult elective surgery. It has not been well studied in acute peritoneal inflammatory conditions. We hypothesized that IPLA would improve recovery in pediatric acute laparoscopic appendectomy. METHODS: This randomized controlled trial in acute laparoscopic appendectomy recruited children aged 8 to 14 years to receive 20 mL 0.25% or 0.125% bupivacaine (according to weight) atomized onto the peritoneum of the right iliac fossa and pelvis, or 20 mL 0.9% NaCl control. Unrestricted computer-generated randomization was implemented by surgical nurses. Participants, caregivers, and outcome assessors were blinded. The primary outcome was pain score. Analysis was by a linear mixed-effects model. RESULTS: Of 184 randomized participants (92 to each group), the final analysis included 88 IPLA and 87 control participants. There was no statistically significant difference in overall pain scores (effect estimate 0.004, standard error 0.028, 95% confidence interval -0.052, 0.061), and no difference in right iliac fossa or suprapubic site-specific pain scores, opioid use, recovery parameters, or complications. No child experienced a complication related to the intervention. CONCLUSION: IPLA imparted no clinical benefit to children undergoing acute laparoscopic appendectomy and cannot be recommended in this setting.