Comparative effectiveness of pathological techniques to improve lymph node yield from colorectal cancer specimens: a systematic review and network meta-analysis.

A number of randomised controlled trials (RCT) have compared different techniques to improve lymph node yield (LNY) in colorectal cancer specimens, but data on comparative effectiveness are sparse. Our aim was to compare the relative effectiveness and rank all available techniques. A systematic search of Embase, Cochrane, PubMed and Scopus was performed for randomised trials. Pairwise was meta-analysis performed if more than two homogeneous studies were available for each comparison. Network meta-analysis was used to rank and compare all available techniques. Fifteen studies fulfilled the inclusion criteria. Techniques that were compared included methylene blue (MB), glacial acetic acid, ethanol, distilled water and formaldehyde (GEWF), Carnoy solution (CS), patent blue (PB), formalin, fat clearing (FC) and their combinations. The overall quality of studies was found to be fair. In pairwise meta-analysis MB had a higher lymph node yield weighted mean difference (WMD) = 13.67 (4.83-22.51), P < 0.01, lower number of specimens with fewer than 12 lymph nodes log odds ratio = -1.88 (-2.8, -0.91), P < 0.01 and higher LNY in patients with prior chemoradiotherapy [WMD = 9.11 (3.15, 15.08), P = 0.02] compared to formalin. Evaluation of the network plot revealed a well-connected network. In network meta-analysis MBFC had a higher LNY with [mean difference (MD) 13 and 95% credible interval (CrI) = 2.09-23.91] compared to formalin. MBFC probability of being the best technique for LNY was 91.4%. In network meta-analysis MB did not have a statistically significant difference when compared to formalin. MBFCS seems to be the most effective technique for LNY. Further studies are required to make safe conclusions for outcomes such positive lymph nodes and upstaging.

Referrers' point of view on the referral process to neurosurgery and opinions on neurosurgeons: a large-scale regional survey in the UK.

OBJECTIVES: There is an increased reliance on online referral systems (ORS) within neurosurgical departments across the UK. Opinions of neurosurgeons on ORS are extensively reported but those of referrers have hardly been sought. Our study aims at ascertaining our referring colleagues' views on our ORS and its impact on patient care, their opinions on neurosurgeons and how to improve our referral process. SETTING: 14 district general hospitals and one teaching hospital. PARTICIPANTS: 641 healthcare professionals across a range of medical and surgical specialties including doctors of all grades, nurses and physiotherapists. Survey responses were obtained by medical students using a smartphone application. RESULTS: Although 92% of respondents were aware of the ORS, 74% would routinely phone the on-call registrar either before or after making referrals online. The majority (44%) believed their call to relate to a life-threatening emergency. 62% of referrers considered the ORS helpful in informing patients' care and 48% had a positive opinion of their interaction with neurosurgical registrars. On ways to improve the ORS, 50% selected email/text confirmation of response sent to referrers and 16% to referring consultants. CONCLUSION: Our results confirm that referrers feel that using our ORS positively impacts patient care but that it remains in need of improvement in order to better suit our colleagues' needs when it comes to managing neurosurgical patients. We feel that the promotion of neurosurgical education and mitigation of the effects of adverse workplace human factors are likely to achieve the common goal of neurosurgeons and referrers alike: a high standard in patient care.