Adherence to General Medical Council guidance regarding disclosure of alternative treatments during the consent process.

INTRODUCTION: General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis. METHODS: We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy. RESULTS: Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it (p<0.001). CONCLUSION: In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Laparoscopy uptake for paediatric appendicectomy: a comparison of general surgeons versus specialist paediatric surgeons in England from 1997 to 2015.

INTRODUCTION: Laparoscopy is used in as many as 95% of adult appendicectomies. There is level I evidence showing that it reduces wound infection, postoperative ileus and length of inpatient stay in children compared with the open approach. The aim of this study was to report the uptake of laparoscopy for paediatric appendicectomy in England and to determine whether this was similar for general surgeons (GS) and specialist paediatric surgeons (SPS). METHODS: Hospital Episode Statistics data were obtained for all children aged <16 years who had an OPCS 4.6 code for emergency appendicectomy from 1997 to 2015 (18 years). Data are analysed to compare rate of laparoscopic vs open procedures for GS and SPS over time and to investigate factors associated with the use of laparoscopy. RESULTS: There were 196,987 appendicectomies and where specialty was available, 133,709 (79%) cases were undertaken by GS and 35,141 (21%) by SPS. The rate of cases undertaken with laparoscopy for both specialties combined increased from 0.8% in 1998 to 50% in 2014 (p<0.0001). In 2014, this rate was 41% for GS compared with 71% for SPS (p<0.0001). Female gender (odds ratio (OR)=1.84, 95% confidence interval (CI) 1.80-1.90), increasing age (OR=1.18, 95% CI 1.18-1.19 per year) and treatment by SPS (OR=3.71, 95% CI 3.60-3.82) were all factors positively associated with use of laparoscopy in multivariate analysis. CONCLUSIONS: There has been a vast increase in the proportion of appendicectomies undertaken laparoscopically in children. Despite adjusting for patient factors, laparoscopy was used significantly less by GS when compared with SPS. This difference is most apparent in younger children.

Barrett's oesophagus and oesophageal cancer following oesophageal atresia repair: a systematic review.

BACKGROUND: Concern exists that patients born with oesophageal atresia (OA) may be at high risk for Barrett's oesophagus (BO), a known malignant precursor to the development of oesophageal adenocarcinoma. Screening endoscopy has a role in early BO identification but is not universal in this population. This study aimed to determine prevalence of BO after OA repair surgery, to quantify the magnitude of this association and inform the need for screening and surveillance. METHODS: A systematic review, undertaken according to PRISMA guidelines, was preregistered on PROSPERO (CRD42017081001). PubMed and EMBASE were interrogated using a standardized search strategy on 31 July 2020. Included papers, published in English, reported either: one or more patients with either BO (gastric/intestinal metaplasia) or oesophageal cancer in patients born with OA; or long-term (greater than 2 years) follow-up after OA surgery with or without endoscopic screening or surveillance. RESULTS: Some 134 studies were identified, including 19 case reports or series and 115 single- or multi-centre cohort studies. There were 13 cases of oesophageal cancer (9 squamous cell carcinoma, 4 adenocarcinoma) with a mean age at diagnosis of 40.5 (range 20-47) years. From 6282 patients under long-term follow-up, 317 patients with BO were reported. Overall prevalence of BO was 5.0 (95 per cent c.i. 4.5 to 5.6) per cent, with a mean age at detection of 13.8 years (range 8 months to 56 years). Prevalence of BO in series reporting endoscopic screening or surveillance was 12.8 (95 per cent c.i. 11.3 to 14.5) per cent. CONCLUSION: Despite a limited number of cancers, the prevalence of BO in patients born with OA is relatively high. While limited by the quality of available evidence, this review suggests endoscopic screening and surveillance may be warranted, but uncertainties remain over the design and effectiveness of any putative programme.

Parental decisional satisfaction after hypospadias repair in the United Kingdom.

BACKGROUND: In hypospadias, the aim of surgical treatment is to achieve both desirable functional and cosmetic outcomes; however, complications following surgery are common and 18% of boys require re-operation. In mild degrees of hypospadias, repair may be offered entirely to improve cosmesis, meaning parents should be fully informed of this and the potential for complications, during the consent process. Parents' decision-making may be aided by making them aware of how others in a similar position have felt about the decision that they made for their child. One method of measuring parental satisfaction is decisional regret (DR). OBJECTIVES: To assess parental satisfaction following hypospadias surgery in the United Kingdom by assessing DR and to determine the feasibility of obtaining meaningful data via a mobile phone survey. STUDY DESIGN: The National Outcomes Audit in Hypospadias database was commissioned by the British Association of Paediatric Surgeons to capture clinical information from hypospadias repairs. Following ethical approval (16/NW/0819), a text message was sent to mobile numbers in the database inviting participation in a questionnaire incorporating the validated DR scale (DRS). The primary outcome measure was mean DRS score, which was correlated with clinical information, a score of zero indicated no regret and 100 indicated maximum regret. RESULTS: There were 340 (37%) responses. The median age at the primary procedure was 16 (interquartile range 13-20) months. No DR (score = 0) was detected in 186 (55% [95%CI 49-60]) respondents; however, moderate-to-severe DR (score = 26-100) was seen in 21 (6.2% [95%CI 3.6-8.7]) respondents. On multivariate analysis, a distal meatus, a small glans and developing complications requiring repeat surgery were all associated with increased levels of regret (Table). There was no association between DR and cases performed per surgeon. DISCUSSION: Around half of respondents demonstrated no DR and postoperative complications requiring surgery were associated with the highest levels of DR, which is similar to a Canadian study. Lorenzo et al. however found that DR was associated with circumcision, which was undertaken in all boys; however, in this UK study, around a third of boys were circumcised and regret levels between those circumcised and those not circumcised were similar. The limitations of this work include the following: surgeons submitting their own data on complications and there is potential of selection bias between respondents and non-respondents as with any survey. CONCLUSIONS: Data from this study can be used to improve pre-operative counselling during the consent process. Smart mobile phone technology can be used successfully to distribute and collect parent-reported outcomes.

Views of general practitioners and head and neck surgeons on the referral system for suspected cancer: a survey.

BACKGROUND: The two-week wait referral system for suspected cancer was introduced in the National Health Service in 2000. This study aimed to identify areas for improvement to the two-week wait system by seeking the opinions of doctors working in primary and secondary care. METHOD: A questionnaire was distributed to general practitioners and head and neck surgeons within North West England with ethical consent. RESULTS: Twenty-seven general practitioners and 15 head and neck surgeons responded. Of the general practitioners, 59.3 per cent declared that they never attend training on referrals in this specialty. Overall, 59.3 per cent of general practitioners and 86.7 per cent of head and neck surgeons felt that the two-week wait system could be improved. CONCLUSION: The main areas for further work are development of pre-referral communication between primary and secondary care along with development of practical educational measures for general practitioners.

Application of 1,1'-carbonyldiimidazole-activated matrices for the purification of proteins. III. The use of 1,1'-carbonyldiimidazole-activated agaroses in the biospecific affinity chromatographic isolation of serum antibodies.

The characteristics of ligands immobilised into 1,1'-carbonyldiimidazole-treated cross-linked agarose have been further evaluated. Since the intermediate activated matrix (an imidazolyl carbamate-agarose) is susceptible to nucleophilic attack by free amino groups, but is relatively stable to oxygen nucleophiles, ligands ranging from simple organic primary amines, amino acids, proteins and other biological substances, which contain amino group functionality, can be bound to the agarose via a N-alkylcarbamate (urethane) linkage. This covalent linkage has been found to exhibit good chemical stability to mildly acidic and basic elution conditions. The use of 1,1'-carbonyldiimidazole-activated agarose in the biospecific affinity chromatography of immunoglobulins, present in normal and pathological sera, is described.

Application of 1,1'-carbonyldiimidazole-activated agarose for the purification of proteins. II. The use of an activated matrix devoid of additional charged groups for the purification of thyroid proteins.

The use of 1,1'-carbonyldiimidazole-activated agarose for biospecific affinity chromatography is described. Activation of agarose with this carbonylating reagent gives a matrix devoid of additional charged groups. Conditions for the coupling of a range of ligands and leashes have been evaluated. The efficient purification of bovine trypsin, human thyroglobulin and sheep thyroid membrane glycoproteins demonstrates the suitability of the new activated matrix for affinity chromatography.

A novel method of activation of cross-linked agaroses with 1,1'-carbonyldiimidazole which gives a matrix for affinity chromatography devoid of additional charged groups.

1,1'-Carbonyldiimidazole, a carbonylating reagent, has been shown to be suitable for the activation of cross-linked agaroses for affinity chromatography. The activated matrix (an imidazolyl carbamate) is relatively stable to hydrolysis but smoothly reacts with N-nucleophiles such as those present in either affinity chromatography ligands or leashes, e.g. ethylenediamine or 6-aminohexanoic acid. If butylamine was attached via the 1,1'-carbonyldiimidazole method, the resulting product was devoid of charged groups and thus had the same titration curve as agarose. The suitability of this new matrix for affinity chromatography was demonstrated by the successful purification of trypsin by several different systems.