Three Centuries of Appendicectomy.

BACKGROUND: Save for the contribution of Charles McBurney, who described his eponymous point and the appendicectomy incision, the history of appendicectomy is largely unknown among the medical profession. This review traces the history from the first anatomical depiction of the appendix to the development of open appendicectomy and the recent minimally invasive and non-operative methods. METHODS: Historical articles, monographs and books containing anatomical descriptions of the vermiform appendix and reports of appendicitis and its surgical treatment were retrieved after searching the PubMed, Google Scholar and Embase databases from their inception to 31 March 2022. RESULTS: The first inadvertent appendicectomy was performed during an operation for a groin hernia by Cookesley in 1731, and Mestivier was the first to drain a right iliac fossa abscess, due to appendicitis, in 1757. Krönlein performed the first appendicectomy for acute appendicitis in 1884 but his patient died. The first successful appendicectomy for acute appendicitis leading to patient survival was by Morton in 1887. In 1976, Wirschafter and Kaufman performed an inadvertent colonoscopic appendicectomy and, in 1980, Semm carried out the first laparoscopic appendicectomy. The first appendicectomy via a natural orifice (transgastric) appendicectomy was by Rao and Reddy in 2004. CONCLUSION: This historical review charts the development of surgical knowledge concerning the management of appendicitis, from the first anatomical drawings of the appendix and descriptions of appendicitis to the development of surgical and conservative treatments up to the present day. It also corrects some inaccuracies of attribution in previous historical reviews.

Time-efficient physical activity interventions to reduce blood pressure in older adults: a randomised controlled trial.

BACKGROUND: Hypertension is a risk factor for both cardiovascular and cerebrovascular disease, with an increasing incidence with advancing patient age. Exercise interventions have the potential to reduce blood pressure in older adults, however, rates of exercise uptake and adherence are low, with 'lack of time' a commonly cited reason. As such, there remains the need for time-efficient physical activity interventions to reduce blood pressure in older adults. OBJECTIVE: To compare the effect of three, novel time-efficient physical activity interventions on resting blood pressure in older adults. METHODS: Forty-eight, healthy, community-dwelling older adults (mean age: 71 years) were recruited to a 6-week randomised control trial. Resting blood pressure was measured before and after one of three supervised, time-efficient interventions: high-intensity interval training (HIIT) on a cycle ergometer; isometric handgrip training (IHG); unilateral, upper limb remote ischaemic preconditioning (RIPC) or non-intervention control. RESULTS: Both HIIT and IHG led to a statistically significant reduction in resting systolic blood pressure (SBP) of 9 mmHg, with no significant change in the RIPC or control groups. There was no change in diastolic blood pressure or pulse pressure in any group. CONCLUSIONS: Supervised HIIT or IHG using the protocols described in this study can lead to statistically significant and clinically relevant reductions in resting SBP in healthy older adults in just 6 weeks.

One- and two-year outcomes and predictors of mortality following emergency laparotomy: a consecutive series from a United Kingdom teaching hospital.

BACKGROUND: Data on outcomes of patients who underwent emergency laparotomy (EML) are limited. This prospective observational study examined aspects of inpatient care and outcomes following EML with a view to identifying predictors of mortality. METHODS: Data collected from consecutive inpatients who underwent EML in a UK teaching hospital over a 3-month period included perioperative physiology, treatment, morbidity, and mortality (30-day, in-hospital, 12-month, and 24-month). Univariate and multiple logistic regression analyses were used to identify predictors of mortality. RESULTS: Eighty-five patients (44 male) with a mean ± SD age of 61 ± 18 years were studied. Postoperatively, 51 % of patients were admitted to the intensive care (ICU) or the high-dependency unit (HDU). 30-day, in-hospital, 12-month, and 24-month mortality was 14, 16.5, 22.4, and 25.9 %, respectively. After adjusting for confounding variables, age ≥70 years (odds ratio [OR] = 9.2, P = 0.004) and a need for postoperative ICU/HDU (OR = 15.0, P = 0.014) were independent predictors of 30-day mortality. Independent predictors of in-hospital mortality were age ≥70 years (OR = 18.2, P = 0.016), ASA ≥III (OR = 22.1, P = 0.034), preoperative sepsis (OR = 20.6, P = 0.045), and need for postoperative ICU/HDU (OR = 21.5, P = 0.038). Independent predictors of 12-month mortality were preoperative urea >7.5 mmol/L (OR = 3.5, P = 0.038) and need for postoperative ICU/HDU (OR = 3.7, P = 0.044). Age ≥70 years was the only independent predictor of 24-month mortality (OR = 4.5, P = 0.014). Almost all deaths recorded in the 24 months following surgery resulted from disseminated malignancy. CONCLUSION: Patients who underwent EML had favourable outcomes, with 2-year survival close to 75 %. Age ≥70 years and the need for postoperative ICU/HDU care were independent predictors of mortality.

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis.

BACKGROUND: This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis. METHODS: A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented. RESULTS: Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. -0.05 to 0.35)). CONCLUSIONS: Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.

Six weeks of high-intensity interval training enhances contractile activity induced vascular reactivity and skeletal muscle perfusion in older adults.

Impairments in muscle microvascular function are associated with the pathogenesis of sarcopenia and cardiovascular disease. High-intensity interval training (HIIT) is an intervention by which a myriad of beneficial skeletal muscle/cardiovascular adaptations have been reported across age, including capillarisation and improved endothelial function. Herein, we hypothesised that HIIT would enhance muscle microvascular blood flow and vascular reactivity to acute contractile activity in older adults, reflecting HIIT-induced vascular remodelling. In a randomised controlled-trial, twenty-five healthy older adults aged 65-85 years (mean BMI 27.0) were randomised to 6-week HIIT or a no-intervention control period of an equal duration. Measures of microvascular responses to a single bout of muscle contractions (i.e. knee extensions) were made in the m. vastus lateralis using contrast-enhanced ultrasound during a continuous intravenous infusion of Sonovue™ contrast agent, before and after the intervention period, with concomitant assessments of cardiorespiratory fitness and resting blood pressure. HIIT led to improvements in anaerobic threshold (13.2 ± 3.4 vs. 15.3 ± 3.8 ml/kg/min, P < 0.001), dynamic exercise capacity (145 ± 60 vs. 159 ± 59 W, P < 0.001) and resting (systolic) blood pressure (142 ± 15 vs. 133 ± 11 mmHg, P < 0.01). Notably, HIIT elicited significant increases in microvascular blood flow responses to acute contractile activity (1.8 ± 0.63 vs. 2.3 ± 0.8 (arbitrary contrast units (AU), P < 0.01)), with no change in any of these parameters observed in the control group. Six weeks HIIT improves skeletal muscle microvascular responsiveness to acute contractile activity in the form of active hyperaemia-induced by a single bout of resistance exercise. These findings likely reflect reports of enhanced large vessel distensibility, improved endothelial function, and muscle capillarisation following HIIT. Moreover, our findings illustrate that HIIT may be effective in mitigating deleterious alterations in muscle microvascular mediated aspects of sarcopenia.

Fasting and surgery timing (FaST) audit.

BACKGROUND & AIMS: International guidance advocates the avoidance of prolonged preoperative fasting due to its negative impact on perioperative hydration. This study aimed to assess the adherence to these guidelines for fasting in patients undergoing elective and emergency surgery in the East Midlands region of the UK. METHODS: This prospective audit was performed over a two-month period at five National Health Service (NHS) Trusts across the East Midlands region of the UK. Demographic data, admission and operative details, and length of preoperative fasting were collected on adult patients listed for emergency and elective surgery. RESULTS: Of the 343 surgical patients included within the study, 50% (n = 172) were male, 78% (n = 266) had elective surgery and 22% (n = 77) underwent emergency surgery. Overall median fasting times (Q1, Q3) were 16.1 (13.0, 19.4) hours for food and 5.8 (3.5, 10.7) hours for clear fluids. Prolonged fasting >12 h was documented in 73% (n = 250) for food, and 21% (n = 71) for clear fluids. Median fasting times from clear fluids and food were longer in the those undergoing emergency surgery when compared with those undergoing elective surgery: 13.0 (6.4, 22.6) vs. 4.9 (3.3, 7.8) hours, and 22.0 (14.0, 37.4) vs. 15.6 (12.9, 17.8) hours respectively, p < 0.0001. CONCLUSIONS: Despite international consensus on the duration of preoperative fasting, patients continue to fast from clear fluids and food for prolonged lengths of time. Patients admitted for emergency surgery were more likely to fast for longer than those having elective surgery.

Hypo- and hypernatraemia in surgical patients: is there room for improvement?

BACKGROUND: Up to 30% of surgical inpatients develop complications related to fluid and electrolyte therapy. We sought to study the occurrence of hypo- and hypernatraemia in these patients to inform current standards of care. METHODS: This prospective audit took place over 80 days in a university hospital. Patients with a serum sodium concentration less than 130 or greater than 150 mmol/l were included. Daily intakes of Na(+), K(+) and Cl(-), and fluid balance were recorded before and after development of dysnatraemia. Fluid balance charts were assessed, as was the presence of documented patient weights. Patients were followed up until one of these milestones was reached: normonatraemia, death, or hospital discharge. RESULTS: During the study period 55 (4%) of the 1,383 surgical admissions met the inclusion criteria. Fifteen patients had hypernatraemia, 13 (87%) of whom were identified on ICU/HDU. In the days preceding the hypernatraemia, patients received (in mmol/day) a median (IQR) of 157 (76-344) Na(+), 38 (6-65) K(+), 157 (72-310) Cl(-), and 1.96 (1.13-2.96) L water. In the days preceding the hyponatraemia, patients received 50 (0-189) Na(+), 0 (0-10) K(+), 56 (0-188) Cl(-), and 1.45 (0-2.60) L water. Before the dysnatraemias only 28% of fluid balance charts were completed accurately. During the audit 42% of patients were not weighed. Dysnatraemic patients had a higher hospital mortality rate than those who did not develop dysnatraemia (12.7 vs. 2.3%, P < 0.001). CONCLUSIONS: Four percent of surgical inpatients developed dysnatraemias, which were associated with increased mortality. Fluid balance documentation was suboptimal and daily weights were not measured routinely, even in patients with severe electrolyte derangements.

The time course of physiological adaptations to high-intensity interval training in older adults.

OBJECTIVE: High-intensity interval training (HIIT) has been shown to be more effective than moderate continuous aerobic exercise for improving cardiorespiratory fitness (CRF) in a limited time frame. However, the length of time required for HIIT to elicit clinically significant improvements in the CRF of older adults is currently unknown. The aim of this study was to compare changes in the CRF of older adults completing identical HIIT protocols of varying durations. METHODS: Forty healthy, community-dwelling older adults completed a cardiopulmonary exercise test (CPET) before and after 2, 4, or 6 weeks of fully supervised HIIT on a cycle ergometer, or a no-intervention control period. RESULTS: Anaerobic threshold (AT) was increased only after 4 (+1.9 [SD 1.1] mL/kg/min) and 6 weeks (+1.9 [SD 1.8] mL/kg/min) of HIIT (both P < 0.001), with 6-week HIIT required to elicit improvements in VO2 peak (+3.0 [SD 6] mL/kg/min; P = 0.04). Exercise tolerance increased after 2 (+15 [SD 15] W), 4 (+17 [SD 11] W), and 6 weeks (+16 [SD 11] W) of HIIT (all P < 0.001), with no difference in increase between the groups. There were no changes in any parameter in the control group. CONCLUSION: Improvements in exercise tolerance from HIIT precede changes in CRF. Just 4 weeks of a well-tolerated, reduced-exertion HIIT protocol are required to produce significant changes in AT, with a further 2 weeks of training also eliciting improvements in VO2 peak.

The impact of acute beta-hydroxy-beta-methylbutyrate (HMB) ingestion on glucose and insulin kinetics in young and older men.

Insulin resistance (IR) is a key feature in the development of numerous metabolic diseases. The cornerstone for treatment for IR remains diet and exercise, however these have poor rates of adherence. Beta-hydroxy-beta-methylbutyrate (HMB) is a nutraceutical with contentious effects on IR in animal models. The aim of this study was to evaluate the impact of acute HMB on IR in humans during an oral glucose tolerance test (OGTT). Young and older male volunteers underwent two 75 g OGTT with or without 3 g HMB. In young men, HMB significantly reduced the insulin area-under-the-curve (AUC), with no difference in glucose AUC, resulting in a numerical increase in the Cederholm index of insulin sensitivity. In older men, HMB had no effect on insulin or glucose responses. In conclusion, acute HMB may improve IR following a glucose load in young men; however, this does not appear to be sustained into older age.

Bouncing Back! Counteracting Muscle Aging With Plyometric Muscle Loading.

The preservation of muscle power is crucial in aging for maintaining mobility and performing daily tasks. Resistance training involving high movement velocities represents a valid strategy to slow down the rate of sarcopenia, counteracting the loss of muscle mass and muscle power. Plyometric exercise may represent an effective training modality for increasing muscle power; however, its application in older populations has been sparingly investigated, as the high impact actions involved may reduce its feasibility for older individuals. By adopting a safer modality of plyometric training, we investigated if a 6-week plyometric training intervention could increase knee extensor muscle size, architecture, force and power in 14 young (YM, age = 25.4 ± 3.5 y; means ± SD) and nine older males (OM, age = 69.7 ± 3.4 y). Volunteers trained 3 times/week using a device similar to a leg press machine where the user was required to bounce against his body mass on a trampoline. Pre-to-post training changes in isometric maximum voluntary torque (MVT), leg extension power and vastus lateralis (VL) architecture were assessed. Muscle power increased in both groups (+27% OM -P < 0.001, 20% YM -P < 0.001), although the total external work performed during the training period was significantly lower for OM (i.e., ~-47%). Both groups showed significant increases in muscle thickness (MT) (+5.8 OM -P < 0.01 vs. +3.8% YM -P < 0.01), fascicle length (Lf) (+8% OM -P < 0.001 vs. +6% YM -P < 0.001), and pennation angle (PA) (+7.5% OM -P < 0.001 vs. +4.1% YM -P < 0.001). The current study shows that trampoline-based plyometric training is an effective intervention producing a rapid increase in muscle mass and power in both young and older individuals. The training modality used in this study seems to particularly benefit the older population, targeting the morphological and functional effects of sarcopenia in human muscle.

Winter cancellations of elective surgical procedures in the UK: a questionnaire survey of patients on the economic and psychological impact.

OBJECTIVES: To quantify the economic and psychological impact of the cancellation of operations due to winter pressures on patients, their families and the economy. DESIGN: This questionnaire study was designed with the help of patient groups. Data were collected on the economic and financial burden of cancellations. Emotions were also quantified on a 5-point Likert scale. SETTING: Five NHS Hospital Trusts in the East Midlands region of England. PARTICIPANTS: We identified 796 participants who had their elective operations cancelled between 1 November 2017 and 31 March 2018 and received responses from 339 (43%) participants. INTERVENTIONS: Participants were posted a modified version of a validated quality of life questionnaire with a prepaid return envelope. MAIN OUTCOME MEASURES: The primary outcome measures were the financial and psychological impact of the cancellation of elective surgery on patients and their families. RESULTS: Of the 339 respondents, 163 (48%) were aged <65 years, with 111 (68%) being in employment. Sixty-six (19%) participants had their operations cancelled on the day. Only 69 (62%) of working adults were able to return to work during the time scheduled for their operation, with a mean loss of 5 working days (SD 10). Additional working days were lost subsequently by 60 (54%) participants (mean 7 days (SD 10)). Family members of 111 (33%) participants required additional time off work (mean 5 days (SD 7)). Over 30% of participants reported extreme levels of sadness, disappointment, anger, frustration and stress. At least moderate concern about continued symptoms was reported by 234 (70%) participants, and 193 (59%) participants reported at least moderate concern about their deteriorating condition. CONCLUSIONS: The cancellation of elective surgery during the winter had an adverse impact on patients and the economy, including days of work lost and health-related anxiety. We recommend better planning, and provision of more notice and better support to patients.

An Analysis of Endocannabinoid Concentrations and Mood Following Singing and Exercise in Healthy Volunteers.

The euphoric feeling described after running is, at least in part, due to increased circulating endocannabinoids (eCBs). eCBs are lipid signaling molecules involved in reward, appetite, mood, memory and neuroprotection. The aim of this study was to investigate whether activities other than running can increase circulating eCBs. Nine healthy female volunteers (mean 61 years) were recruited from a local choir. Circulating eCBs, haemodynamics, mood and hunger ratings were measured before and immediately after 30 min of dance, reading, singing or cycling in a fasted state. Singing increased plasma levels of anandamide (AEA) by 42% (P < 0.05), palmitoylethanolamine (PEA) by 53% (P < 0.01) and oleoylethanolamine (OEA) by 34% (P < 0.05) and improved positive mood and emotions (P < 0.01), without affecting hunger scores. Dancing did not affect eCB levels or hunger ratings, but decreased negative mood and emotions (P < 0.01). Cycling increased OEA levels by 26% (P < 0.05) and tended to decrease how hungry volunteers felt, without affecting mood. Reading increased OEA levels by 28% (P < 0.01) and increased the desire to eat. Plasma AEA levels were positively correlated with how full participants felt (P < 0.05). Plasma OEA levels were positively correlated with positive mood and emotions (P < 0.01). All three ethanolamines were positively correlated with heart rate (HR; P < 0.0001). These data suggest that activities other than running can increase plasma eCBs associated with changes in mood or appetite. Increases in eCBs may underlie the rewarding and pleasurable effects of singing and exercise and ultimately some of the long-term beneficial effects on mental health, cognition and memory.

Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis.

The incidence of hypertension increases with advancing age and represents a significant burden of disease. Lifestyle modification represents the first-line intervention in treatment algorithms; however, the majority of evidence for this comes from studies involving young participants using interventions that may not always be feasible in the elderly. This manuscript presents a systematic review of all randomized controlled trials involving participants with a mean age of 65 or over investigating nonpharmacological strategies to reduce blood pressure (BP). Fifty-three randomized controlled trials were included. The majority of interventions described aerobic exercise training, dynamic resistance exercise training, or combined aerobic and dynamic resistance exercise training (COM), with limited studies reporting isometric exercise training or alternative lifestyle strategies. Aerobic exercise training, dynamic resistance exercise training, COM, and isometric exercise training all elicited significant reductions in both systolic and diastolic BP, with no additional benefit of COM compared with single modality exercise training. Three months of traditional exercise-based lifestyle intervention may produce a reduction in BP of approximately 5 mmHg systolic and 3 mmHg diastolic in older individuals, similar to that expected in younger individuals.

Short-Term (<8 wk) High-Intensity Interval Training in Diseased Cohorts.

BACKGROUND AND AIM: Exercise training regimes can lead to improvements in measures of cardiorespiratory fitness (CRF), improved general health, and reduced morbidity and overall mortality risk. High-intensity interval training (HIIT) offers a time-efficient approach to improve CRF in healthy individuals, but the relative benefits of HIIT compared with traditional training methods are unknown in across different disease cohorts. METHODS: This systematic review and meta-analysis compares CRF gains in randomized controlled trials of short-term (<8 wk) HIIT versus either no exercise control (CON) or moderate continuous training (MCT) within diseased cohorts. Literature searches of the following databases were performed: MEDLINE, EMBASE, CINAHL, AMED, and PubMed (all from inception to December 1, 2017), with further searches of Clinicaltrials.gov and citations via Google Scholar. Primary outcomes were effect on CRF variables: V˙O2peak and anaerobic threshold. RESULTS: Thirty-nine studies met the inclusion criteria. HIIT resulted in a clinically significant increase in V˙O2peak compared with CON (mean difference [MD] = 3.32 mL·kg·min, 95% confidence interval [CI] = 2.56-2.08). Overall HIIT provided added benefit to V˙O2peak over MCT (MD = 0.79 mL·kg·min, 95% CI = 0.20-1.39). The benefit of HIIT was most marked in patients with cardiovascular disease when compared with MCT (V˙O2peak: MD = 1.66 mL·kg·min, 95% CI = 0.60-2.73; anaerobic threshold: MD = 1.61 mL·kg·min, 95% CI = 0.33-2.90). CONCLUSIONS: HIIT elicits improvements in objective measures of CRF within 8 wk in diseased cohorts compared with no intervention. When compared with MCT, HIIT imparts statistically significant additional improvements in measures of CRF, with clinically important additional improvements in V˙O2peak in cardiovascular patients. Comparative efficacy of HIIT versus MCT combined with an often reduced time commitment may warrant HIIT's promotion as a viable clinical exercise intervention.

Knowledge and attitudes of surgical trainees towards nutritional support: food for thought.

BACKGROUND & AIMS: Up to 40% of patients admitted to UK hospitals are malnourished and appropriate nutritional intervention can improve outcomes. We investigated the knowledge and attitudes of UK surgical trainees towards nutritional support and compared their responses with dieticians. METHODS: Trainee surgeons and qualified dieticians were asked to complete a multiple choice question test derived from topics relating to nutritional support, followed by a questionnaire on their attitudes towards nutrition. Participants were unaware that they would be tested. RESULTS: The test was administered to 63 doctors and 25 dieticians. There were 19 newly qualified doctors (foundation year 1 [FY(1)]), 21 junior surgeons (speciality-training years 1 and 2 [ST(1-2)]) and 23 senior surgeons (speciality-training years 3 and above [ST(3+)]). Mean [SE] test scores were lower for doctors compared to dieticians (14.0 [0.64] versus 26.4 [0.22], p<0.001). The respective test scores for FY(1), ST(1-2), ST(3+) doctors were 9.8 [0.78], 14.3 [1.10] and 17.3 [0.76]. Only 47% of doctors felt they had adequate knowledge of this subject and 65% stated that they regularly made decisions on nutritional support. Furthermore, only 25% stated they could calculate daily energy and nutritional requirements. CONCLUSION: Despite making decisions related to nutritional support regularly, surgical doctors in the UK demonstrated less knowledge of the fundamental principles of nutritional support than dieticians.