Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

The Comparison of Strattice and SurgiMend in Acellular Dermal Matrix-Assisted, Implant-Based Immediate Breast Reconstruction.

BACKGROUND: Strattice (porcine derivative) and SurgiMend (bovine derivative) are the two most common acellular dermal matrices used in breast reconstruction in the United Kingdom. This retrospective study compared clinical outcomes in immediate implant-based breast reconstruction patients. METHODS: The study, conducted across three hospitals, included all patients who underwent immediate implant-based breast reconstruction using Strattice and SurgiMend. The primary outcome measure was implant loss rate. Secondary outcome measures included acellular dermal matrix loss rate, seroma formation, and minor and major complication rates. Intergroup comparison was performed. RESULTS: Eighty-two patients (Strattice, n = 45; SurgiMend, n = 37) underwent 97 immediate implant-based breast reconstructions (Strattice, n = 54; SurgiMend, n = 43). There were no differences between groups for age, comorbidities, specimen weight, or implant volume. Drains were used in all Strattice and 36 (84 percent) SurgiMend cases. The implant loss rate was higher for Strattice (n = 10, 20 percent) compared with SurgiMend (n = 3, 7 percent) but failed to reach statistical significance (chi-square test, p = 0.077). The acellular dermal matrix loss rate was significantly higher (Fisher's exact test, p = 0.014) in the Strattice group (n = 7, 14 percent), with no acellular dermal matrix loss with SurgiMend. The reoperation rate was also significantly higher (chi-square test, p = 0.002) in the Strattice group (n = 17, 33 percent, versus n = 3, 7 percent). The incidence of red breast was significantly higher (chi-square test, p = 0.022) in the SurgiMend group (n = 9, 21 percent, versus n = 3, 6 percent). Seroma, wound problems, and infection rates were similar. CONCLUSIONS: Clinical outcomes, including implant loss, acellular dermal matrix loss, and reoperation rates, are significantly better when using SurgiMend in immediate implant-based breast reconstruction compared with Strattice. An appropriately powered randomized trial is needed to provide further information. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The impact of "Be Clear on Cancer" campaign on breast care services provided by a specialist oncoplastic unit - A retrospective case control study.

INTRODUCTION: "Be Clear on Cancer" (BCOC) was a national campaign to raise awareness of breast cancer in women over seventy years old. Cancer Research UK conducted this campaign from 03 February 2014 to 15 March 2014. This study assesses its impact on breast care services. METHODS: BCOC campaign guidelines for hospital trusts were used as standard comparator for this retrospective case-control study. All new patients referred to breast clinic over four months from February 2014 were included, and compared to the same period in 2013. Information was recorded for referrals, biopsy rates and pathological diagnoses. Intra & inter-group comparisons were performed. RESULTS: 1646 patients were included. An increase of 25.2%(n = 184) was observed in referrals in 2014(n = 915) compared to 2013(n = 731). Cancer detection rates went down significantly (P = 0.002,Chi-square) in 2014 (5.1%,n = 47) compared to 2013 (9.0%,n = 66) due to the increase in number of referrals. In the over 70s group, a higher than predicted increase of 64.2%(n = 52) in all referrals, and 8%(n = 44) in two-week wait referrals was observed. The number of biopsies and cancers detected remained stable although the proportions undergoing biopsies (2014-29.3%,n = 39/133 versus 2013-38.3%,n = 31/81) or being diagnosed with cancer (2014-19.5%,n = 26/133 versus 2013-30.9%,n = 25/81) declined significantly (P = 0.001,McNemar) during the campaign due to an inflation in the number of referrals. Despite the overall reduction, cancer detection rate for biopsies performed remained significantly high in the over 70s (66.7%,n = 26/39) when compared with the under 70s (23.9%,n = 21/88) during the campaign. CONCLUSIONS: Although "Be Clear on Cancer" campaign resulted in a significant increase in breast cancer referrals, it did not translate into an increase in biopsy rates or cancer detection rates. The amount of work generated for the hospital because of this campaign was far greater than the predicted increase from campaign pilots. Therefore, the overall effectiveness of this campaign is questionable.

Outcome of single-stage breast reconstruction using the Natrelle 150 expander implant.

The Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3-65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P<0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P<0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.

Going out-of-programme as a specialty trainee: procrastination or optimisation of training?

Out-of-programme (OOP) activities enable postgraduate trainees to undertake an experience outside of their individual subspecialty training programmes. Activities vary but may include a period of research, additional clinical experiences or time for a planned career break. Determining whether to go OOP is a common dilemma faced by many trainees as they progress through postgraduate training. This review assesses the options trainees have with regards to going OOP, evaluates the potential advantages and disadvantages and also provides advice for those considering an OOP activity.

A new insight into non-specific abdominal pain.

This review aims to change clinical practice and alert clinicians to consider that unrecognised coeliac disease may present acutely with abdominal pain. Targeting patients who have non-specific abdominal pain or coeliac-associated symptoms/diseases may improve diagnosis.

Association of adult celiac disease with surgical abdominal pain: a case-control study in patients referred to secondary care.

BACKGROUND: Acute abdominal pain is the most common indication for surgical admission. Nonspecific abdominal pain (NSAP) may account for up to 40% of cases. There has been no published prospective study in which adult patients presenting with acute abdominal pain are investigated for celiac disease. AIMS: We aimed to assess the association of celiac disease with surgical abdominal pain. PATIENTS AND METHODS: A case-control study was undertaken involving 300 consecutive new unselected patients presenting with acute abdominal pain (in a university hospital) and healthy controls (age and sex matched) without abdominal pain (n = 300). Initial investigations for celiac disease were immunoglobulins, IgA/IgG anti-gliadin (AGA), and endomysial antibodies (EMA). Any patient with a positive IgA AGA, EMA, or only IgG AGA in the presence of IgA deficiency was offered a small bowel biopsy to confirm the diagnosis. RESULTS: : There were 33 patients with abdominal pain who had positive antibodies, of whom 9 had histologically confirmed celiac disease (6 EMA positive; 3 EMA negative). One antibody positive patient (EMA in isolation) declined duodenal biopsy and the remaining 23 had normal duodenal mucosa. Within the control group, there were 2 cases of celiac disease. Compared with matched controls the association of acute abdominal pain with celiac disease gave an odds ratio 4.6. (P = 0.068, 95% confidence interval, 1.11-19.05). When only considering NSAP the prevalence of celiac disease was highly significant at 10.5% (9 of 86, P = 0.006). Patients' symptoms improved on a gluten-free diet at 12- to 18-month follow-up. CONCLUSION: Celiac disease was diagnosed in 3% of patients who presented with unselected acute abdominal pain to secondary care. Targeting patients who have NSAP or celiac associated symptoms/diseases may improve the diagnostic yield.

Role of tumour necrosis factor gene polymorphisms (-308 and -238) in breast cancer susceptibility and severity.

INTRODUCTION: Genetic polymorphisms in the promoter region of the tumour necrosis factor (TNF) gene can regulate gene expression and have been associated with inflammatory and malignant conditions. We have investigated two polymorphisms in the promoter of the TNF gene (-308 G>A and -238 G>A) for their role in breast cancer susceptibility and severity by means of an allelic association study. METHODS: Using a case-control study design, breast cancer patients (n = 709) and appropriate age-matched and sex-matched controls obtained from the Breast Screening Unit (n = 498) were genotyped for these TNF polymorphisms, using a high-throughput allelic discrimination method. RESULTS: Allele frequencies for both polymorphisms were similar in both breast cancer cases and controls. However, the -308 polymorphism was found to be associated with vascular invasion in breast tumours (P = 0.024). Comparison with other standard prognostic indices did not show any association for either genotype. CONCLUSIONS: We demonstrated no association between the -308G>A polymorphism and the -238G>A polymorphism in the promoter region of TNF and susceptibility to breast cancer, in a large North European population. However, the -308 G>A polymorphism was found to be associated with the presence of vascular invasion in breast tumours.

A rough guide to research for senior house officers and specialist registrars.

Although not mandatory, a period of formalized research leading to a higher degree is still commonplace for doctors wishing to pursue a career in hospital medicine. This may be undertaken before or during specialist registrar training. This article provides practical information for those planning to undertake research. The potential pitfalls of research are discussed and strategies are suggested to ensure that this phase of medical training is both productive and fulfilling.