Surgery for Ulcerative Colitis in the White British and South Asian Populations in Selected Trusts in England 2001-2020: An Absence of Disparate Care and a Need for Specialist Centres.

Over the last decade, there has been extensive evidence that patients with inflammatory bowel disease from minority communities in the UK receive less than optimal care. In none of the studies has the role of surgery in the management of acute and severe ulcerative colitis been considered in any detail. A freedom of information (FOI) request was sent to 14 NHS Trusts in England, which serve significant South Asian populations. Details of the type of surgery patients from the South Asian and White British communities received between 2021 and 2020 were requested. Detailed responses were obtained from eight Trusts. Four hundred and ten White British patients underwent surgery for ulcerative colitis over this period at these eight Trusts, together with 67 South Asian patients. There was no statistically significant difference in the distribution across the types of surgery undergone by the two communities overall (χ2 = 1.3, ns) and the proportions who underwent an ileo-anal anastomosis with pouch (z = -1.2, ns). However, within individual trusts, at the University Hospital Southampton NHS Foundation Trust, a significantly greater proportion of South Asian patients had an ileo-anal anastomosis with pouch compared to White British patients. At Cambridge University Hospitals NHS Foundation Trust, all 72 patients who underwent surgery for ulcerative colitis were White British. This study has shown that, in general, for patients with a severe flare of ulcerative colitis where medical treatment has failed and surgery is warranted, the nature of the procedures offered is the same in the White British and South Asian communities. However, of concern is the number of units with low volume procedures. For most Trusts reported in this study, the overall number of Ileo-anal pouch anastomosis or anastomosis of ileum to anus procedures performed over a number of years was substantially below that required for a single surgeon to achieve competence. These findings reinforce the argument that inflammatory bowel disease surgery should be performed in a limited number of high-volume centres rather than across a wide range of hospitals so as to ensure procedures are carried out by surgeons with sufficient and on-going experience.

Ancient surgeons: A characterization of Mesopotamian surgical practices.

BACKGROUND: The Ancient Mesopotamian civilization, the earliest known, emerged in the fourth millennium BCE.1 While the advent of medicine is established, there is little understanding of surgery's origins. We sought to describe the characteristics and medical acumen of the surgeons of the first civilization. METHODS: Source documents and commentary on Mesopotamian medicine were systematically analyzed for evidence of surgery and physician descriptions. RESULTS: Early tablets reveal evidence of the incisional drainage of a scalp abscess and empyema, advanced wound care, fracture alignment, and possible caesarians without evidence of wound suturing, emergency procedures, trephination, or circumcision.2 While the asû and asipu understood disease processes, strong evidence of an inextricable connection between spiritual and diagnostic/curative roles exists. CONCLUSIONS: Mesopotamian physicians were diagnosticians and healers, approaching surgery as part of their holistic practice rather than a separate entity. Surgery was utilized as an endpoint to a careful process aided by objective evaluation and spiritual incantation.

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles.

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

Surveillance for colorectal cancer and chemoprevention in ulcerative and Crohn's colitis: The need for clinical strategies to increase effectiveness.

This review considers why current strategies for surveillance and the prevention of colorectal cancer as a long-term complication are ineffective. The role of endoscopists, pathologists, and patients are investigated. Colorectal cancer is linked to poor compliance with therapy, and attention may be better directed at improving adherence to treatment than strengthening current surveillance programs. Clearly, 5-ASA compounds, particularly mesalazine, are the most appropriate agents to choose, but there may also be a place for the daily intake of folic acid. Currently, the evidence in support of ursodeoxycholic acid is mixed, and it cannot be recommended, in general, to patients for the prophylaxis of colorectal cancer risk. An alternative approach through better concordance with medications is considered. The situation in Crohn's colitis is less clear. Although the risk of colorectal cancer mirrors that in ulcerative colitis, there are no published community-based studies that exclusively assess the effects of surveillance on the early detection of cancer, and the benefits of 5-ASA compounds in treatment seem less certain than in ulcerative colitis. In addition, there have been no assessments of the effects of any medications on cancer risk in Crohn's disease.

Medical negligence and likely developments in Oman.

Medical mistakes can never be eliminated but they can be minimised. From the world of aviation, it is clear that simulation training can have dramatic beneficial effects. Such training, however, is compulsory. In contrast, in the world of medicine there are few countries which have adopted a comparable approach. Unless continued medical registration is directly linked to satisfactory performance in simulated exercises and real events, it is unlikely that significant reductions will be achieved. This review will concentrate on the situation where mistakes and their mismanagement have direct and adverse consequences for patients. It will not be concerned with the recognised complications of procedures and treatments, with the exceptions of poor communication where patients have entered into treatments unaware of the associated risks.

Risk of esophageal cancer in achalasia cardia: A meta-analysis.

INTRODUCTION: The association between cancer of the esophagus and achalasia has long been recognized. However, it has also been recognized that cancers themselves can give rise to achalasia-like syndromes. The risk of developing cancer is also a factor in assessing whether there is a potential role for surveillance in this disease. This paper uses published work to form the basis for a meta-analysis of the risk of developing esophageal cancer among patients with pre-existing achalasia. METHODS: This paper considered cancer risk reported in a range of studies of achalasia published over a 50-year period. Twenty-seven potential studies were identified. In 16 reports, it was possible to extract information on both length of follow-up and duration of achalasia so that person-years duration (PYD) could be calculated. The analysis was stratified between cancers identified in the first year after diagnosis of achalasia and cancers identified in subsequent years. RESULTS: From pooling the results of 16 studies, the incidence rate of esophageal cancer in achalasia patients was estimated to be 1.36 (95% CI: 0.56, 2.51) per 1000 person years. This is over 10 times higher than the general population incidence rates as reported by the lARC. CONCLUSIONS: Therefore, our meta-analysis shows that achalasia is a major risk factor for the development of esophageal cancer. This is supported by the results from the time-stratified analysis. Incidence of esophageal cancer per 1000 person years was lower in the first year after diagnosis of achalasia than in subsequent years. This is strong evidence against the idea that achalasia may be induced by esophageal cancer instead of vice versa.

The utility of CT scan for the diagnostic evaluation of acute abdominal pain.

AbdCT for the evaluation of AAP in the ED in the US may be excessive and is potentially (although rarely) misleading and harmful. A selective policy of 'AbdUS first' combined with an observation unit and/or surgeon evaluation prior to AbdCT is preferred to a 'routine AbdCT' policy. Repeated AbdCTs for abdominal pain are not recommended because of cumulative radiation exposure. Standardized and complete history and physical examination, such as that originally designed for computer-aided diagnosis of AAP, along with select laboratory testing and higher utilization of AbdUS lessens the necessity of AbdCT. 'Routine AbdCT' is particularly not necessary for the evaluation of suspected appendicitis. 'Routine AbdCT' lowers the negative appendectomy rate but at the expense of exposure to radiation. Right lower quadrant US and selective use of observation prior to AbdCT for suspected appendicitis, particularly in children, adolescents, and young adults, are warranted. MRI should substitute for AbdCT for the evaluation of suspected appendicitis during pregnancy.

Use of Standardized Patient Simulations to Assess Impact of Motivational Interviewing Training on Social⁻Emotional Development.

The objective of this study was to assess the impact of motivational interviewing (MI) training on students' social⁻emotional development. Two simulations using standardized patients (SP) were conducted within a smoking cessation module. Students first completed a 4 h self-study module focused on smoking cessation tools and general counseling techniques. Faculty then administered a 15-item rubric focused on students' self-assessment of their verbal/non-verbal communication, social⁻emotional competence and MI skills. Students then participated in a smoking cessation counseling session with an SP. SPs used the same rubric to assess student performance. Teaching assistants (TAs) observed and assessed the students using the same rubric and an additional 22 items related to clinical skills. TAs and SPs then provided feedback on areas of improvement. The following week, students first completed a 3 h self-study module on MI then participated in a different smoking cessation scenario. After completion, the 15-item self-assessment rubric was administered. There was a significant improvement in TA assessed student performance with an average score improvement of 8% (pre-intervention score = 67%; post-intervention mean = 75%). Students had dramatic gains in their self-assessment with their scores rising by an average of 22%. Using MI techniques can improve students' self-assessed and perceived social⁻emotional competency.

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon.

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.

Adherence to a Gluten Free Diet Is Associated with Receiving Gluten Free Foods on Prescription and Understanding Food Labelling.

Treatment of coeliac disease requires a strict gluten-free (GF) diet, however, a high proportion of patients do not adhere to a GF diet. The study explores the practical challenges of a GF diet and dietary adherence in Caucasian and South Asian adults with coeliac disease. Patients with biopsy- and serology-proven coeliac disease were recruited from a hospital database. Participants completed a postal survey (n = 375), including a validated questionnaire designed to measure GF dietary adherence. Half of Caucasians (53%) and South Asians (53%) were adhering to a GF diet. The quarter of patients (n = 97) not receiving GF foods on prescription had a lower GF dietary adherence score compared with those receiving GF foods on prescription (12.5 versus 16.0; p < 0.001). Not understanding food labelling and non-membership of Coeliac UK were also associated with lower GF dietary adherence scores. A higher proportion of South Asian patients, compared with Caucasians, reported difficulties understanding what they can eat (76% versus 5%; p < 0.001) and understanding of food labels (53% versus 4%; p < 0.001). We recommend retaining GF foods on prescription, membership of a coeliac society, and regular consultations with a dietitian to enable better understanding of food labels. Robust studies are urgently needed to evaluate the impact of reducing the amount of GF foods prescribed on adherence to a GF diet in all population groups.

Farming and ranching related injuries in Southern Idaho.

INTRODUCTION: Agriculture is an inherently dangerous industry. We sought injury data for use with the Idaho Time Sensitive Emergency (TSE) system to formulate goals and track improvements. METHODS: Registries in southern Idaho were queried for ICD-9-CM diagnoses related to agriculture in 2014. Injuries known or likely to have occurred on properties intended for farming, ranching, animal care, or milk production, and relating to those activities were included. RESULTS: Among 72 patients, injuries were related to horses (31%), machinery (17%), ATVs (17%), and hay bales/haystacks (13%). Average age was 45 (3-82), 82% male, and mean ISS of 13 (1-50). Transportation utilized air (31%) and ground (69%) methods, with an average of 35 min (9-132). There was 1 inhospital death and 4 on-scene fatalities. CONCLUSIONS: We established baseline transport and injury data for the Idaho TSE system. These results can help our TSE system track improvements intended to increase quality of care.

Patients with ulcerative colitis from diverse populations: The Leicester experience.

BACKGROUND: Ulcerative colitis is common in migrant communities. There is evidence that access to care in general is impaired among such communities. The purpose of this study was to investigate whether South Asians experienced the same quality of care as English patients with ulcerative colitis. METHOD: The study assessed clinical care in the decade subsequent to diagnosis through a retrospective review of case notes. Newly diagnosed patients who lived in Leicester were identified and the frequency and type of consultation, in-patient admissions, surveillance colonoscopies, discharge rates, surgery and death were recorded. RESULTS: Of 372 candidate cases identified, 70 met the criteria to be included in the study. Forty-two were of English origin and 28 South Asian. South Asian patients were significantly less likely to see a consultant and more likely to be discharged. South Asian patients were admitted to hospital more often but had significantly fewer tests than European patients. This trend was also seen in surveillance colonoscopy, although it did not reach significance. Despite these differences in the provision of care, surgical and death rates were comparable. CONCLUSIONS: Patients with ulcerative colitis who are of South Asian origin receive poorer quality clinical care than their European counterparts.

Has patient knowledge of Inflammatory Bowel Disease improved since 1999?

BACKGROUND: In the UK Inflammatory Bowel Disease (IBD) Standards have highlighted the importance of patient education and support [1]. Little literature exists however regarding the impact of these standards on patient's understanding of their disease. AIM: To utilise the Crohn's and Colitis Knowledge Score (CCKNOW) to assess patient knowledge and make a comparison with results achieved in 1999. To assess whether disease CCKNOW scores differ between white and Asian populations in Leicestershire. METHODOLOGY: 100 outpatients with CD or UC were prospectively enrolled to complete the CCKNOW questionnaire between May and September 2013 at two Leicestershire Hospitals. RESULTS: Mean and median scores for IBD patients were 10.15 (95% C.I. 9.2-11.1) and 9 (95% CI 8-11) respectively. CD (38) patients achieved a significantly higher score than UC (61), median scores of 10.5 and 9 respectively, p=0.007. CCKNOW scores achieved were significantly lower with increasing age, p=0.0006. Patient ethnicity, gender, disease duration or perceived disease activity had no significant effect upon CCKNOW score. CONCLUSION: Patient understanding of inflammatory bowel disease is no better now than when assessed in 1999, median scores being 9 and 10 respectively. There are persisting knowledge deficits regarding the subjects of fertility and the complications of IBD. CCKNOW scores achieved were significantly lower with increasing age, elderly patients may therefore benefit the most from increased access to appropriate educational programmes and support.