Preoperative nutrition therapy in people undergoing gastrointestinal surgery.

BACKGROUND: Poor preoperative nutritional status has been consistently linked to an increase in postoperative complications and worse surgical outcomes. We updated a review first published in 2012. OBJECTIVES: To assess the effects of preoperative nutritional therapy compared to usual care in people undergoing gastrointestinal surgery. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases and two trial registries on 28 March 2023. We searched reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of people undergoing gastrointestinal surgery and receiving preoperative nutritional therapy, including parenteral nutrition, enteral nutrition or oral nutrition supplements, compared to usual care. We only included nutritional therapy that contained macronutrients (protein, carbohydrate and fat) and micronutrients, and excluded studies that evaluated single nutrients. We included studies regardless of the nutritional status of participants, that is, well-nourished participants, participants at risk of malnutrition, or mixed populations. We excluded studies in people undergoing pancreatic and liver surgery. Our primary outcomes were non-infectious complications, infectious complications and length of hospital stay. Our secondary outcomes were nutritional aspects, quality of life, change in macronutrient intake, biochemical parameters, 30-day perioperative mortality and adverse effects. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology. We assessed risk of bias using the RoB 1 tool and applied the GRADE criteria to assess the certainty of evidence. MAIN RESULTS: We included 16 RCTs reporting 19 comparisons (2164 participants). Seven studies were new for this update. Participants' ages ranged from 21 to 79 years, and 62% were men. Three RCTs used parenteral nutrition, two used enteral nutrition, eight used immune-enhancing nutrition and six used standard oral nutrition supplements. All studies included mixed groups of well-nourished and malnourished participants; they used different methods to identify malnutrition and reported this in different ways. Not all the included studies were conducted within an Enhanced Recovery After Surgery (ERAS) programme, which is now current clinical practice in most hospitals undertaking GI surgery. We were concerned about risk of bias in all the studies and 14 studies were at high risk of bias due to lack of blinding. We are uncertain if parenteral nutrition has any effect on the number of participants who had a non-infectious complication (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.36 to 1.02; 3 RCTs, 260 participants; very low-certainty evidence); infectious complication (RR 0.98, 95% CI 0.53 to 1.80; 3 RCTs, 260 participants; very low-certainty evidence) or length of hospital stay (mean difference (MD) 5.49 days, 95% CI 0.02 to 10.96; 2 RCTs, 135 participants; very low-certainty evidence). None of the enteral nutrition studies reported non-infectious complications as an outcome. The evidence is very uncertain about the effect of enteral nutrition on the number of participants with infectious complications after surgery (RR 0.90, 95% CI 0.59 to 1.38; 2 RCTs, 126 participants; very low-certainty evidence) or length of hospital stay (MD 5.10 days, 95% CI -1.03 to 11.23; 2 RCTs, 126 participants; very low-certainty evidence). Immune-enhancing nutrition compared to controls may result in little to no effect on the number of participants experiencing a non-infectious complication (RR 0.79, 95% CI 0.62 to 1.00; 8 RCTs, 1020 participants; low-certainty evidence), infectious complications (RR 0.74, 95% CI 0.53 to 1.04; 7 RCTs, 925 participants; low-certainty evidence) or length of hospital stay (MD -1.22 days, 95% CI -2.80 to 0.35; 6 RCTs, 688 participants; low-certainty evidence). Standard oral nutrition supplements may result in little to no effect on number of participants with a non-infectious complication (RR 0.90, 95% CI 0.67 to 1.20; 5 RCTs, 473 participants; low-certainty evidence) or the length of hospital stay (MD -0.65 days, 95% CI -2.33 to 1.03; 3 RCTs, 299 participants; low-certainty evidence). The evidence is very uncertain about the effect of oral nutrition supplements on the number of participants with an infectious complication (RR 0.88, 95% CI 0.60 to 1.27; 5 RCTs, 473 participants; very low-certainty evidence). Sensitivity analysis based on malnourished and weight-losing participants found oral nutrition supplements may result in a slight reduction in infections (RR 0.58, 95% CI 0.40 to 0.85; 2 RCTs, 184 participants). Studies reported some secondary outcomes, but not consistently. Complications associated with central venous catheters occurred in RCTs involving parenteral nutrition. Adverse events in the enteral nutrition, immune-enhancing nutrition and standard oral nutrition supplements RCTs included nausea, vomiting, diarrhoea and abdominal pain. AUTHORS' CONCLUSIONS: We were unable to determine if parenteral nutrition, enteral nutrition, immune-enhancing nutrition or standard oral nutrition supplements have any effect on the clinical outcomes due to very low-certainty evidence. There is some evidence that standard oral nutrition supplements may have no effect on complications. Sensitivity analysis showed standard oral nutrition supplements probably reduced infections in weight-losing or malnourished participants. Further high-quality multicentre research considering the ERAS programme is required and further research in low- and middle-income countries is needed.

Prognostic models for surgical-site infection in gastrointestinal surgery: systematic review.

BACKGROUND: Identification of patients at high risk of surgical-site infection may allow clinicians to target interventions and monitoring to minimize associated morbidity. The aim of this systematic review was to identify and evaluate prognostic tools for the prediction of surgical-site infection in gastrointestinal surgery. METHODS: This systematic review sought to identify original studies describing the development and validation of prognostic models for 30-day SSI after gastrointestinal surgery (PROSPERO: CRD42022311019). MEDLINE, Embase, Global Health, and IEEE Xplore were searched from 1 January 2000 to 24 February 2022. Studies were excluded if prognostic models included postoperative parameters or were procedure specific. A narrative synthesis was performed, with sample-size sufficiency, discriminative ability (area under the receiver operating characteristic curve), and prognostic accuracy compared. RESULTS: Of 2249 records reviewed, 23 eligible prognostic models were identified. A total of 13 (57 per cent) reported no internal validation and only 4 (17 per cent) had undergone external validation. Most identified operative contamination (57 per cent, 13 of 23) and duration (52 per cent, 12 of 23) as important predictors; however, there remained substantial heterogeneity in other predictors identified (range 2-28). All models demonstrated a high risk of bias due to the analytic approach, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (83 per cent, 19 of 23); however, calibration (22 per cent, 5 of 23) and prognostic accuracy (17 per cent, 4 of 23) were infrequently assessed. Of externally validated models (of which there were four), none displayed 'good' discrimination (area under the receiver operating characteristic curve greater than or equal to 0.7). CONCLUSION: The risk of surgical-site infection after gastrointestinal surgery is insufficiently described by existing risk-prediction tools, which are not suitable for routine use. Novel risk-stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.

This study is about finding ways to predict if someone will get an infection after having surgery on their stomach and intestines. If doctors know who is at high risk of getting an infection, they can take steps to prevent it and help the patient recover faster. The researchers looked at all the recent studies that have tried to predict who might get an infection after surgery. They found 23 studies that were good enough to look at in more detail. The researchers found that the studies they looked at were not very good at predicting who might get an infection. Most of the studies did not even check if their predictions were accurate. The few studies that did check were not very good at it. This means that doctors cannot use these predictions to help their patients. This means that doctors need to find better ways to predict who might get an infection after surgery on their stomach and intestines. If they can do this, they can help their patients recover faster and avoid problems like infections.

Educational impact and recommendations from implementation of student-led clinical trial recruitment: a mixed-methods study.

Medical students have an essential role in medical research, yet often lack opportunities for involvement within randomised trials. This study aimed to understand the educational impact of clinical trial recruitment for medical students. Tracking wound infection with smartphone technology (TWIST) was a randomised controlled trial that included adult patients undergoing emergency abdominal surgery across two university teaching hospitals. All recruiters underwent prerecruitment training based on 'Generating Student Recruiters for Randomised Trials' principles, and completed prerecruitment and postrecruitment surveys. Respondent agreement with statements were assessed using 5-point Likert scales (from 1 ('strongly disagree') to 5 ('strongly agree')). Quantitative data were analysed using paired t-tests to compare differences pre-involvement and post-involvement. Thematic content analysis was performed on free-text data to generate recommendations for future student research involvement. Of 492 patients recruited to TWIST between 26 July 2016 and 4 March 2020, 86.0% (n=423) were recruited by medical students. Following introduction of student co-investigators (n=31), the overall monthly recruitment rate tripled (4.8-15.7 patients). 96.8% of recruiters (n=30/31) completed both surveys, and all respondents reported significant improvement in clinical and academic competencies. Three higher-level thematic domains emerged from the qualitative analysis: (1) engagement, (2) preparation and (3) ongoing support. Student recruitment in clinical trials is feasible and accelerates recruitment to clinical trials. Students demonstrated novel clinical research competencies and increased their likelihood of future involvement. Adequate training, support and selection of suitable trials are essential for future student involvement in randomised trials.

Characterisation of in-hospital complications associated with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol UK: a prospective, multicentre cohort study.

BACKGROUND: COVID-19 is a multisystem disease and patients who survive might have in-hospital complications. These complications are likely to have important short-term and long-term consequences for patients, health-care utilisation, health-care system preparedness, and society amidst the ongoing COVID-19 pandemic. Our aim was to characterise the extent and effect of COVID-19 complications, particularly in those who survive, using the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK. METHODS: We did a prospective, multicentre cohort study in 302 UK health-care facilities. Adult patients aged 19 years or older, with confirmed or highly suspected SARS-CoV-2 infection leading to COVID-19 were included in the study. The primary outcome of this study was the incidence of in-hospital complications, defined as organ-specific diagnoses occurring alone or in addition to any hallmarks of COVID-19 illness. We used multilevel logistic regression and survival models to explore associations between these outcomes and in-hospital complications, age, and pre-existing comorbidities. FINDINGS: Between Jan 17 and Aug 4, 2020, 80 388 patients were included in the study. Of the patients admitted to hospital for management of COVID-19, 49·7% (36 367 of 73 197) had at least one complication. The mean age of our cohort was 71·1 years (SD 18·7), with 56·0% (41 025 of 73 197) being male and 81·0% (59 289 of 73 197) having at least one comorbidity. Males and those aged older than 60 years were most likely to have a complication (aged ≥60 years: 54·5% [16 579 of 30 416] in males and 48·2% [11 707 of 24 288] in females; aged <60 years: 48·8% [5179 of 10 609] in males and 36·6% [2814 of 7689] in females). Renal (24·3%, 17 752 of 73 197), complex respiratory (18·4%, 13 486 of 73 197), and systemic (16·3%, 11 895 of 73 197) complications were the most frequent. Cardiovascular (12·3%, 8973 of 73 197), neurological (4·3%, 3115 of 73 197), and gastrointestinal or liver (0·8%, 7901 of 73 197) complications were also reported. INTERPRETATION: Complications and worse functional outcomes in patients admitted to hospital with COVID-19 are high, even in young, previously healthy individuals. Acute complications are associated with reduced ability to self-care at discharge, with neurological complications being associated with the worst functional outcomes. COVID-19 complications are likely to cause a substantial strain on health and social care in the coming years. These data will help in the design and provision of services aimed at the post-hospitalisation care of patients with COVID-19. FUNDING: National Institute for Health Research and the UK Medical Research Council.

Prospective validation of the 4C prognostic models for adults hospitalised with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol.

PURPOSE: To prospectively validate two risk scores to predict mortality (4C Mortality) and in-hospital deterioration (4C Deterioration) among adults hospitalised with COVID-19. METHODS: Prospective observational cohort study of adults (age ≥18 years) with confirmed or highly suspected COVID-19 recruited into the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study in 306 hospitals across England, Scotland and Wales. Patients were recruited between 27 August 2020 and 17 February 2021, with at least 4 weeks follow-up before final data extraction. The main outcome measures were discrimination and calibration of models for in-hospital deterioration (defined as any requirement of ventilatory support or critical care, or death) and mortality, incorporating predefined subgroups. RESULTS: 76 588 participants were included, of whom 27 352 (37.4%) deteriorated and 12 581 (17.4%) died. Both the 4C Mortality (0.78 (0.77 to 0.78)) and 4C Deterioration scores (pooled C-statistic 0.76 (95% CI 0.75 to 0.77)) demonstrated consistent discrimination across all nine National Health Service regions, with similar performance metrics to the original validation cohorts. Calibration remained stable (4C Mortality: pooled slope 1.09, pooled calibration-in-the-large 0.12; 4C Deterioration: 1.00, -0.04), with no need for temporal recalibration during the second UK pandemic wave of hospital admissions. CONCLUSION: Both 4C risk stratification models demonstrate consistent performance to predict clinical deterioration and mortality in a large prospective second wave validation cohort of UK patients. Despite recent advances in the treatment and management of adults hospitalised with COVID-19, both scores can continue to inform clinical decision making. TRIAL REGISTRATION NUMBER: ISRCTN66726260.

Perioperative interventions to reduce pancreatic fistula following pancreatoduodenectomy: meta-analysis.

BACKGROUND: Data on interventions to reduce postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) are conflicting. The aim of this study was to assimilate data from RCTs. METHODS: MEDLINE and Embase databases were searched systematically for RCTs evaluating interventions to reduce all grades of POPF or clinically relevant (CR) POPF after PD. Meta-analysis was undertaken for interventions investigated in multiple studies. A post hoc analysis of negative RCTs assessed whether these had appropriate statistical power. RESULTS: Among 22 interventions (7512 patients, 55 studies), 12 were assessed by multiple studies, and subjected to meta-analysis. Of these, external pancreatic duct drainage was the only intervention associated with reduced rates of both CR-POPF (odds ratio (OR) 0.40, 95 per cent c.i. 0.20 to 0.80) and all-POPF (OR 0.42, 0.25 to 0.70). Ulinastatin was associated with reduced rates of CR-POPF (OR 0.24, 0.06 to 0.93). Invagination (versus duct-to-mucosa) pancreatojejunostomy was associated with reduced rates of all-POPF (OR 0.60, 0.40 to 0.90). Most negative RCTs were found to be underpowered, with post hoc power calculations indicating that interventions would need to reduce the POPF rate to 1 per cent or less in order to achieve 80 per cent power in 16 of 34 (all-POPF) and 19 of 25 (CR-POPF) studies respectively. CONCLUSION: This meta-analysis supports a role for several interventions to reduce POPF after PD. RCTs in this field were often relatively small and underpowered, especially those evaluating CR-POPF.

External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis.

BACKGROUND: Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation and are the most accurate. The aim of this study was to identify risk scores for POPF, and assess the clinical validity of these scores. METHODS: Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models. RESULTS: Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so included in the meta-analysis, (Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores). Overall predictive accuracies were similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%. CONCLUSION: Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.

A modified Delphi process to establish future research priorities in malignant oesophagogastric surgery.

BACKGROUND: With rapid advancement in the genomics of oesophagogastric (OG) cancer and raised expectations in clinical outcomes from patients and clinicians alike there is a clear need to determine the current research priorities in OG cancer surgery. The aim of our study was to use a modified Delphi process to determine the research priorities among OG cancer surgeons in the United Kingdom. METHODS: Delphi methodology may be utilised to develop consensus opinion amongst a group of experts. Members of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland were invited to submit individual research questions via an online survey (phase I). Two rounds of prioritisation by multidisciplinary expert healthcare professionals (phase II and III) were completed to determine a final list of high priority research questions. All questions submitted and subsequently ranked were analysed on an anonymised basis. RESULTS: In total, 427 questions were submitted in phase I and 75 with an OG cancer focus were taken forward for prioritisation in phase II. Phase III produced a final list of 12 high priority questions with an emphasis on tailored or personalised treatment strategies in OG cancer surgery. CONCLUSION: A modified Delphi process produced a list of 12 high priority research questions in OG cancer surgery. Future studies and awards from funding bodies should reflect this consensus list of prioritised questions in the interest of improving patient care and encouraging collaborative research across multiple centres.

Stoma-Related Complications Following Ostomy Surgery in 3 Acute Care Hospitals: A Cohort Study.

PURPOSE: The aim of this study was to evaluate both surgical and patient-centered stomal complications after stoma formation, with emphasis on underreported symptoms and complaints. DESIGN: Prospective, single-group study. SUBJECTS AND SETTING: Patients undergoing emergency and elective ostomy surgery between January 1, 1999, and June 1, 2016, in 3 acute care hospitals were followed up by stoma care nurse specialists in NHS Lanarkshire, Scotland. METHODS: Data were collected on surgery type (emergency or elective), stoma type (ileostomy or colostomy), stoma-related complications including surgical complications (stenosis, retractions, hernia, and prolapse) and so-called "patient-centered" complications (skin changes, odor, leakage, soiling, and nighttime emptying) at 5 time points: 10 days, 3 months, 6 months, 1 year, and 2 years postoperatively. For this study, we report comparisons at 10 days and 2 years, using frequencies reported as percentages. RESULTS: Data from 3509 consecutive stoma surgeries were analyzed. Complication rates were similar in both emergency and elective cases. The nighttime symptoms of leakage and soiling were significantly greater in the ileostomy group and worsened over the 2-year period. The parastomal hernia rate was 34.5% at 2 years, a finding more common in the colostomy group (46.4% vs 20.1%, P < .001). However, the rate of clinically significant hernia was similar when comparing the colostomy group with the ileostomy group (3.6% vs 2.2%, P = .38). Emergency stoma surgeries (40.2%) were preoperatively sited compared with 95.9% of elective cases. CONCLUSIONS: Our prospective multicenter study demonstrated that stoma-related complications are similar irrespective of whether the stoma was formed via an elective surgery or emergency surgery. Nighttime symptoms of leakage, soiling, and emptying were high post-stoma formation, particularly in the ileostomy group, and worsened over the 2-year period. Findings from our study highlight the presence and persistence of complications. We believe our work highlights the importance of having frequent discussions with patients about making decisions about approaches to reduce complications to enhance patient outcomes.

The effect of liver transplantation on patient-centred outcomes: a propensity-score matched analysis.

It is unclear whether liver transplantation confers an increase in health-related quality of life (HR-QoL) across all dimensions of health. This study aimed to estimate the effect of liver transplantation on HR-QoL. Pre- and post-transplantation patients attending an outpatient clinic were invited to complete the condition-specific 'Short form of liver disease QOL' questionnaire. Mixed-effect linear regression and propensity-score matching (PSM) on pretransplantation characteristics were used to estimate the difference in overall HR-QoL associated with transplantation. Of 454/609 (74.5%) eligible patients who were included in the analysis, 102 (22.5%) patients fall under pretransplantation category, and 352 (77.5%) were under post-transplantation category. Overall HR-QoL post-transplantation significantly increased in patients without hepatocellular carcinoma (HCC) (ß = 16.84, 95% CI: 13.33 to 20.35, P < 0.001), but not with HCC (ß = 1.25, 95% CI: -5.09 to 7.60, P = 0.704). Donation after circulatory death (DCD) organ recipients had a significantly lower HR-QoL (ß = -4.61, 95% CI: -8.95 to -0.24, P = 0.043). Following PSM, transplantation was associated with a significant increase in overall HR-QoL (average treatment effect: 6.3, 95% CI: 2.1-10.9). There is a significant improvement in HR-QoL attributable to transplantation in this cohort. Post-transplantation HR-QoL was affected by several factors, including HCC status and DCD transplantation, which has important implications for counselling prior to liver transplantation.

Patient consent in the post-Montgomery era: A national multi-speciality prospective study.

BACKGROUND: The Montgomery ruling has had a wide-ranging impact on the consent process and has been the subject of new guidelines by bodies, including the Royal College of Surgeons (RCSEng). This is the first study to examine the current standard of consent for surgical procedures at a national level. METHOD: A national collaborative research model was used, with prospective data collection performed across hospitals in Scotland. Variables associated with the consent process were audited across three surgical specialities (general surgery, urology and orthopaedics) and measured against standards set by RCSEng, the Scottish Public Services Ombudsman and medical defence organisations. RESULTS: A total of 289 cases were identified from 12 hospitals. The majority of patients were reviewed by a consultant surgeon in clinic (79.9%) or on the day of surgery (55.4%). The clinic consent rate was 27.0%, while a copy of the documented discussion was only provided to 4.2% of patients. On the day of surgery, the benefits, risks and alternatives to the planned procedure were discussed in less than half of cases. This rate was similar across different clinician grades, while marked variation was seen across hospitals. CONCLUSION: In this prospective multi-centre study we have demonstrated wide variation in the consent processes in many surgical specialities across Scotland. Following the Montgomery ruling, we have demonstrated the current consent process in elective surgery is likely to be substandard, and may require additional steps to be taken by clinicians to ensure patients are fully informed to make decisions regarding their treatment.

Use of a modified Delphi approach to develop research priorities in HPB surgery across the United Kingdom.

BACKGROUND: Research prioritisation can help identify clinically relevant questions and encourage high-quality, patient-centred research. Delphi methodology aims to develop consensus opinion within a group of experts, with recent Delphi projects helping to define the research agenda and funding within several medical and surgical specialties. METHODS: All members of the Association of Upper Gastrointestinal Surgeons (AUGIS) were asked to submit clinical research questions using an online survey (Phase 1). Two consecutive rounds of Delphi prioritisation by multidisciplinary HPB healthcare professionals (Phase 2) were undertaken to establish a final list of the most highly prioritised research questions. A multidisciplinary steering committee analysed the results of each phase. RESULTS: Ninety-three HPB-focussed questions were identified in Phase 1, with thirty-seven questions of sufficient priority to enter a further prioritisation round. A final group of 11 questions considered highest priority were identified. The most highly ranked research questions related to treatment pathways, operative strategies and the impact of HPB procedures on quality of life, particularly for malignant disease. CONCLUSION: Expert consensus has identified research priorities within the UK HPB surgical community over the coming years. Funding applications, to establish well-designed, high quality collaborative research are now required to address these questions.

Decision modeling in donation after circulatory death liver transplantation.

Donation after circulatory death (DCD) liver allografts are increasingly used for transplantation. However, the posttransplantation clinical and quality of life outcomes of DCD recipients are traditionally considered to be inferior compared with donation after brain death (DBD) allograft recipients. Decision making for such marginal organs can be difficult. This study investigated the optimal decision to accept or decline a DCD liver allograft for a patient based on their current health. A Markov decision process model was constructed to predict the 5-year clinical course of patients on the liver transplant waiting list. Clinical outcomes were determined from the UK transplant registry or appropriate literature. Quality-adjusted life years (QALYs) were determined using the condition-specific short form of liver disease quality of life (SF-LDQoL) questionnaire. There were 293/374 (78.3%) eligible patients who completed the SF-LDQoL questionnaire. A total of 73 respondents (24.9%) were before transplant and 220 were after transplant (DBD recipient, 56.3%; DCD recipient, 8.5%; ischemic cholangiopathy patient, 2.4%; retransplant recipient, 7.9%). Predictive modeling indicated that QALYs gained at 5 years were significantly higher in DCD recipients (3.77; 95% confidence interval [CI], 3.44-4.10) compared with those who remained on the waiting list for a DBD transplant with Model for End-Stage Liver Disease (MELD) scores of 15-20 (3.36; 95% CI, 3.28-3.43), or >20 (3.07; 95% CI, 3.00-3.14). There was no significant advantage for individuals with MELD scores <15 (3.55; 95% CI, 3.47-3.63). In conclusion, this model predicts that patients on the UK liver transplant waiting list with MELD scores >15 should receive an offered DCD allograft based on the QALYs gained at 5 years. This analysis only accounts for donor-recipient risk pairings seen in current practice. The optimal decision for patients with MELD scores <15 remains unclear. However, a survival benefit was observed when a DCD organ was accepted. Liver Transplantation 23 594-603 2017 AASLD.

The acceptability of three vaccine injections given to infants during a single clinic visit in South Africa.

BACKGROUND: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa. METHODS: A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions. RESULTS: The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators' care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs. CONCLUSIONS: We found high acceptance by caregivers and vaccinators of three injections. Caregivers' poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants' pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI's expansion in resource-limited countries.

Teaching research: a programme to develop research capacity in undergraduate medical students at the University of KwaZulu-Natal, South Africa.

BACKGROUND: Improved research ability is a core competency to achieve in health professionals. The Selectives is a three-year, longitudinal, community-based programme within the undergraduate curriculum which aims to develop research capacity in all medical students during the prescribed curriculum. In relation to the programme, the authors describe the types of studies conducted by students, conditions that facilitated their learning, how the experience improved students' knowledge of research and public health and their development of reflective learning practices. METHODS: A cohort of 212 students completed the Selectives Programme in 2014, and 69 (32 %) completed an anonymous online evaluation thereafter. Data collected include students' perceptions of the research component of Selectives; its impact on their knowledge of research and a documentary analysis of their research protocols and posters. Ethical approval for the ongoing evaluation of the Selectives was sought and obtained from the institutional Biomedical Research Ethics Committee. RESULTS: During Selectives, 75 groups of 2-4 students conducted research studies of primary health care problems in community settings. Each group is assessed on their presentation of research findings as a scientific poster. The Selectives facilitated learning for the majority of the cohort. Students reported positive learning experiences about the research process, including ethics; protocol writing; data processing; dissemination of findings and results; and their use in informing a health promotion intervention. Students reported having gained a better understanding of their strengths and weaknesses through reflective learning from this academic activity. The Selectives is scheduled adjacent to the students' mid-year vacation. This scheduling together with the placement in the students' home community minimizes travel and accommodation costs associated with working outside the academic teaching platform and therefore makes it a cost-effective model in a low resource context. CONCLUSIONS: The Selectives has proven beneficial to develop a range of generic and practical research competencies for a full cohort of students enrolled in the undergraduate medical curriculum. The Selectives research process is integrated with learning about population health and the social determinants of health in a primary health care setting.

Thrombus-in-Transit: A Case for a Multidisciplinary Hospital-Based Pulmonary Embolism System of Care.

BACKGROUND: Venous thromboembolism, including pulmonary embolism (PE), is a common disease identified in the emergency department that carries significant morbidity and mortality. In its most severe form, PE is fulminant and characterized by cardiac arrest and death. CASE REPORT: In the midst of risk-stratifying PE by using echocardiography to assess right ventricular function, thrombus-in-transit (free-floating clot in the right atrium or ventricle) may be seen. We present a case of a 49-year-old man diagnosed with an acute saddle PE who was incidentally found to have a thrombus-in-transit and patent foramen ovale and required open thrombectomy. Identification of these additional potentially life-threatening features was possible only due to our availability of risk-stratification resources, specifically bedside echocardiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Albeit rare, with a reported incidence estimated at 4%, the presence of thrombus-in-transit may change emergent clinical management. A multidisciplinary team of resources should be considered emergently as part of a hospital-based PE system of care.

Use of Polyclonal Intravenous Immunoglobulin at a Paediatric Referral Hospital in South Africa Between 2009 and 2012.

BACKGROUND: Polyvalent intravenous immunoglobulin (IVIG) is registered for a limited number of specific indications in South Africa but is increasingly being used for unregistered uses. No guideline exists nationally to monitor and control IVIG prescription, which results in its use in many clinical situations with varying levels of evidence. PURPOSE: This study describes the registered and unregistered use, and cost of IVIG at a tertiary paediatric hospital in South Africa. METHODS: A cross sectional descriptive study design was employed. Data on all patients (0 to 18 years) who attended the hospital during a 39 month period from 2009 to 2012 as out- or inpatients and were dispensed IVIG, was obtained from the pharmacy dispensing and National Health Laboratory Service electronic databases, and supplemented by a patient record review. RESULTS: During the study period, 185 patients received at least one dose of IVIG and a total 916 issues (3641.5 g) were dispensed. In 70 (41 %) of the 171 patients (involving 398 IVIG issues, 46 %), the South African Medicines Control Council registered indications for its use were followed. IVIG accounted for between 1.6, 1.7 and 4.6 % of the annual pharmacy expenditure during this 3-year study period. CONCLUSIONS: More than half of all IVIG dispensed at this paediatric hospital was used for unregistered indications. Considering the pressures on supply and the pharmaceutical costs, a more standardized, protocol-driven approach to the prescription of IVIG is called for.