Novel Textbook Outcomes following emergency laparotomy: Delphi exercise.

BACKGROUND: Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy. METHODS: A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round. RESULTS: A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'. CONCLUSION: Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.

Anogenital injury following sexual assault and consensual sexual intercourse: a systematic review and meta-analysis.

Background: Sexual violence is a grave human rights violation and a serious global public health challenge. Rates of reporting of sexual violence and subsequent passage of cases through the criminal justice system are poor all over the world. The presence or absence of anogenital injury following sexual assault may influence survivors in their willingness to report a crime, and law enforcement officers and jurors in their decision making regarding the laying of charges and/or conviction of offenders. The aim of this systematic review was to compare rates of identification of anogenital injury (AGI) in women following sexual assault and consensual sexual intercourse using the same examination techniques. Methods: In this systematic review and meta-analysis, Medline, Embase and Google Scholar were searched for relevant studies (in any language, with no age or sex criteria) published between February 25, 1993, and February 25, 2023, that directly compared AGI between individuals after either sexual assault or consensual sexual intercourse. Abstracts, conference proceedings, and case reports were excluded. The primary outcome of interest was any form of detected AGI. The Mantel-Haenszel method was used for meta-analysis using random effects modelling to determine the risk ratio (RR) of AGI between sexual assault and consensual sexual intercourse. Quality assessment was undertaken using the Newcastle-Ottawa scale tool. The I2 statistic was used to determine heterogeneity among studies. An I2 >75% was considered high heterogeneity. Funnel plots were used to assess the risk of publication bias, by determining any visually apparent asymmetry. This analysis is registered with PROSPERO, CRD42023402468. Findings: We included 10 studies, accounting for 3165 study participants. All participants were female. AGI was detected in 901 (48%) of 1874 participants following sexual assault and 394 (31%) of 1291 participants following consensual sexual intercourse. Meta-analysis of all included studies demonstrated that the presence of AGI was significantly more likely for participants following sexual assault than consensual sexual intercourse (RR 1.59 (95% CI 1.21, 2.09); p < 0.001). There was a significant heterogeneity among studies and funnel plots suggest that this RR may be an over-estimation. Subgroup analysis including only high-quality studies showed no significant difference between groups. Interpretation: Although AGI was significantly more likely to be detected after sexual assault than consensual sexual intercourse, more than half of survivors of sexual assault have no detectable injuries. The presence of AGI, therefore, does not prove there has been sexual violence and absence of injury does not refute that sexual assault has occurred. Funding: The University of Birmingham.

Engagement with a youth violence intervention programme is associated with lower re-attendance after violent injury: A UK major trauma network observational study.

The hospital based Redthread Youth Violence Intervention Programme (YVIP) utilises experienced youth workers to support 11-24 year olds following an episode of violent injury, assault or exploitation who present to the Emergency Department (ED) at the East Midlands Major Trauma Centre (MTC), Nottingham, UK. The YVIP aims to promote personal change with the aim of reducing the incidence of further similar events. We conducted a retrospective, observational, cohort study to examine the association between engagement with the YVIP and re-attendance rates to the ED following a referral to Redthread. We also examined factors associated with engagement with the full YVIP. We found that 573 eligible individuals were referred to the YVIP over two years. Assault with body parts 34.9% (n = 200) or a bladed object 29.8% (n = 171) were the commonest reason for referral. A prior event rate ratio (PERR) analysis was used to compare rates of attendance between those who did and did not engage with the full YVIP. Engagement was associated with a reduction in re-attendances of 51% compared to those who did not engage (PERR 0.49 [95% 0.28-0.64]). A previous attendance to the ED by an individual positively predicted engagement. (OR 2.82 [95% CI 1.07-7.42], P = 0.035). A weekend attendance (OR 0.26 [0.15-0.44], P<0.001) and a phone call approach (OR 0.25 [0.14-0.47], P = 0.001), rather than a face-to-face approach by a Redthread worker, negatively impacted engagement. In conclusion, assaults with or without a weapon contributed to a significant proportion of attendances among this age group. The Redthread YVIP was associated with reduced rates of re-attendance to the East Midlands MTC among young persons who engaged with the full programme.

Improvements over time for patients following liver trauma: A 17-year observational study.

Background: Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre. Methods: All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V). Results: There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively). Conclusions: Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

Traumatic appendicitis is probably not real: an illustrative analysis of coincidental occurrences in nature.

There have been sporadic case reports describing 'traumatic appendicitis' (acute appendicitis occurring following injury) for almost a hundred years. Although this might seem to be an interesting and rare diagnosis for the journal reader, both appendicitis and trauma are very common, and their occurrence together may only give the illusion of causality. Indeed, such a diagnosis may not even exist. We provide an illustration of the statistical phenomenon of coincidental occurrences in nature using a computer simulation of traumatic appendicitis in the UK population. In our simulation, there are enough cases of traumatic appendicitis every 2 years to 3 years to account for the entire global literature on the topic. We suggest that unless there is a credible pathological process reported with demonstrable causality, further case reports of traumatic appendicitis need to have robust justification.

Injuries among children attributed to violence and social funding: a 10-year observational study.

BACKGROUND: Mechanisms and patterns of injury in children are changing, with violent mechanisms becoming more prevalent over time. Government funding of services for children and young people has reduced nationally over the last decade. We aimed to investigate the trends in admissions of injured children to a Major Trauma Centre (MTC) and examine the relationship between injuries sustained by violent mechanisms and local authority funding of children and youth services within the same catchment area. METHODS: A 10-year observational study included all patients aged<18 years treated at a regional MTC between April 2012 and April 2022. Number of admissions with violent trauma, mechanism of injury, requirement for operative intervention and mortality were compared with published annual local authority expenditure reports. RESULTS: 1126 children were included; 71.3% were boys, with median age 11 years (IQR 3-16). There were 154/1126 (14%) children who were victims of violent trauma; they were more likely to be boys than children injured by non-violent mechanisms (84% vs 69%). The proportion of injuries attributed to violence increased over the study period at the same time as reductions in local authority funding of services for the early years, families and youth services. However, there were insufficient data to formally assess the interdependency between these factors. CONCLUSIONS: The proportion of injuries attributed to violence has increased over time, and government spending on specific children and young people's services has decreased over the same time period. Further work is needed to examine the interdependency between spending and violent injuries in children, and public health interventions to target violence-related injuries should take into account youth service funding.

Follow-up of patients with retroperitoneal sarcoma.

Retroperitoneal sarcomas (RPS) are rare malignancies that are potentially curable by complete surgical resection. A regular surveillance program is normally commenced following surgery due to the risk of local recurrence (LR), especially in low-intermediate grade disease, and distant metastases (DM), especially in high-grade RPS. Consensus guidelines usually advocate for more frequent imaging during the first 2-3 years and less intensive imaging over a prolonged period thereafter, reflecting the incidence pattern of LR and DM. Definitive evidence for the most effective imaging schedule has never been provided, and retrospective studies have not shown an association between follow-up intensity and survival. Improvement in the prediction of recurrence patterns has been sustained by prognostic dynamic nomograms, which are now capable of forecasting disease behaviour in each patient according to specific features. Incorporation of such tools in clinical practice may help to stratify patients and tailor ongoing surveillance to the risk of recurrence. This may help to relieve patients' anxiety while awaiting results of surveillance investigations, and also reduce the economic and environmental burden of repeated imaging. A randomized controlled study (SARveillance Trial) is proposed to shed light on this controversial topic, allowing clinicians to harmonize the follow-up protocol of patients undergoing surgery for RPS.

Establishing a COVID-secure site for elective surgery during the COVID pandemic: An observational study.

INTRODUCTION: Maintaining timely and safe delivery of major elective surgery during the COVID-19 pandemic is essential to manage cancer and time-critical surgical conditions. Our NHS Trust established a COVID-secure elective site with a level 2 Post Anaesthetic Care Unit (PACU) facility. Patients requiring level 3 Intensive Care Unit admission were transferred to a non-COVID-secure site. We investigated the relationship between perioperative anaesthetic care and outcomes. MATERIALS AND METHODS: All consecutive patients undergoing major surgery at the COVID-secure site between June and November 2020 were included. Patient demographics, operative interventions and 30-day outcomes were recorded. Multivariate logistic regression was used to determine the odds ratio of outcomes according to PACU length of stay and the use of spinal or epidural anaesthesia, with age, sex, malignancy status and American Society of Anesthesiologists grade as independent co-variables. RESULTS: There were 280 patients. PACU length of stay >23h was associated with increased 30-day complications. Epidural anaesthesia was associated with PACU length of stay >23h, increased total length of stay, increase hospital transfer and 30-day complications. Two patients acquired nosocomial COVID-19 following hospital transfer. DISCUSSION: Establishing a separate COVID-secure site has facilitated delivery of major elective surgery during the COVID-19 pandemic. Choice of perioperative anaesthesia and utilisation of PACU appear likely to affect the risk of adverse outcomes.

One size does not fit all: Impact of hand size on ease of use of instruments for minimally invasive surgery.

BACKGROUND: Consideration of ergonomic factors is important for the practice of safe and efficient minimally invasive surgery (MIS). Surgeons with smaller glove sizes have previously been reported to have increased difficulties with some minimally invasive instruments. We aim to investigate hand anthropometrics and their relationship to surgeon comfort when using MIS instruments. METHODS: Male and female surgeons from two centres were surveyed on their experience of handling MIS instruments and images obtained of the dorsal and palmar aspects of their dominant hand. Photographs of hands were transformed to calibrated coordinates to enable anthropometric measurements of finger length and width as well as palm width and hand span photogrammetrically. Surgeon-perceived discomfort, fatigue, pressure points and techniques to mitigate difficulty handling instruments were compared to hand measurements. RESULTS: Questionnaires were completed by 58 surgeons; 20 (34%) were consultants, 17 (29%) were women. Glove size ranged from 6 to 8 (median 7.5). Male participants had significantly larger hands than females in all measured dimensions. Female surgeons and those with smaller finger and hand dimensions were significantly more likely to experience difficulty or discomfort across a range of variables when using MIS instruments. CONCLUSIONS: Surgeons with smaller hands reported increased problems handling MIS instruments. This represents an issue of equity in surgery, with women being more significantly affected than men. Hand size varies greatly between surgeons and anthropometric variability should be considered in design of MIS instruments.

Injury by knife crime amongst children is associated with socioeconomic deprivation: an observational study.

PURPOSE: Children who live in areas of socioeconomic deprivation may be at higher risk of being victims of violent crime such as knife wounds. The current study investigated whether socioeconomic disparity was associated with higher risk of knife crime. METHODS: An observational study included patients aged ≤ 17 years at a UK Major Trauma Centre injured by knife trauma from 2016 to 2022. Indices of deprivation were recorded according to the zip code of residence and compared with those of all of England. These included Index of Multiple Deprivation (IMD); income; employment; education and skills; health and disability; crime; barriers to housing and services; living environment; and Income Deprivation Affecting Children Index (IDACI). RESULTS: There were 139 patients (96% male) with median age of 16 years. When compared with the whole of England, patients had worse indices of IMD (p = 0.021); income (p < 0.001); employment (p < 0.001); education and skills (p < 0.001); health and disability; and IDACI (p < 0.001). There were no significant differences in indices of crime, barriers to housing and services or living environment. CONCLUSIONS: Paediatric knife injury was associated with poor socioeconomic status in multiple domains. Focussed efforts to address socioeconomic disparities should be a priority as a public health measure for vulnerable children.

Dealing with malignancy involving the inferior vena cava in the 21st century.

INTRODUCTION: Malignancies involving the inferior vena cava (IVC) have historically been considered not amendable to surgery. More recently, involvement of the IVC by neoplastic processes in the kidney, liver or in the retroperitoneum can be managed successfully. EVIDENCE ACQUISITION: In this systematic review we summarize the current evidence regarding the surgical management of the IVC in cases of involvement in neoplastic processes. Current literature was searched, and studies selected on the base of the PRISMA guidelines. Evidence was synthesized in narrative form due to heterogeneity of studies. EVIDENCE SYNTHESIS: Renal cell carcinoma accounts for the greatest proportion of studied patients and can be managed with partial or complete vascular exclusion of the IVC, thrombectomy and direct closure or patch repair with good oncological prognosis. Hepatic malignancies or metastases may involve the IVC, and the joint expertise of hepatobiliary and vascular surgeons has developed various strategies, according to the location of tumor and the need to perform a complete vascular exclusion above the hepatic veins. In retroperitoneal lymph node dissection, the IVC can be excised en-block to guarantee better oncological margins. Also, in retroperitoneal sarcomas not arising from the IVC a vascular substitution may be required to improve the overall survival by clearing all the neoplastic cells in the retroperitoneum. Leiomyoma can have a challenging presentation with involvement of the IVC requiring either thrombectomy, partial or complete substitution, with good oncological outcomes. CONCLUSIONS: A multidisciplinary approach with specialist expertise is required when dealing with IVC involvement in surgical oncology. Multiple techniques and strategies are required to deliver the most efficient care and achieve the best possible overall survival. The main aim of these procedures must be the complete clearance of all neoplastic cells and achievement of a safe margin according to the perioperative treatment strategy.

Concussion in Non-athletes: Assessment of Cognition and Symptomatology (CONTACTS) study protocol - an exploratory cohort study investigating the utility of sports concussion assessment tools and salivary microRNAs to diagnose concussion in NHS patients.

INTRODUCTION: Concussion is a complex pathophysiological process with a wide range of non-specific signs and symptoms. There are currently no objective diagnostic tests to identify concussion, and diagnosis relies solely on history and examination. Recent research has identified a unique panel of microRNAs (miRNAs) that distinguish between concussed and non-concussed rugby players. This study aims to assess the diagnostic utility of salivary miRNAs in concussion for a sample of UK National Health Service patients and whether well-established sports-related concussion (SRC) assessment tools may be translated into the emergency department (ED). METHODS AND ANALYSIS: Concussion in Non-athletes: Assessment of Cognition and Symptomatology is a single-centre, prospective, two-phase cohort study. The concussed cohort will consist of participants with maxillofacial trauma and concurrent concussion. The control cohort will consist of participants with isolated limb trauma and no evidence of concussion. Participants will be recruited in the ED and saliva samples will be taken to identify the presence of miRNAs. The SRC assessments being investigated include the Sports Concussion Assessment Test, Fifth Edition (SCAT5), the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and the ImPACT Quick. Follow-up will be at 24-48 hours in-hospital and remotely via telephone and email at 14 days and 6 months. ETHICS AND DISSEMINATION: Ethical approval was granted in February 2021 by the West Midlands Coventry & Warwickshire Research Ethics Committee (ref 20/WM/0299). The investigators intend to submit their study findings for publication in peer-reviewed journals and to disseminate study findings via presentation at academic meetings. The results will also form part of a doctorate thesis, registered at the University of Birmingham.

Secure app-based secondary healthcare clinical decision support to deployed forces in the UK Defence Medical Services.

BACKGROUND: Modern instant messaging systems facilitate reach-back medical support for Defence Medical Services (DMS) by connecting deployed clinicians to remote specialists. The mobile app Pando (Forward Clinical, UK) has been used for this purpose by the DMS via the 'Ask Advice' function. We aimed to investigate the usage statistics for this technology in its first 1000 days to better understand its role in the DMS. METHODS: An observational study was undertaken using metadata extracted from the prospective database within the application server for clinical queries between June 2019 and February 2022. These data included details regarding number and name of specialties, timings, active users per day and the number of conversations. RESULTS: There were 29 specialties, with 298 specialist users and 553 requests for advice. The highest volume of requests were for trauma and orthopaedics (n=116; 21.0%), ear, nose and throat (n=67; 12.1%) and dermatology (n=50; 9.0%). There was a median of 164 (IQR 82-257) users logged in per day (range 2-697). The number of requests during each day correlated with the number of users on that day (r=0.221 (95% CI 0.159 to 0.281); p<0.001). There were more daily users on weekdays than weekends (215 (IQR 123-277) vs 88 (IQR 58-121), respectively; p<0.001). For the top 10 specialties, the median first response time was 9 (IQR 3-42) min and the median time to resolution was 105 (IQR 21-1086) min. CONCLUSION: In the first 1000 days of secure app-based reach-back by the DMS there have been over 500 conversations, responded to within minutes by multiple specialists. This represents a maturing reach-back capability that may enhance the force multiplying effect of defence healthcare while minimising the deployed 'medical footprint'. Further discussions should address how this technology can be used to provide appropriately responsive clinical advice within DMS consultant job-planned time.

Emergency multivisceral resection for spontaneous haemorrhage rupture of huge solid pseudopapillary neoplasm of the pancreas during pregnancy†.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare malignancy with a low malignant potential and strong female preponderance. Diagnosis during pregnancy is extraordinary, and management must consider the risks to the mother and foetus of tumour growth and rupture. A large 35-cm SPN was identified on magnetic resonance imaging (MRI) in a 24-year-old woman at 6 weeks of gestation following presentation with an abdominal mass. Surgery was delayed to allow the foetus to reach as close to term as possible because surveillance MRIs showed incremental mass growth. Emergency c-section was undertaken at 35 weeks of gestation due to persistent tachycardia and suspected haemorrhage into the tumour. A Hb of 70 g/l post-delivery despite four units of RBCs and an albumin of 11 g/l necessitated urgent multivisceral surgery. Surgical resection is the mainstay of treatment for SPN. However, the strategy of choice during pregnancy remains undetermined, with more recent reports delaying surgery until post-partum.

Oligometastatic deposits of prostate cancer found within the sigmoid pericolic fat that was resected for colonic adenocarcinoma: a case report.

BACKGROUND: Prostate cancer may rarely metastasize to the colon and colonic lymph nodes, and local treatment of oligometastatic deposits may improve oncological outcomes. Immunohistochemical stains are used to determine the most likely source of metastatic deposits when they are seen within surgical specimens. The aim of this case report is to illustrate how such techniques were used to identify unexpected prostatic metastases within the pericolic fat of a sigmoid colon resection specimen following elective curative surgery for colorectal cancer. To our knowledge, this is the first report of complete excision of oligometastatic deposits of prostate cancer found incidentally within the specimen of another cancer. CASE REPORT: An 89-year-old Caucasian man underwent sigmoid colectomy for an obstructing colorectal cancer in the sigmoid colon with some mesenteric lymphadenopathy. He had previously received radical radiotherapy for prostate cancer 10 years earlier. When the specimen was examined by the histopathologist, it was noted that the pericolic fat adjacent to the colorectal adenocarcinoma contained some metastatic deposits. Positive immunohistochemical staining for prostate-specific antigen and prostate-specific acid phosphatase with negative staining for CDX2 and CK20 revealed these to be prostatic metastases rather than colonic. Since these were completely excised, and there were no other metastases, this represented a serendipitous, curative excision of oligometastatic deposits of an additional cancer to the one that was being treated. CONCLUSIONS: This case illustrates how immunohistochemical staining may be used to distinguish the source of metastatic deposits based on the likelihood of primary tumor from a careful and thorough patient history.

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study.

BACKGROUND: Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging. METHODS: A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score. RESULTS: There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups. CONCLUSION: Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.