Real-world experience of using stereotactic radiotherapy combined with anti-vascular endothelial growth factor to treat neovascular AMD.

INTRODUCTION: Adjunctive treatment or longer-acting drugs are required to treat nAMD to help ease burdens for patients and hospital clinics alike. Stereotactic therapy is one such option, providing a reduction in the number of injections over time. OBJECTIVE: To determine the clinical outcomes in a cohort of patients with nAMD receiving a combination therapy of stereotactic radiotherapy (SRT) with intravitreal anti-VEGF injections (IVI). METHOD: A retrospective analysis of 74 patients with nAMD, who had received IVI and SRT (16 Gray maximum dose to the macula) at a large tertiary university eye hospital, between March 2018 and September 2019 was performed. The number of IVIs, visual acuity (VA), and central retinal thickness (CRT) were evaluated at 12, 24, and 36 months after patients received SRT and compared to the same time interval prior to SRT. RESULTS: Follow-up data at 12, 24, and 36 months following and prior to SRT was available for 74, 48, and 22 patients respectively. Overall there was a significant reduction in the number of injections post-SRT. Twelve months following SRT, the median number of IVI was reduced by 1 (p < 0.05). The reduction in the median number of IVI was significantly reduced by 3 and 6 injections at 24- and 36-month follow-up respectively (p < 0.05). The CRT was significantly reduced post-SRT compared to the baseline values at all time periods. There was no statistically significant difference in VA at 12-month follow-up compared to baseline. The VA, however, significantly decreased at 24- and 36-month follow-up (p < 0.05). CONCLUSION: A therapy combining SRT with IVI has shown an overall reduction in the number of injections required in nAMD patients at 12, 24, and 36 months following SRT compared to IVI treatment alone. These real-world outcomes are comparable to other studies while also confirming the maintenance of the reduced frequency of required IVI for patients with nAMD.

Risk factors associated with the development of chronic suppurative otitis media in children: Systematic review and meta-analysis.

OBJECTIVES: Chronic suppurative otitis media (CSOM) is defined as persistent discharge through a tympanic membrane perforation for greater than 2 weeks. It is associated with a significant disease burden, including hearing loss, and reducing its incidence could significantly improve short- and long-term health. We aimed to identify risk factors associated with the development of CSOM in children. DESIGN AND SETTING: Systematic review and meta-analysis of studies set in community, primary and secondary care settings, identified from Medline, Embase and Cochrane databases from 2000 to 2022. PARTICIPANTS: Children 16 years old and below. MAIN OUTCOME MEASURES: Clinical diagnosis of CSOM. RESULTS: In total, 739 papers were screened, with 12 deemed eligible for inclusion in the systematic review, of which, 10 were included in the meta-analysis. Risk factors examined included perinatal, patient, dietary, environmental and parental factors. Meta-analysis results indicate that atopy (RR = 1.18, 95% CI [1.01-1.37], p = .04, 2 studies); and birth weight <2500 g (RR = 1.79 [1.27-2.50], p < .01, 2 studies) are associated with an increased risk of CSOM development. Factors not associated were male sex (RR = 0.96 [0.82-1.13], p = .62, 8 studies); exposure to passive smoking (RR = 1.27 [0.81-2.01], p = .30, 3 studies); and parental history of otitis media (RR = 1.14 [0.59-2.20], p = .69, 2 studies). CONCLUSION: Optimal management of risk factors associated with CSOM development will help reduce the burden of disease and prevent disease progression or recurrence. The current quality of evidence in the literature is variable and heterogeneous. Future studies should aim to use standardised classification systems to define risk factors to allow meta-analysis.

Children using a unilateral cochlear implant and contralateral hearing aid: bimodal hearing outcomes when one ear is outside the UK (NICE 2009) audiological criteria for cochlear implantation - a single site case-control study.

INTRODUCTION: In the new revised National Institute for Health & Care Excellence (NICE, TA566, 2019) guidelines for cochlear implantation (CI) have clearly stipulated that the hearing loss must be bilateral. Prior to this revision, children and young people (CYP) with asymmetrical thresholds have been considered for unilateral CI when one ear was in audiological criteria. Children with asymmetrical hearing loss represent an important cohort of potential CI candidates, who will continue to be prevented from benefiting from CI unless evidence is produced to support implantation and maximise subsequent benefit.The aim of this study is to evaluate the 'real-life' hearing performance in a group of children who have received a unilateral CI and who have hearing thresholds in the contralateral ear that are outside the current UK NICE 2019 audiological criteria for CI. The contralateral ear will be aided using a conventional hearing aid (HA). The outcomes from this 'bimodal' group will be compared with a group of children who have received bilateral CI, and a group of children using bilateral HA, to extend the current knowledge about the different performance levels between bilateral CI, bilateral HA and bimodal hearing in CYP. METHODS AND ANALYSIS: Thirty CYP aged 6-17 years old, 10 bimodal users, 10 bilateral HA users and 10 bilateral cochlear implant users will be subjected to a test battery consisting of: (1) spatial release from masking, (2) complex pitch direction discrimination, (3) melodic identification, (4) perception of prosodic features in speech and (5) TEN test. Subjects will be tested in their optimal device modality. Standard demographic and hearing health information will be collected. In the absence of comparable published data to power the study, sample size was determined on pragmatic grounds. Tests are exploratory and for hypothesis generating purposes. Therefore, the standard criterion of p<0.05 will be used. ETHICS AND DISSEMINATION: This has been approved by the Health Research Authority and NHS REC within the UK (22/EM/0104). Industry funding was secured via a competitive researcher-led grant application process. Trial results will be subject to publication according to the definition of the outcome presented in this protocol.

Can MRI biomarkers for hearing loss in enlarged vestibular aqueduct be measured reproducibly?

OBJECTIVE: Morphological features of an enlarged endolymphatic duct (ED) and sac (ES) are imaging biomarkers for genotype and hearing loss phenotype. We determine which biomarkers can be measured in a reproducible manner, facilitating further clinical prediction studies in enlarged vestibular aqueduct hearing loss. METHODS: A rater reproducibility study. Three consultant radiologists independently measured previously reported MRI ED & ES biomarkers (ED midpoint width, maximal ED diameter closest to the vestibule, ES length, ES width and presence of ES signal heterogeneity) and presence of incomplete partition Type 2 from 80 ears (T2 weighted axial MRI). Interclass correlation coefficients (ICC) and Gwet's Agreement Coefficients (AC) were generated to give a measure of reproducibility for both continuous and categorical feature measures respectively. RESULTS: ES length, width and sac signal heterogeneity showed adequate reproducibility (ICC 95% confidence intervals 0.77-0.95, Gwet's AC for sac heterogeneity 0.64). When determining ED midpoint width, measurements from multiple raters are required for "good" reliability (ICC 95% CI 0.75-0.89). Agreement on the presence of incomplete partition Type 2 ranged from "moderate" to "substantial". CONCLUSIONS: Regarding MR imaging, the opinion of multiple expert raters should be sought when determining the presence of an enlarged ED defined by midpoint width. ED midpoint, ES length, width and signal heterogeneity have adequate reproducibility to be further explored as clinical predictors for audiological phenotype. ADVANCES IN KNOWLEDGE: We report which ED & ES biomarkers are reproducibly measured. Researchers can confidently utilise these specific biomarkers when modelling progressive hearing loss associated with enlarged vestibular aqueduct.

'Real-life' benefit of hearing preservation cochlear implantation in the paediatric population: a single-site case-control study.

INTRODUCTION: Cochlear implantation with hearing preservation (HPCI) has allowed a cochlear implant (CI) electrode to be implanted while trying to preserve residual acoustic low-frequency hearing. The concept arises from the importance of this low-frequency information and the limitations of a CI in several auditory domains. The combination of electrical hearing with either preserved acoustic hearing or amplified 'natural' hearing has the potential to address these issues and enable children with HPCI to closely follow normal auditory development.The aim of this study is to evaluate the 'real-life' benefit of preserved acoustic low-frequency hearing in children with a CI, understand the benefits of preserved natural hearing in complex listening situations and so enable parents and children to make an informed choice about implantation. Ultimately, helping to ensure the maximum number of children benefit from this life-changing intervention. METHODS AND ANALYSIS: Nineteen ears in children and young people aged 6-17 years old with 'successful' HPCI will be subjected to a test battery consisting of: (1) spatial release from masking; (2) complex pitch direction discrimination; (3) melodic identification; (4) perception of prosodic features in speech and (5) threshold equalising noise test. Subjects will be tested in the electro-acoustic stimulation (EAS)/electro-natural stimulation (ENS) and the electric-only (ES) condition, thereby acting as their own control group. Standard demographic and hearing health information will be collected. In the absence of comparable published data to power the study, sample size was determined on pragmatic grounds. Tests are exploratory and for hypothesis-generating purposes. Therefore, the standard criterion of p<0.05 will be used. ETHICS AND DISSEMINATION: This study has been approved by the Health Research Authority and NHS Research Ethics Committee (REC) within the UK (22/EM/0017). Industry funding was secured via a competitive researcher-led grant application process. Trial results will be subject to publication according to the definition of the outcome presented in this protocol.

Listening effort and downstream effects due to hearing loss in children and young people: an online quantitative questionnaire-based observational study.

INTRODUCTION: The clinical application of listening effort (LE) is challenging due to the lack of consensus regarding measuring the concept. Correlational analysis between different measuring instruments shows conditional and weak relationships, indicating they capture different dimensions of LE. Current research has suggested possible links between LE and downstream consequences such as fatigue, stress and confidence. One way to clinically measure LE would be to focus on its corollaries. Further research is needed to explore whether tools used to measure these downstream effects can be applied to capture LE. This study explores using existing questionnaire-based outcome instruments to evaluate LE and its associated consequences in children and young people (CYP), with and without hearing loss. METHODS AND ANALYSIS: One hundred CYP aged 12-17 years with normal hearing and a range of hearing loss levels will be invited to complete a series of online questionnaires (Speech, Spatial and Qualities, Vanderbilt Fatigue Scale-Child, Perceived Stress Scale and Rosenberg Self-Esteem Scale) and a hearing test (Digits in Noise). They will complete the questionnaires at two time points (1) at the end of a rest day and (2) at the end of a workday. Standard demographic and hearing health information will be collected. The sample size was determined pragmatically due to a lack of comparable published data to power the study. Tests are exploratory and for generating hypotheses; therefore, the standard criterion of p<0.05 will be used. ETHICS AND DISSEMINATION: This study has been reviewed within the funding organisation (Cochlear Research and Development Limited) by an independent and relevant peer reviewer/committee. This study has had a favourable ethics committee review by both NHS ethics and University of Manchester ethics. The study will be disseminated through newsletters, publication and presentations at conferences. The results will be made available to participants on request.

From prehab to rehab: Nutritional support for people undergoing pancreatic cancer surgery.

BACKGROUND: There is an urgent need to identify and treat potentially modifiable factors that may improve quality of life and influence survival of people with pancreatic cancer. The present study aimed to assess nutritional status at diagnosis and in the early and later stages of postoperative recovery and to evaluate the feasibility of optimising nutritional status and symptoms in patients undergoing surgery, as part of a multidisciplinary prehabilitation intervention. METHODS: Nutritional data collection and intervention took place at four time points: (1) baseline at diagnosis; (2) prior to surgery; (3) first postoperative review (within 6 weeks); and (4) at 6-12 months postoperatively. The 'Patient Generated Subjective Global Assessment' (PG-SGA) tool was used to undertake a detailed nutritional assessment and the modified 'Gastrointestinal Symptom Rating Scale' (GISRS) was completed for all patients. Handgrip strength was measured by dynamometry. RESULTS: During the period between April 2016 and April 2018, 137 patients scheduled for pancreatic cancer surgery were included who had a baseline dietetic assessment and at least one further review. Baseline assessment demonstrated that malnutrition was highly prevalent, with 62.3% experiencing more than 5% and 29.2% experiencing more than 10% weight loss over the prior 6 months. With dietetic assessment and support for at least 14 days, these patients gained a mean 1.8% body weight during this period and a mean improved handgrip of 7.9%. Symptoms also improved, with absolute change in PG-SGA scores reduced by a mean of 6.19 and a 6.3 reduction of GISRS. CONCLUSIONS: Dietetic assessment and intervention for all patients undergoing pancreatic resection ensures timely identification of nutritional deficiencies and correction of avoidable causes of weight loss, such as pancreatic enzyme insufficiency.

Identifying the prevalence of genito-anal injuries amongst clients attending St Mary's Sexual Assault Referral Centre following an allegation of anal penetration.

BACKGROUND: There is a lack of clarity around the prevalence of anal injuries sustained following anal penetration. The aim of this study was to identify the prevalence of injury amongst clients attending Saint Mary's Sexual Assault Referral Centre (SARC), Manchester, UK following anal penetration and identify predisposing or protective factors such as age, sex and pubertal status. This should facilitate an evidence-based approach to providing evidence statements in court for allegations of anal penetration. METHOD: This was an observational retrospective study analysing the forensic medical examination (FME) case notes of 239 clients between January 2015 and December 2016. Subjects were excluded if the nature of alleged assault was unclear. Data was extracted from the FME case notes on to a data collection proforma and statistical analysis undertaken. RESULTS: Of the 239 subject, 156 [65.3%] were female and 83 [34.7%] male. Subjects were predominantly post-pubertal, 185 [79.4%]. The alleged assaults were categorised in to penile anal, digital anal and object anal; penile anal assault was the most common type, 177 [75.97%]. No association was found between type of assault and presence of anal injury. Anal injuries did not occur more frequently in one sex than another [21.15% female, 21.69% male]. Logistic regression indicated pre-pubertal children were less likely to have injury [(odds ratio = 0.34, 95% CI (0.078, 0.70), p = 0.016)], although this was not significant when adjusted for time since assault. Most pre-pubertal children presented more than 72 h after alleged assault, [68.2% female, 73.1% male] The presence of anal injury was significantly associated with time since assault across all subjects, with those examined after 72 h less likely to have injury [p = 0.0016]. A greater proportion of single suspect assaults [22.8%] resulted in anal injury than multiple suspect assaults [13.9%]. Whilst there was alcohol consumption in most alleged assaults against post-pubertal subjects [56.1% female, 50.9% male], there was no statistically significant data to associate alcohol consumption with anal injury. And, the same was true of drug consumption. Among post-pubertal females 96.21% of assaults involved threats or violence, comparable with 71.70% amongst post-pubertal males. The data did not suggest threats and violence increase the rate of anal injury. CONCLUSION: The study identifies a statistically significant relationship between time since assault and prevalence of anal injury. Further, a relationship between pubertal status and prevalence of anal injury was found. The low prevalence of anal injury amongst pre-pubertal children suggests that absence of injury at the time of examination, following allegation of anal assault, is a common finding. Importantly, whilst not demonstrating statistical significance, it should be noted that the majority of assaults reported in the study did not result in anal injury. The study provides contemporary evidence in the field of forensic medicine which can be used in court proceedings in allegations of anal assault.

Enlarged Vestibular Aqueduct: Disease Characterization and Exploration of Potential Prognostic Factors for Cochlear Implantation.

OBJECTIVES: There is an unmet need to match the anticipated natural history of hearing loss (HL) in enlarged vestibular aqueduct (EVA) with clinical management strategies. The objectives of this study are therefore to provide a detailed case characterization of an EVA cohort and explore the relationship between candidate prognostic factors and timing of cochlear implant (CI) surgery. STUDY DESIGN: A multicenter retrospective review of patients diagnosed with EVA. SETTING: Patient data recruitment across three CI centers in the UK. PATIENTS: One hundred fifty patients with a radiological diagnosis of EVA from January 1995 to January 2021. MAIN OUTCOME MEASURES: Age at audiological candidacy for CI and age at first implant surgery. RESULTS: EVA was predominately a bilateral condition (144/ 150) with increased prevalence in women (M:F, 64:86). 51.7% of patients failed new-born hearing screening, with 65.7% having HL diagnosed by 1 year. Initial moderate to severe and severe to profound HL were reported most frequently. In 123 patients, median age that audiological candidacy for CI was met for at least one ear was 2.75 years. Median age at first CI was 5 years (140/150).Pendred syndrome (confirmed in 73 patients) and ethnicity, were not significantly associated with earlier CI surgery. Multivariate linear regression demonstrated that male patients have first CI surgery significantly earlier than females (coefficient -0.43, 95% CI [-0.82, -0.05), p-value = 0.028). CONCLUSIONS: This large UK EVA cohort provides evidence that patients should be closely monitored for CI candidacy within the first 3 years of life. Significantly, male gender is emerging as an independent prognostic factor for earlier assessment and first CI surgery.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown. OBJECTIVE: To assess the number, type and outcome of radiological investigations for children presenting to hospital with suspected physical abuse (SPA; including abusive head trauma) during the first national COVID-19 enforced lockdown compared with the prelockdown period. DESIGN: Multicentre, retrospective, observational, interrupted time series analysis. SETTING: Eight secondary/tertiary paediatric centres between January 2018 and July 2020 inclusive. PARTICIPANTS: 1587 hospital assessed children undergoing radiographic skeletal surveys (SkS) and head CT imaging performed for SPA/child protection concerns. MAIN OUTCOME MEASURES: Incidence and severity of fractures identified on SkS; head injury (composed of incidence rates and ratios of skull fracture, intracranial haemorrhage (ICH) and hypoxic ischaemic injury (HII)) on head CT imaging; and ratio of antemortem and postmortem SkS. RESULTS: 1587 SkS were performed: 1282 (81%) antemortem, 762 (48%) male, and positive findings in 582 (37%). Median patient age was 6 months. There were 1.7 fractures/child prelockdown versus 1.1 fractures/child during lockdown. There was no difference between positive/negative SkS rates, the absolute ratio of antemortem/postmortem SkS or absolute numbers of head injury occurring between January 2018 and February 2020 and the lockdown period April-July 2020. Likewise, prelockdown incidence and rates of skull fracture 30/244 (12%), ICH 28/220 (13%) and HIE 10/205 (5%) were similar to lockdown, 142/1304 (11%), 171/1152 (15%) and 68/1089 (6%), respectively. CONCLUSION: The first UK COVID-19 lockdown did not lead to an increase in either the number of antemortem or postmortem radiological investigations performed for SPA, or the number or severity of fractures and intracranial injuries identified by these investigations.

Prospective validation of a virtual clinic pathway in the management of choroidal naevi: the NAEVUS study Report no. 1: safety assessment.

BACKGROUND: Choroidal naevi are a common incidental finding prompting specialist referrals to ocular oncology. Rarely, such lesions have sufficient suspicious features to diagnose a small melanoma. The aim of the study is to show that 'virtual' imaging-based pathways are a safe and efficient option to manage such referrals. METHODS: A prospective cohort study at the Manchester Royal Eye Hospital and Moorfields Eye Hospital between June 2016 and July 2017 of the management decision of 400 patients reviewed by an ophthalmologist in a face-to-face consultation (gold standard) supported by fundus photography, optical coherence tomography, autofluorescence (AF) and B-mode ultrasound. The images were also read independently by blinded graders (non-medical) and blinded ophthalmologists, and a management decision was made based on image review alone (virtual pathway). The two pathways were compared for safety. RESULTS: The agreement for management decisions between face-to-face and virtual pathways was 83.1% (non-medical) and 82.6% (medical). There were more over-referrals in the virtual pathway (non-medical 24.3%, medical 23.3% of gold standard discharge) and only two under-referrals (10.5% of gold standard referrals), both borderline cases with minimal clinical risk. The agreement for risk factors of growth (orange pigment, subretinal fluid, hyper-AF) ranged between 82.3% and 97.3%. CONCLUSIONS: We prospectively validated a virtual clinic model for the safe management of choroidal naevi. Such a model of care is feasible with low rate of under-referral. An over-referral rate of almost 24% from the vitrual pathway needs to be factored into designing such pathways in conjunction with evidence on their cost-effectiveness.

Transfusion-associated necrotizing enterocolitis (NEC) in extremely preterm infants: experience of a tertiary neonatal center in UK.

OBJECTIVE: To compare the characteristics and short-term outcomes in extremely preterm infants, who developed necrotizing enterocolitis (NEC) following a packed red blood cell transfusion (pRBC) within 48 h (TANEC), with those who developed NEC beyond 48 h (non-TANEC). SETTING: A single-center retrospective cohort study in a Tertiary neonatal intensive care unit in the UK over a 5-year period. PATIENTS AND METHODS: Extremely premature infants (23-27 weeks gestation) were selected. TANEC and non-TANEC incidence were calculated from the confirmed NEC group (defined as modified Bell's stage II and beyond). The characteristics and short-term outcomes of infants with TANEC in the first 8 weeks of life were compared to infants with non-TANEC. RESULTS AND INTERPRETATION: Incidence of confirmed NEC was 14% (28/207). On further subgroup analysis of the confirmed NEC cases, 46% (13/28) of infants were identified with TANEC and 54% (15/28) with non-TANEC. The incidence of TANEC did not correlate with the number of antecedent pRBC transfusions or the pre-transfusion median hemoglobin (Hb) levels. There were no significant differences in characteristics between the TANEC and non-TANEC groups. Infants within the TANEC group required more intensive neonatal care support, greater surgical intervention (p-value 0.043) with loss of gut integrity and an increase in number of TPN dependency days (p-value 0.014). CONCLUSIONS: A significantly worse clinical course and short-term outcome was observed in the TANEC group when compared with the non-TANEC group.

Effects of losartan and enalapril on serum uric acid and GFR in children with proteinuria.

BACKGROUND: Studies have shown that losartan reduces serum uric acid in adults, unlike angiotensin-converting enzyme inhibitors. A previous study demonstrated that losartan and enalapril had comparable effects on proteinuria in children. METHODS: We conducted a post hoc analysis of results from a prospective trial in which the proteinuria-reducing effects of losartan and enalapril were compared. We have now evaluated (a) the effects of these medications on SUA in 248 children with proteinuria and (b) the correlation between changes in SUA and eGFR. RESULTS: SUA levels after 36 months were found to be increased when compared to baseline in both losartan and enalapril groups. The mean change in SUA from baseline was significantly different at 12 months between 23 hypertensive patients randomised to losartan (3.69% decrease [95% CI 11.31%, 3.93%]) and 24 randomised to enalapril (12.57% increase [95% CI 3.72%, 21.41%]), p = 0.007. This significant difference remained after 24, 30 and 36 months but was observed in the entire group of 248 patients only at 12 months. There was a statistically significant negative correlation between changes in SUA and changes in eGFR at each time point over 36 months. CONCLUSIONS: Losartan may have long-term beneficial effects on SUA and eGFR in children with proteinuria.

Study protocol for randomised clinical trial comparing the effectiveness of side-lying sleep positioning to back-lying at reducing oxygen desaturation resulting from obstructive sleep apnoea in infants with cleft palate (SLUMBRS2).

INTRODUCTION: The craniofacial abnormalities found in infants with cleft palate (CP) decrease their airway patency and increase their risk of obstructive sleep apnoea (OSA). We hypothesise that optimising sleep position in infants with CP may improve airway patency and offer a 'low-cost, high-impact' intervention to prevent the negative impacts of OSA. Because cleft centres give inconsistent advice about sleep position: some recommend back-lying and others side-lying, we will compare these in a randomised controlled trial. METHODS AND ANALYSIS: The aim is to determine the clinical effectiveness of side-lying as compared with back-lying sleep positioning in terms of reducing oxygen desaturation resulting from OSA in 244 infants aged 3-5 weeks of age, diagnosed with an isolated CP in/by UK cleft centres. Primary outcome is the 4% Oxygen Desaturation Index measured using pulse oximetry during sleep. RESEARCH PLAN: 1. Multicentre randomised controlled trial of side-lying compared with back-lying sleep positioning in reducing oxygen desaturation resulting from OSA in infants with CP at one month of age. 2. Internal pilot questionnaire-based study to support parents and clinicians regarding study participation, seeking to identify and address any barriers to recruitment. Monitoring data from the internal pilot will be used in the final analysis. 3. Co-development of new UK recommendations with Cleft Lip and Palate Association (CLAPA) regarding sleep position for infants with CP. ETHICS AND DISSEMINATION: The study protocol has received the favourable opinion of the West Midlands-South Birmingham Research Ethics Committee. Study results will be published on affiliated webpages and in peer-reviewed publications and conference contributions. TRIAL REGISTRATION NUMBER: NCT04478201.

A multicentre review comparing long term outcomes of endoscopic vein harvesting versus open vein harvesting for coronary artery bypass surgery.

Background: Utilisation of the Endoscopic Vein Harvesting (EVH) technique has been increasing for coronary artery bypass grafting (CABG) for the last two decades. Some surgeons remain concerned about the long-term patency of the long saphenous vein harvested endoscopically compared to traditional Open Vein Harvesting (OVH). The aim of this study was to perform a retrospective analysis of the outcomes between EVH and OVH from three UK centres with 10 years follow-up. Methods: 27,024 patients underwent CABG with long saphenous vein harvested by EVH (n=13,794) or OVH (n=13,230) in three UK centres between 2007 and 2019. Propensity modelling was used to calculate the Inverse Probability of Treatment Weights (IPTW). The primary endpoint was mortality from all causes and secondary endpoints were length of hospital stay, postoperative complications, and incidence of repeat coronary re-vascularisation for symptomatic patients. IPTW was used to balance the two intervention groups for baseline and preoperative co-morbidities. Results: Median follow-up time was 4.54 years for EVH and 6.00 years for OVH. Death from any cause occurred in 13.8% of the EVH group versus 20.8% in the OVH group over the follow-up period. The hazard ratio of death (EVH to OVH) was 0.823 (95% CI: 0.767, 0.884). Length of hospital stay was similar between the groups (p=0.86). Post-operative pulmonary complications were more common in EVH vs OVH (14.7% vs. 12.8%, p<0.001), but repeat coronary re-vascularisation was similar between the groups. Conclusions: This large retrospective multicentre analysis indicates that EVH has a lower risk of mortality compared with OVH during the follow-up period of the study. The observed benefits of EVH may outweigh the risks but should be considered on a case-by-case basis. We hope this review gives confidence to other cardiac centres that offering an EVH approach to conduit harvesting does not affect long term patient outcomes.

Use of keyhole vein removal technique has been increasing for coronary artery bypass surgery for last two decades. However, some surgeons remain worried about the quality and long-term effect of the vein tube removed using keyhole method compared to traditional Open Vein Harvesting (OVH). The aim of this study was to perform a retrospective analysis of the outcomes between keyhole and OVH from three UK centres with 10 years follow-up. In total, 27,024 patients underwent coronary artery bypass surgery with long saphenous vein harvested by either keyhole (n=13,794) or OVH (n=13,230) over a period of 2007­2019. The median follow-up time was 4.54 years for keyhole method and 6.00 years for OVH. Death from any cause occurred in 13.8% of the keyhole group versus 20.8% in the OVH group over the follow-up period. In conclusion, the keyhole surgery survival is not as bad as we hypothesised.

A service evaluation to determine where and who delivers pessary care in the UK.

INTRODUCTION AND HYPOTHESIS: Pessaries offer effective conservative management for symptoms of pelvic organ prolapse and are frequently used in the UK. Previous publications have highlighted a lack of evidence-based pessary guidelines. There is also a dearth of evidence regarding who UK pessary practitioners are and the training received. METHODS: A Freedom of Information request was sent to 167 healthcare organisations in the UK. Requested information included the number of pessaries inserted or changed, the grade and profession of pessary practitioners and training requirements at the organisation. RESULTS: Responses were received from 128 organisations. One hundred and ten had provided information for practitioners managing pessaries. At 66% (72) of organisations, pessary care was provided by both doctors and nurses of varying grades. At 23% of organisations either solely doctors or solely nurses provided pessary care. At the remaining 9% there was a multidisciplinary approach to pessary care. At 3 hospitals, unregistered healthcare professionals provided pessary care. At the majority of organisations, respondents undertook supervised practise to gain skills in pessary management. Additional methods of training cited were learning through observation or achieving set competencies. Twenty-six percent received didactic training. At 21% of organisations there were no training requirements. CONCLUSIONS: At most organisations, there was a multidisciplinary approach to pessary care. It is questionable whether unregistered healthcare professionals should be delegated responsibility for pessary care. A standardised approach to pessary practitioner training is advocated to ensure that women receive safe, evidence-based pessary care. The UK Clinical Guidance Group for the Use of Pessaries in Vaginal Prolapse is currently developing national evidence-based guidelines to support pessary practitioners in their practice, including training requirements.

"Voice your choice": a study of women's choice of surgery for primary stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: This was an observational study aiming to determine factors which influence women's choice of surgery for primary stress urinary incontinence (SUI). METHODS: Two hundred twelve women undergoing a primary SUI procedure were recruited to this study from 12 hospitals in the north of England. After choosing a procedure, women were asked to complete a standardized semi-structured questionnaire about their health, demographics and a free text box to record factors important to them when choosing their procedure. Statistical analysis was performed to determine the impact of demographic, lifestyle or healthcare factors on women's decision-making. Thematic analysis of the free text data was performed to identify factors important for women when choosing a surgical procedure. RESULTS: Sixty-four percent of women chose urethral bulking. There was no significant difference among age, BMI, smoking status or previous laparotomy between women choosing the four types of surgery. Women were less likely to choose urethral bulking if seen in a tertiary centre compared with a secondary centre (p < 001). Major themes in decision-making were efficacy, invasiveness, recovery, risk of complications, use of mesh, the clinician, the media, hierarchy of treatments and type of anaesthetic. Some women expressed a hierarchical approach to treatment. CONCLUSIONS: Our findings suggest decision-making is not influenced by patient factors such as age, BMI, smoking status or previous laparotomies. Women's choices are a complex mix of factors and not simply related to efficacy.

PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP): study protocol for a randomised controlled trial.

BACKGROUND: Differentiating infection from inflammation in acute pancreatitis is difficult, leading to overuse of antibiotics. Procalcitonin (PCT) measurement is a means of distinguishing infection from inflammation as levels rise rapidly in response to a pro-inflammatory stimulus of bacterial origin and normally fall after successful treatment. Algorithms based on PCT measurement can differentiate bacterial sepsis from a systemic inflammatory response. The PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP) trial tests the hypothesis that a PCT-based algorithm to guide initiation, continuation and discontinuation of antibiotics will lead to reduced antibiotic use in patients with acute pancreatitis and without an adverse effect on outcome. METHODS: This is a single-centre, randomised, controlled, single-blind, two-arm pragmatic clinical and cost-effectiveness trial. Patients with a clinical diagnosis of acute pancreatitis will be allocated on a 1:1 basis to intervention or standard care. Intervention will involve the use of a PCT-based algorithm to guide antibiotic use. The primary outcome measure will be the binary outcome of antibiotic use during index admission. Secondary outcome measures include: safety non-inferiority endpoint all-cause mortality; days of antibiotic use; clinical infections; new isolates of multiresistant bacteria; duration of inpatient stay; episode-related mortality and cause; quality of life (EuroQol EQ-5D); and cost analysis. A 20% absolute change in antibiotic use would be a clinically important difference. A study with 80% power and 5% significance (two-sided) would require 97 patients in each arm (194 patients in total): the study will aim to recruit 200 patients. Analysis will follow intention-to-treat principles. DISCUSSION: When complete, PROCAP will be the largest randomised trial of the use of a PCT algorithm to guide initiation, continuation and cessation of antibiotics in acute pancreatitis. PROCAP is the only randomised trial to date to compare standard care of acute pancreatitis as defined by the International Association of Pancreatology/American Pancreatic Association guidelines to patients having standard care but with all antibiotic prescribing decisions based on PCT measurement. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number, ISRCTN50584992. Registered on 7 February 2018.

Non-reassuring results in agreement trial comparing glass and plastic capillary tubes for neonatal blood gas sampling.

AIM: To determine agreement between neonatal capillary blood gases taken with plastic and glass tubes. METHODS: An agreement study was carried out in a regional tertiary neonatal unit. Inpatient babies ≥1 kg were recruited to the study when parents gave consent. After taking the routine glass capillary tube sample, a plastic tube sample was taken and run if the heel continued to bleed. Successful sample pairs were recorded and analysed against pre-defined acceptable differences. Assessment was also made of differences in failure rates between tube types for each parameter. RESULTS: Twenty-eight babies provided 135 blood gas pairs, of which five pairs were excluded. Successful pairing of results was achieved for pH in 105 valid samples. There were more failed plastic samples than glass, reaching significance for almost all parameters. pH, pO2 and pCO2 showed poor agreement (<80%) between glass and plastic tubes. On limited analysis of one successful blood gas pair per neonate to minimise bias, results remained non-reassuring. CONCLUSION: The findings of this study do not advocate switching from glass to plastic capillary tubes in our Newborn Intensive Care Unit. Further studies are required to assess agreement of glass and plastic capillary tubes for neonatal blood gas sampling.