Clinical characteristics of people with intellectual disability admitted to hospital with constipation: identifying possible specific high-risk factors.

BACKGROUND: People with intellectual disabilities (ID) die on an average 20 years earlier to the general population. They have higher rates of multimorbidity and polypharmacy. Around 25% of people with ID report chronic constipation. The England Learning Disabilities Mortality Review found that nearly 25% of deaths identified constipation as a long-term health problem. However, the likely risk factors for constipation related harm are poorly enumerated. We sought to identify possible specific high-risk factors by examining the clinical characteristics of people with ID admitted to hospital with constipation. METHODS: Data of people with ID admitted with constipation in two general hospitals covering a population of 1.3 million from 2017 to 2022 were reported using the STROBE guideline for cohort studies. Collected data included age, gender, intellectual disability severity, recorded medication, presenting complaint and co-morbidities. The medication anticholinergic burden was calculated using the anticholinergic burden scale. Continuous variables were summarised by mean and standard deviation if normally distributed, with categorical variables summarised by the number and percentage in each category. RESULTS: Of 46 admissions (males 52%), 57% had moderate to profound ID, 37% had epilepsy, 41% prescribed antiseizure medication (ASM) and 45% were on laxatives. Average age was 46 years. The anticholinergic burden score mean was 2.3 and median, one. CONCLUSIONS: We can hypothesise that people with more severe ID, suffering from epilepsy and on ASM may be more at risk of developing severe constipation. Some admissions may be avoided with earlier use of laxatives in the community.

Can we use a simple blood test to reduce unnecessary adverse effects from radiotherapy by timely identification of radiotherapy-resistant rectal cancers? MeD-Seq rectal study protocol.

BACKGROUND: Chemoradiation therapy (CRT) followed by surgery is currently the standard of care to treat patients with locally advanced rectal cancer (LARC). CRT reduces local recurrences, but is associated with significant damage to the surrounding healthy tissue that can severely impact patients quality of life. Additionally, a proportion of patients (hardly) benefit from CRT. We aim to develop a diagnostic innovation, using DNA-methylation, which can enable a more selective and thereby more effective use of the available therapies for rectal cancer patients. METHODS: MeD-Seq Rectal is a prospective single centre, observational study. 75 patients diagnosed with rectal cancer and will receive CRT as neoadjuvant treatment are will be included. DNA-methylation profiling will be performed on liquid biopsies to predict pathological response to CRT. DISCUSSION: To data no clinical or image-based features were found that predict response to CRT. we hypothesize that DNA methylation patterns in liquid biopsies may provide a promising and patient-friendly strategy to predict CRT resistance upfront. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov (NCT06035471).

A 15-year experience: intraoperative parathyroid hormone assay for the management of primary hyperparathyroidism in a UK endocrine surgical unit.

PURPOSE: This study aims to evaluate the outcomes of first-time parathyroidectomy for primary hyperparathyroidism using intraoperative PTH (IOPTH) assay in the light of the UK National Institute for Health and Care Excellence (NICE) guidelines for the management of primary hyperparathyroidism. METHOD: This is a retrospective cohort analysis of a prospectively maintained database of endocrine surgery in a tertiary centre. Preoperative radiological localisation (concordance and accuracy), intraoperative PTH parameters and adjusted serum calcium at minimum 6-month follow-up were analysed. The accuracy of IOPTH to predict post-operative normocalcaemia and the number needed to treat (NNT) within the cohort when IOPTH was utilised were determined. Differences between groups were evaluated with Chi-squared and Fisher's exact test. RESULTS: Between January 2004 and September 2018, 849 patients (75.4% women), median age 64 years (IQR 54-72), were analysed. The median preoperative adjusted serum calcium was 2.80mmol/l (IQR 2.78-2.90), and the median preoperative PTH was 14.20pmol/l (IQR 10.70-20.25). The overall first-time cure (normocalcaemia) rate was 96.4%. The sensitivity, specificity, positive predictive value and negative predictive values of IOPTH were 96.8%, 83.2%, 97.6% and 78.8%, respectively, with an accuracy of 95.1%. For patients with concordant scans (48.3%), a targeted approach without IOPTH would have achieved a cure rate of 94.1% compared with 98.0% using IOPTH (p<0.01) CONCLUSION: The use of IOPTH assay significantly improved the rate of normocalcaemia at 6 months. The low NNT to benefit from IOPTH, particularly those patients with a single positive scan, and the inevitable reduction in the potential costs incurred from failure and reoperation justify its utilisation.

Locally recurrent rectal cancer and distant metastases: is there still a chance ofcure?

INTRODUCTION: Patients with locally recurrent rectal cancer (LRRC) generally have poor prognosis, especially those who have (a history of) distant metastases. The aim of this study was to investigate the impact of distant metastases on oncological outcomes in LRRC patients undergoing curative treatment. METHODS: Consecutive patients with surgically treated LRRC between 2005 and 2019 in two tertiary referral hospitals were retrospectively analysed. Oncological survival of patients without distant metastases were compared with outcomes of patients with synchronous distant metastases with the primary tumour, patients with distant metastases in the primary-recurrence interval, and patients with synchronous LRRC distant metastases. RESULTS: A total of 535 LRRC patients were analysed, of whom 398 (74%) had no (history of) metastases, 22 (4%) had synchronous metastases with the primary tumour, 44 (8%) had metachronous metastases, and 71 (13%) had synchronous LRRC metastases. Patients with synchronous LRRC metastases had worse survival compared to patients without metastases (adjusted hazard ratio: 1.56 [1.15-2.12]), whilst survival of patients with synchronous primary metastases and metachronous metastases of the primary tumour was similar as those patients who had no metastases. In LRRC patients who had metastases in primary-recurrence interval, patients with early metachronous metastases had better disease-free survival as patients with late metachronous metastases (3-year disease-free survival: 48% vs 22%, p = 0.039). CONCLUSION: LRRC patients with synchronous distant metastases undergoing curative surgery have relatively poor prognosis. However, LRRC patients with a history of distant metastases diagnosed nearby the primary tumour have comparable (oncological) survival as LRRC patients without distant metastases.

Assessing isometric kicking force and post-match responses using the Kicker test.

This study examined the inter-session reliability of force output from a novel isometric strength assessment protocol (the Kicker); and its suitability to monitor soccer player's combined hip flexion and knee extension force capacity over 72-h post-competitive matches. Reliability (Part-A) testing was completed over three sessions on 20 individuals participating in various sports at a recreational level or higher. Post-match strength response (Part-B) data were collected for 72-h after a game (24-h (+24), 48-h (+48) and 72-h (+72) post-match) in 17 male academy soccer players. After familiarisation, Kicker force for each limb showed high inter-session reliability (ICC >0.95; typical error <14 N, CV <6%); minimum detectable change at a 95% confidence interval <40 N). Across the 72-h post-match period, Kicker force for each limb was suppressed compared to baseline (force loss range = -5.8% to -12.5%; effect sizes range = -0.26 to -0.43) at all time points. The Kicker assessment protocol measures combined isometric hip flexor and knee extensor force capacity with high inter-session reliability. The proof of concept that the protocol can be used as a monitoring tool was evidenced by sustained suppression of baseline force capacity in both kicking limbs for 72-h post soccer matches.

Management of adults and children receiving CAR T-cell therapy: 2021 best practice recommendations of the European Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association (EHA).

BACKGROUND: Several commercial and academic autologous chimeric antigen receptor T-cell (CAR-T) products targeting CD19 have been approved in Europe for relapsed/refractory B-cell acute lymphoblastic leukemia, high-grade B-cell lymphoma and mantle cell lymphoma. Products for other diseases such as multiple myeloma and follicular lymphoma are likely to be approved by the European Medicines Agency in the near future. DESIGN: The European Society for Blood and Marrow Transplantation (EBMT)-Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association collaborated to draft best practice recommendations based on the current literature to support health care professionals in delivering consistent, high-quality care in this rapidly moving field. RESULTS: Thirty-six CAR-T experts (medical, nursing, pharmacy/laboratory) assembled to draft recommendations to cover all aspects of CAR-T patient care and supply chain management, from patient selection to long-term follow-up, post-authorisation safety surveillance and regulatory issues. CONCLUSIONS: We provide practical, clinically relevant recommendations on the use of these high-cost, logistically complex therapies for haematologists/oncologists, nurses and other stakeholders including pharmacists and health sector administrators involved in the delivery of CAR-T in the clinic.

Angiographic and Clinical Profile of Patients With COVID-19 Referred for Coronary Angiography During SARS-CoV-2 Outbreak: Results From a Collaborative, European, Multicenter Registry.

Data regarding angiographic characteristics, clinical profile, and inhospital outcomes of patients with coronavirus disease 2019 (COVID-19) referred for coronary angiography (CAG) are scarce. This is an observational study analyzing confirmed patients with COVID-19 referred for CAG from 10 European centers. We included 57 patients (mean age: 66 ± 15 years, 82% male) , of whom 18% had previous myocardial infarction (MI) and 29% had renal insufficiency and chronic pulmonary disease. ST-segment elevation myocardial infarction (STEMI) was the most frequent indication for CAG (58%). Coronavirus disease 2019 was confirmed after CAG in 86% and classified as mild in 49%, with 21% fully asymptomatic. A culprit lesion was identified in 79% and high thrombus burden in 42%; 7% had stent thrombosis. At 40 days follow-up, 16 (28%) patients experienced a major adverse cardiovascular event (MACE): 12 deaths (92% noncardiac), 1 MI, 2 stent thrombosis, and 1 stroke. In an European multicenter registry, patients with confirmed COVID-19 infection referred for CAG during the first wave of the severe acute respiratory syndrome coronavirus 2 pandemic presented mostly with STEMI and were predominantly males with comorbidities. Severity of COVID-19 was in general noncritical and 21% were asymptomatic at the time of CAG. Culprit coronary lesions with high thrombus burden were frequently identified, with a rate of stent thrombosis of 7%. The incidence of MACE at 40 days was high (28%), mostly due to noncardiac death.

Predicting pain and function outcomes in people consulting with shoulder pain: the PANDA-S clinical cohort and qualitative study protocol.

INTRODUCTION: People presenting with shoulder pain considered to be of musculoskeletal origin is common in primary care but diagnosing the cause of the pain is contentious, leading to uncertainty in management. To inform optimal primary care for patients with shoulder pain, the study aims to (1) to investigate the short-term and long-term outcomes (overall prognosis) of shoulder pain, (2) estimate costs of care, (3) develop a prognostic model for predicting individuals' level and risk of pain and disability at 6 months and (4) investigate experiences and opinions of patients and healthcare professionals regarding diagnosis, prognosis and management of shoulder pain. METHODS AND ANALYSIS: The Prognostic And Diagnostic Assessment of the Shoulder (PANDA-S) study is a longitudinal clinical cohort with linked qualitative study. At least 400 people presenting to general practice and physiotherapy services in the UK will be recruited. Participants will complete questionnaires at baseline, 3, 6, 12, 24 and 36 months. Short-term data will be collected weekly between baseline and 12 weeks via Short Message Serevice (SMS) text or software application. Participants will be offered clinical (physiotherapist) and ultrasound (sonographer) assessments at baseline. Qualitative interviews with ≈15 dyads of patients and their healthcare professional (general practitioner or physiotherapist).Short-term and long-term trajectories of Shoulder Pain and Disability Index (using SPADI) will be described, using latent class growth analysis. Health economic analysis will estimate direct costs of care and indirect costs related to work absence and productivity losses. Multivariable regression analysis will be used to develop a prognostic model predicting future levels of pain and disability at 6 months using penalisation methods to adjust for overfitting. The added predictive value of prespecified physical examination tests and ultrasound findings will be examined. For the qualitative interviews an inductive, exploratory framework will be adopted using thematic analysis to investigate decision making, perspectives of patients and clinicians on the importance of diagnostic and prognostic information when negotiating treatment and referral options. ETHICS AND DISSEMINATION: The PANDA-S study has ethical approval from Yorkshire and The Humber-Sheffield Research Ethics Committee, UK (18/YH/0346, IRAS Number: 242750). Results will be disseminated through peer-reviewed publications, social and mainstream media, professional conferences, and the patient and public involvement and engagement group supporting this study, and through newsletters, leaflets and posters in participating sites. TRIAL REGISTRATION NUMBER: ISRCTN46948079.

Relation between body composition and severe diarrhea in patients treated with preoperative chemoradiation with capecitabine for rectal cancer: a single-centre cohort study.

BACKGROUND: Chemoradiation with capecitabine followed by surgery is standard care for locally advanced rectal cancer (LARC). Severe diarrhea is considered a dose-limiting toxicity of adding capecitabine to radiation therapy. The aim of this study was to describe the risk factors and the impact of body composition on severe diarrhea in patients with LARC during preoperative chemoradiation with capecitabine. METHODS: A single centre retrospective cohort study was conducted in a tertiary referral centre. All patients treated with preoperative chemoradiation with capecitabine for LARC from 2009 to 2015 were included. Patients with locally recurrent rectal cancer who received chemoradiation for the first time were included as well. Logistic regression analyses were performed to identify risk factors for severe diarrhea. RESULTS: A total of 746 patients were included. Median age was 64 years (interquartile range 57-71) and 477 patients (64%) were male. All patients received a radiation dosage of 25 × 2 Gy during a period of five weeks with either concomitant capecitabine administered on radiation days or continuously during radiotherapy. In this cohort 70 patients (9%) developed severe diarrhea. In multivariable logistic regression analyses female sex (OR: 4.42, 95% CI 2.54-7.91) and age ≥ 65 (OR: 3.25, 95% CI 1.85-5.87) were the only risk factors for severe diarrhea. CONCLUSIONS: Female patients and patients aged sixty-five or older had an increased risk of developing severe diarrhea during preoperative chemoradiation therapy with capecitabine. No relation was found between body composition and severe diarrhea.

Central importance of emotional and quality-of-life outcomes in the public's perception of face transplantation.

BACKGROUND: Face transplantation is a surgical innovation to manage people with severely interrupted facial function and form. How the public perceive face transplantation and its potential implications for the recipient, donor, and society is unclear. The aim of this study was to understand the public perception of face transplantation, including when it is appropriate, what information is required to feel adequately informed, and which factors influence a person's willingness to donate their face. METHODS: This was a nationwide survey of participants representative of the GB public. A quantitative analysis was performed. Free-text qualitative responses were coded with thematic content analysis and a narrative analysis was constructed. RESULTS: The survey included 2122 participants. Face transplantation was considered worth the potential risks if it improved an individual's quality of life, gave them a 'normal life', and/or increased their confidence and social interaction. Respondents were worried about the impact face transplantation might have on donor families, especially recipient families adapting to the identity of the donor. Respondents most concerned about the concept of face transplantation were aged at least 55 years (χ2(4) = 38.9, P < 0.001), women (χ2(1) = 19.8, P < 0.001) , and Indian/Asian (χ2(4) = 11.9, P = 0.016). CONCLUSION: The public perceive emotional and psychological outcomes as equally as important as, or more important than, surgical outcomes when determining the appropriateness of face transplantation. Future research should focus on measuring and describing emotional and psychological outcomes after face transplantation.

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management.

INTRODUCTION: Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits. MATERIALS AND METHODS: A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance. RESULTS: Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period. DISCUSSION: The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.

The clinical relevance of indeterminate lung nodules in patients with locally recurrent rectal cancer.

AIM: To evaluate the clinical relevance of indeterminate lung nodules (ILN) in patients with locally recurrent rectal cancer (LRRC) treated in a tertiary referral centre. METHODS: All patients with LRRC diagnosed between 2000 and 2017 were retrospectively reviewed. Reports of staging chest CT-scans were evaluated for ILN. Patients with distant metastases including lung metastases at time of LRRC diagnosis were excluded. Overall (OS), progression-free survival (PFS) and the cumulative incidence of lung metastases were compared between patients with and without ILN. RESULTS: In total 556 patients with LRRC were treated during the study period. In the 243 patients eligible for analysis, 68 (28%) had ILN at LRRC diagnosis. Median OS was 37 months for both the patients with and without ILN (p = 0.37). Median PFS was 14 months for the patients with ILN and 16 months for patients without ILN (p = 0.80). After correction for potential confounding, ILN present at LRRC diagnosis was not associated with impaired OS or PFS (adjusted hazards ratio [95% confidence interval]: 0.81 [0.54-1.22] and 1.09 [0.75-1.59]). The 5-year cumulative incidence of lung metastases was 31% in patients with ILN and 28% in patients without ILN (p = 0.19). CONCLUSION: Our study shows that ILN are present in roughly a quarter of patients with LRRC. No differences in OS, PFS, or the cumulative incidence of lung metastases were found between patients with and without ILN at LRRC diagnosis. These results suggest that ILN are of little to no clinical relevance in patients with LRRC.

Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis.

OBJECTIVE: To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs). DESIGN: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020. ELIGIBILITY CRITERIA: All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions. DATA EXTRACTION AND SYNTHESIS: Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane). RESULTS: We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%). CONCLUSIONS: While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations. PROSPERO REGISTRATION NUMBER: CRD42017057908.

Incisional hernia formation in hepatobiliary surgery using transverse and hybrid incisions: a systematic review and meta-analysis.

INTRODUCTION: Evidence suggests that midline incisions should be closed with the small-bite technique to reduce IH formation. No recommendations exist for the closure of transverse incisions used in hepatobiliary surgery. This work systematically summarises rates of IH formation and associated technical factors for these transverse incisions. METHODS: A systematic search was undertaken. Studies describing the incidence of IH were included. Incisions were classified as transverse (two incision types) or hybrid (transverse with midline extension, comprising five incision types). The primary outcome measure was the pooled proportion of IH. Subgroup analysis based on minimum follow-up of two years and a priori definition of IH with clinical and radiological diagnosis was undertaken. FINDINGS: Thirteen studies were identified and included 5,427 patients; 1,427 patients (26.3%) underwent surgery for benign conditions, 3,465 (63.8%) for malignancy and 535 (9.9%) for conditions that were not stated or classified as 'other'. The pooled incidence of IH was 6.0% (2.0-10.0%) at a weighted mean follow-up of 17.5 months in the transverse group, compared with 15.0% (11.0-19.0%) at a weighted mean follow-up of 42.0 months in the hybrid group (p = 0.045). Subgroup analysis did not demonstrate a statistical difference in IH formation between the hybrid versus transverse groups. CONCLUSION: Owing to the limitations in study design and heterogeneity, there is limited evidence to guide incision choice and methods of closure in hepatopancreatobiliary surgery. There is an urgent need for a high-quality prospective cohort study to understand the techniques used and their outcomes, to inform future research.

The use of a patch to augment rotator cuff surgery - A survey of UK shoulder and elbow surgeons.

BACKGROUND: Rotator cuff tears are a common cause of shoulder pain and can result in prolonged periods of pain, disability and absence from work. Rotator cuff repair surgery is increasingly used in an attempt to resolve symptoms but has failure rates of around 40%. There is a pressing need to improve the outcome of rotator cuff repairs. Patch augmentation increasingly being used within the NHS in an attempt to reduce repair failures. The aim of this survey was to determine current UK practice and opinion relating to the factors that influence choice of patch, current patient selection and willingness to assist with generation of improved evidence. METHODS: An online survey was sent to the surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent demographics, experience with patches, indications for patch augmentation and willingness to be involved in a randomised trial of patch augmented rotator cuff surgery. RESULTS: The response rate was 105/550 (19%). 58% of respondents had used a patch to augment rotator cuff surgery. 70% of patch users had undertaken an augmented repair within the last 6 months. A wide surgical experience in augmentation was reported (ranging 1 to 200 implants used). However, most surgeons reported low volume usage, with a median of 5 rotator cuff augmentation procedures performed. At least 10 different products had been used. Most of the patches used were constructed from human decellularised dermis tissue, although porcine derived and synthetic based patches had also been used. Only 3-5% stated they would undertake an augmented repair for small tears across ages, whereas 28-40% and 19-59% would do so for large or massive tears respectively. When assessing patient suitability, patient age seemed relevant only for those with large and massive tears. Half of the surgeons reported an interest in taking part in a randomised controlled trial (RCT) evaluating the role of patch augmentation for rotator cuff surgery, with a further 22% of respondent's undecided. CONCLUSIONS: A variety of patches have been used by surgeons to augment rotator cuff repair with a wide range of operator experience. There was substantial uncertainty about which patch to use and differing views on which patients were most suitable. There is a clear need for robust clinical evaluation and further research in this area.

Scoping review of mode of anaesthesia in emergency surgery.

BACKGROUND: Emergency surgery encompasses more than 50 per cent of the surgical workload; however, research efforts are disproportionally low. The mode of anaesthesia used during emergency surgery may affect outcomes, but the extent of research and the impact of the different modes of anaesthesia used are unclear. METHODS: MEDLINE and Embase were searched using scoping review methodology with a rapid systematic search strategy, identifying any study comparing locoregional (local, nerve block, subarachnoid, epidural) anaesthesia with general anaesthesia. All studies describing outcomes of emergency surgery with differing modes of anaesthesia were identified. Excluded were: studies published before 2003, studies enrolling patients aged less than 18 years and studies using sedation only. RESULTS: Forty-two studies were identified, describing 11 surgical procedures. Most publications were retrospective cohort studies (32). A very broad range of clinical and patient-reported outcomes were described, with wide variation in the outcomes reported in different studies. CONCLUSION: Reporting of mode of anaesthesia is inconsistent across different procedures and is often absent. There is a need for directed research efforts to improve the reporting standards of anaesthesia interventions, to understand the role of different modes of anaesthesia in specific emergency surgical procedures, and to standardize outcome reporting using core outcome sets.

ANTECEDENTES: La cirugía de urgencias constituye > 50% de la carga de trabajo quirúrgico, aunque los esfuerzos realizados en investigación en este ámbito son desproporcionadamente bajos. La modalidad de anestesia utilizada durante la cirugía de urgencias puede afectar a los resultados, sin embargo, la investigación realizada y el impacto de los diferentes tipos de anestesia utilizados no están claros. MÉTODOS: Se realizaron búsquedas en Medline y Embase utilizando una metodología enfocada a la recuperación de revisiones, con una estrategia de búsqueda sistemática rápida, identificando cualquier estudio que comparara la anestesia locorregional (local, bloqueo nervioso, subaracnoidea, epidural) con la anestesia general. Se identificaron todos los estudios que describían los resultados de la cirugía de urgencias con diferentes tipos de anestesia. Se excluyeron los estudios publicados antes del 2003, los estudios que reclutaron pacientes < 18 años y los estudios que solo usaron sedación. RESULTADOS: Se identificaron 42 estudios que describían 11 procedimientos quirúrgicos. La mayoría de publicaciones fueron estudios de cohortes retrospectivos (n = 32). Se describió una gama muy amplia de resultados clínicos y resultados aportados por los pacientes, con una amplia variación en los resultados de los diferentes estudios. CONCLUSIÓN: Los resultados publicados respecto a la modalidad de anestesia empleada en diferentes procedimientos quirúrgicos son inconsistentes, a menudo esta información está ausente y no se pueden establecer conclusiones sobre el impacto del tipo de anestesia en los resultados. Es necesario realizar esfuerzos dirigidos a la investigación para mejorar la notificación de los estándares de los procedimientos de anestesia, comprender el papel de los diferentes tipos de anestesia en los procedimientos quirúrgicos específicos de urgencias, y estandarizar la presentación de los resultados obtenidos utilizando un conjunto de datos principales.

Locally recurrent rectal cancer; long-term outcome of curative surgical and non-surgical treatment of 447 consecutive patients in a tertiary referral centre.

INTRODUCTION: The majority of patients with locally recurrent rectal cancer (LRRC) present with extensive metastatic disease or an unresectable recurrence, and will be treated palliatively. Only a minority of patients will be eligible for potential cure by surgical treatment. The aim of this study is to evaluate the long-term outcome of surgical treatment and non-surgical treatment of patients with LRRC. METHODS: All patients with LRRC referred to our tertiary institute between 2000 and 2015 were retrospectively analysed. Patients were discussed in a multidisciplinary tumour board (MDT) and eventually received curative surgical or non-surgical treatment. Overall survival (OS) was compared by resection margin status and non-surgical treatment. RESULTS: A total of 447 patients were discussed in our MDT of which 193 patients underwent surgical treatment and 254 patients received non-surgical treatment. Surgically treated patients were significantly younger, received less neoadjuvant therapy for the primary tumour, had less metastasis at diagnosis and more central recurrences. The 5-year OS was 51% for R0-resections and 34% for R1-resections. Although numbers with R2-resections were too small to implicate prognostic significance, there was no difference in 5-year OS between R2-resections and non-surgical treatment (10% vs. 4%, p = 0.282). In a subgroup analysis the OS of R2-patients was even poorer compared to optimal palliative treated patients with combined chemotherapy and radiotherapy (22 vs 29 months, p = 0.413). CONCLUSION: R2-resections do not result in a survival benefit compared to non-surgical treatment in this non-randomized series. Patients with a high chance on a R2-resection could be offered non-surgical treatment, without local resection.

Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty is an effective treatment for patients with painful elbow arthritis. Infection can be a serious complication. The aim of this scoping review was to document the available evidence on periprosthetic elbow infection. METHODS: A search of Medline, Embase and PubMed was performed; two authors screened results independently. Systematic reviews, randomised controlled trials, cohort studies, case-control studies and case series including periprosthetic elbow infection were eligible. RESULTS: A total of 46 studies were included. The median rate of periprosthetic elbow infection reported from recent published studies is 3.3%. The most commonly identified causative organisms are Staphylococcus aureus and Staphylococcus epidermidis. Risk factors include younger age, rheumatoid arthritis, obesity, previous surgery or infection to the elbow, and postoperative wound complications. Debridement, antibiotics and implant retention results in implant survival rates of 50-90%. Two-stage revision results in improved functional outcome scores, but with recurrent infection rates of 12-28%. CONCLUSIONS: Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. The current body of literature is limited and is almost exclusively low volume retrospective case series. The best management of periprosthetic elbow infection is difficult to determine, but two-stage revision appears to be the gold standard.

Cost-effectiveness analysis of a placebo-controlled randomized trial evaluating the effectiveness of arthroscopic subacromial decompression in patients with subacromial shoulder pain.

AIMS: The aims of this study were to compare the use of resources, costs, and quality of life outcomes associated with subacromial decompression, arthroscopy only (placebo surgery), and no treatment for subacromial pain in the United Kingdom National Health Service (NHS), and to estimate their cost-effectiveness. PATIENTS AND METHODS: The use of resources, costs, and quality-adjusted life-years (QALYs) were assessed in the trial at six months and one year. Results were extrapolated to two years after randomization. Differences between treatment arms, based on the intention-to-treat principle, were adjusted for covariates and missing data were handled using multiple imputation. Incremental cost-effectiveness ratios were calculated, with uncertainty around the values estimated using bootstrapping. RESULTS: Cumulative mean QALYs/mean costs of health care service use and surgery per patient from baseline to 12 months were estimated as 0.640 (standard error (se) 0.024)/£3147 (se 166) in the decompression arm, 0.656 (se 0.020)/£2830 (se 183) in the arthroscopy only arm and 0.522 (se 0.029)/£1451 (se 151) in the no treatment arm. Statistically significant differences in cumulative QALYs and costs were found at six and 12 months for the decompression versus no treatment comparison only. The probabilities of decompression being cost-effective compared with no treatment at a willingness-to-pay threshold of £20 000 per QALY were close to 0% at six months and approximately 50% at one year, with this probability potentially increasing for the extrapolation to two years. DISCUSSION: The evidence for cost-effectiveness at 12 months was inconclusive. Decompression could be cost-effective in the longer-term, but results of this analysis are sensitive to the assumptions made about how costs and QALYs are extrapolated beyond the follow-up of the trial.