The First Modified Delphi Consensus-Building Exercise on Surgical Ward Rounds in the United Kingdom National Health Service.

BACKGROUND: The ward round is an integral part of everyday surgical practice. It is a complex clinical activity that requires both sound clinical management and communication skills. This study reports the results of a consensus-building exercise on the common aspects of the general surgical ward rounds. METHODS: The consensus-building committee involving a range of stakeholders from 16 United Kingdom (UK) National Health Service trusts took part in this consensus exercise. The members discussed and suggested a series of statements concerning surgical ward round. An agreement of ≥ 70% among members was regarded as a consensus. RESULTS: Thirty-two members voted on 60 statements. There was a consensus on fifty-nine statements after the first round of voting, and one statement was modified before it reached consensus in the second round. The statements covered nine sections: a preparation phase, team allocation, multidisciplinary approach to the ward round, structure of the round, teaching considerations, confidentiality and privacy, documentation, post-round arrangements, and weekend round. There was a consensus on spending time to prepare for the round, a consultant-led round, involvement of the nursing staff, an MDT round at the beginning and end of the week, a minimum of 5 min allocated to each patient, utilisation of a round checklist, afternoon virtual round, and a clear handover and plan for the weekend. CONCLUSION: The consensus committee achieved agreement on several aspects concerning the surgical ward rounds in the UK NHS. This should help improve the care of surgical patients in the UK.

Comprehensive cardiovascular magnetic resonance of myocardial mechanics in mice using three-dimensional cine DENSE.

BACKGROUND: Quantitative noninvasive imaging of myocardial mechanics in mice enables studies of the roles of individual genes in cardiac function. We sought to develop comprehensive three-dimensional methods for imaging myocardial mechanics in mice. METHODS: A 3D cine DENSE pulse sequence was implemented on a 7T small-bore scanner. The sequence used three-point phase cycling for artifact suppression and a stack-of-spirals k-space trajectory for efficient data acquisition. A semi-automatic 2D method was adapted for 3D image segmentation, and automated 3D methods to calculate strain, twist, and torsion were employed. A scan protocol that covered the majority of the left ventricle in a scan time of less than 25 minutes was developed, and seven healthy C57Bl/6 mice were studied. RESULTS: Using these methods, multiphase normal and shear strains were measured, as were myocardial twist and torsion. Peak end-systolic values for the normal strains at the mid-ventricular level were 0.29 ± 0.17, -0.13 ± 0.03, and -0.18 ± 0.14 for E(rr), E(cc), and E(ll), respectively. Peak end-systolic values for the shear strains were 0.00 ± 0.08, 0.04 ± 0.12, and 0.03 ± 0.07 for E(rc), E(rl), and E(cl), respectively. The peak end-systolic normalized torsion was 5.6 ± 0.9°. CONCLUSIONS: Using a 3D cine DENSE sequence tailored for cardiac imaging in mice at 7 T, a comprehensive assessment of 3D myocardial mechanics can be achieved with a scan time of less than 25 minutes and an image analysis time of approximately 1 hour.

Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-en-Y Gastric Bypass in Elderly Bariatric Patients: Safety and Efficacy-a Systematic Review and Meta-analysis.

INTRODUCTION: Obesity is a chronic disease due to excess fat storage, a genetic predisposition, and environmental contribution where surgery offers a viable treatment option. The surgical treatment of obesity in the elderly population (> 55 years) remains controversial. PURPOSE: To evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in elderly bariatric patients. MATERIALS AND METHODS: Data was sourced from MEDLINE, EMBASE, CINAHL, PubMed, and Cochrane databases for peer-reviewed, randomized controlled trials, and observational studies in the English language were searched from the year 1991 until 2019. From the extracted data, early and late procedural complications and mortality were used as safety outcomes. Weight loss was the primary outcome for effectiveness while the resolution of obesity-related comorbidities was included as secondary outcomes. The Review Manager (Rev Man 5.3)™ software was used for statistical analysis. RESULTS: Of the forty-one screened studies, nine studies were included in the final analysis. There was no difference between LSG and LRYGB regarding early complications and mortality 3.6% versus 5.8% (p = 0.15) and 0.1% versus 0.8% (p = 0.27). Patients who underwent LRYGB had more late complications compared with those who underwent LSG (0.07% and 0.03%, p = 0.001). There was no difference in terms of weight loss at the end of 1 year. Patients who underwent LRYGB had a better resolution of obesity-related comorbidities, not statistically significant. CONCLUSION: LRYGB has better efficacy when compared with LSG. However, high-risk elderly patients should be considered for LSG given the lesser morbidity and comparable efficacy with LRYGB.

Do theatre staff use face masks in accordance with the manufacturers' guidelines of use?

AIM: Surgical face masks are worn by theatre staff to protect the surgical site from airborne contamination and the wearer from bodily fluid splash. This observational/audit aimed to assess whether theatre staff wear masks in accordance with manufacturers'/Centers for Disease Control and Prevention (CDC) guidelines of use. METHODS: A total of 1034 surgically scrubbed staff were assessed on their technique of applying surgical face masks, compared to the CDC guidelines as manufacturers' guidelines were not available as per Health and Safety Executive guidelines. RESULTS: Only 18% of surgically scrubbed staff fully complied with the CDC guidelines on the application of a face mask. Compliance was worst in urology, ophthalmology and vascular surgeons, whereas orthopaedic and plastic surgeons were the most compliant. DISCUSSION: Compliance with CDC face mask guidelines may have an impact on surgical site infections (SSI) and protection of staff from body fluid splash, but most staff do not comply with these guidelines. CONCLUSIONS: Most operating theatre staff do not apply a face mask using correct technique, outlined in CDC guidance, which may increase SSI rates. Staff are not aware of existing guidelines for donning a mask.

Extended operating times are more efficient, save money and maintain a high staff and patient satisfaction.

Current public sector austerity measures necessitate efficiency savings throughout the NHS. Performance targets have resulted in activity being performed in the private sector, waiting list initiative lists and requests for staff to work overtime. This has resulted in staff fatigue and additional agency costs. Adoption of extended operating theatre times (0800-1800 hours) may improve productivity and efficiency, with potentially significant financial savings; however, implementation may adversely affect staff morale and patient compliance. A pilot period of four months of extended operating times (4.5 hour sessions) was completed and included all theatre surgical specialties. Outcome measures included: the number of cases completed, late starts, early finishes, cancelled operations, theatre overruns, preoperative assessment and 18-week targets. The outcomes were then compared to pre-existing normal working day operating lists (0900-1700). Theatre staff, patient and surgical trainee satisfaction with the system were also considered by use of an anonymous questionnaire. The study showed that in-session utilisation time was unchanged by extended operating hours 88.7% (vs 89.2%). The service was rated as 'good' or 'excellent' by 87.5% of patients. Over £345,000 was saved by reducing premium payments. Savings of £225,000 were made by reducing privately outsourced operation and a further £63,000 by reviewing staff hours. Day case procedures increased from 2.8 to 3.2 cases/day with extended operating. There was no significant increase in late starts (5.1% vs 6.8%) or cancellation rates (0.75% vs 1.02%). Theatre over-runs reduced from 5% to 3.4%. The 18 weeks target for surgery was achieved in 93.7% of cases (vs 88.3%). The number of elective procedures increased from 4.1 to 4.89 cases/day. Only 13.33% of trainees (n = 33) surveyed felt that extended operating had a negative impact on training. The study concludes that extended operating increased productivity from 2.8 patients per session to 3.2 patients per session with potential savings of just over £2.4 million per financial year. Extrapolating this to the other 155 trusts in England could be a potential saving of £372 million per year. Staff, trainee and patient satisfaction was unaffected. An improved 18 weeks target position was achieved with a significant reduction in private sector work. However, some staff had difficulty with arranging childcare and taking public transport and this may prevent full implementation.

A prospective, randomized controlled trial comparing n-butyl cyanoacrylate tissue adhesive (LiquiBand) with sutures for skin closure after laparoscopic general surgical procedures.

The aim of this study was to compare the efficacy of n-butyl-cyanoacrylate tissue adhesive (Liquiband) with nonabsorbable monofilament sutures for laparoscopic port site closure. Adult patients having elective laparoscopic procedures were randomly allocated to wound closure with sutures or tissue adhesive. End points included skin closure time, wound dressing requirements, wound complications, and cosmesis, assessed at discharge, 4 to 6 weeks and 3 months. Seventy-eight patients randomized to receive sutures and 76 to receive tissue adhesive were eligible for final analysis. Mean closure time was significantly longer for sutures (220 vs. 125 s, P < 0.001). Fewer dressings were required in the tissue adhesive group immediately postoperatively (21% vs. 97%, P < 0.001) and at discharge (24% vs. 82%, P < 0.001). There were no significant differences in wound complications or in cosmesis at either 4 to 6 weeks or at 3 months. Tissue adhesive for laparoscopic port site closure offers potential savings with respect to time and has comparable wound complication rates and cosmetic outcomes when compared with nonabsorbable monofilament sutures.

Injuries caused by parachute risers during foreign military parachuting.

OBJECTIVE: The objective was to study the injuries from the deployment of military parachutes when parachuting with foreign armies. METHODS: The number and nature of injuries sustained while military parachuting with domestic and foreign parachute systems and techniques was compared. RESULTS: Of a total of 370 parachutists, 41 (11.1%) suffered minor injuries following two descents on the British parachute, 20 (5.4%) of these were classified as riser injuries. Thirty-eight (25.9%) of 147 British parachutists sustained riser injuries following two descents with the French parachute. Thirty-four (89.5%) of these injuries were minor posterior-auricular bruises and abrasions not requiring treatment. Four (10.5%) were extensive posterior-auricular abrasions that required treatment. Two soldiers (5.3%) suffered lacerations of the attachment of the pinna to the head. There were no riser injuries and no other injuries when the soldiers parachuted with their own countries parachutes in the proceeding two descents. CONCLUSION: Failure to adhere to drills led to injuries with foreign parachute systems.

The biological and therapeutic importance of gastrin gene expression in pancreatic adenocarcinomas.

The gastrin gene is expressed widely in pancreatic adenocarcinomas and the study aimed to assess its role in both the resistance of cancer cells to apoptosis and the sensitivity of cells to chemotherapeutic agents. Two human pancreatic cell lines, PAN1 and BXPC3, expressed gastrin at both the RNA and protein levels and are shown to be representative of human pancreatic adenocarcinomas in terms of gastrin expression. Inhibition of endogenous gastrin production by tumor cells was achieved with neutralizing gastrin antiserum and transfection with a gastrin antisense plasmid. Gastrin antiserum synergized with both taxotere and gemcitabine in inhibiting the in vitro growth of the PAN1 cell line with the inhibitory effect of the antiserum increasing from 12.7% to 70.2% with taxotere (P < 0.05) and 28.6% with gemcitabine (P < 0.01) after controlling for the effects of the cytotoxics. Synergy was only achieved with taxotere in BXPC3 cells with the inhibitory effect of gastrin antiserum increasing from 22.9% to 50.0% (P < 0.005). Cells transfected with gastrin antisense had reduced in vitro growth in low serum conditions and were poorly tumorigenic in nude mice at an orthotopic site. Gastrin antisense-transfected PAN1 cells had increased sensitivity to the antiproliferative effects of both gemcitabine (IC50 of > 100 microg/ml reduced to 0.1 microg/ml) and taxotere (IC50 of 20 microg/ml reduced to < 0.01 microg/ml) when compared with vector controls. The increased sensitivity of PAN1 antisense coincided with increased caspase-3 activity and reduced protein kinase B/Akt phosphorylation in response to both gemcitabine and taxotere. Gastrin gene circumvention may be an optimal adjunct to chemotherapeutic agents, such as taxotere and gemcitabine, in pancreatic adenocarcinoma.

Emerging biological therapies for pancreatic carcinoma.

AIMS: The incidence of pancreatic carcinoma remains approximately equal to its mortality, with the vast majority of patients having advanced disease at presentation. This review is an update of the promising novel approaches involving biological therapy that may be used in conjunction with new chemotherapeutic agents in the near future. METHODS: A literature review was performed using the National Library of Medicine's Pubmed database, combined with recently published data from the AGA and ASCO conferences. RESULTS: Rapid progress is being made in gene and molecular technology potentially enabling us to inhibit pancreatic carcinogenesis and to reduce disease progression. Different targets include signal transduction inhibitors, gene therapy, genetic prodrug activation therapy, antisense therapy, immunotherapy, matrix metalloproteinase and cyclo-oxygenase-2 inhibition and hormonal manipulation. CONCLUSION: A variety of biological agents are currently undergoing clinical trials, targeting different areas of the pancreas'neoplastic process. .

Percutaneous biliary metal wall stenting in malignant obstructive jaundice.

BACKGROUND: Most patients with advanced stage malignant obstructive jaundice will be suitable for palliation only. Metallic stents are safe, effective and minimally invasive. DESIGN: A review of case notes of patients who had Wallstents inserted percutaneously from January 1996 to December 2000. RESULTS: Eighty-nine patients with a median age of 72 years underwent percutaneous insertion of biliary metal stents. The diagnoses were cholangiocarcinoma (41.5%), pancreatic carcinoma (40.5%), nodal metastases at the porta hepatis (14.6%) and gall bladder cancer (3.4%). Ninety-six per cent of patients improved their hyperbilirubinaemia to normal levels by 1 month. The median post-procedure hospital stay was 16 days. Early overall complications (within 30 days of stenting) occurred in 30% of patients (70% of these were disease related). The 30 day mortality rate was 20% (n = 18). Fifty (70%) patients were readmitted to hospital, most commonly because of carcinomatosis (16) or stent obstruction (12). The symptom-free period ranged from 2 weeks to 13 months. Median survival for all patients was 3.5 months. Survival correlated inversely with serum bilirubin at presentation (r = -0.34, P = 0.001), but not with other liver function tests. DISCUSSION: Metal wall stenting for malignant obstructive jaundice provides good palliation with low, procedure-related morbidity and mortality, but poor overall survival from disease-related morbidity. Survival significantly correlates with pre-stenting serum bilirubin levels. There is a need to identify the subgroup of patients in whom stenting has no beneficial effect.

Automated motion estimation for 2-D cine DENSE MRI.

Cine displacement encoding with stimulated echoes (DENSE) is a magnetic resonance (MR) method that directly encodes tissue displacement into MR phase images. This technique has successfully interrogated many forms of tissue motion, but is most commonly used to evaluate cardiac mechanics. Currently, motion analysis from cine DENSE images requires manually delineated anatomical structures. An automated analysis would improve measurement throughput, simplify data interpretation, and potentially access important physiological information during the MR exam. In this paper, we present the first fully automated solution for the estimation of tissue motion and strain from 2-D cine DENSE data. Results using both simulated and human cardiac cine DENSE data indicate good agreement between the automated algorithm and the standard semi-manual analysis method.

An international multicenter randomized controlled trial of G17DT in patients with pancreatic cancer.

OBJECTIVES: This study aimed to investigate G17DT, an immunogen producing neutralizing antibodies against the tumor growth factors amidated and glycine-extended forms of gastrin-17, in the treatment of pancreatic cancer. METHODS: A randomized, double-blind, placebo-controlled, group-sequential multicenter trial of G17DT in patients with advanced pancreatic cancer unsuitable for or unwilling to take chemotherapy. Inclusion criteria were a Karnofsky performance score of 60 or higher and a life expectancy of more than 2 months. Patients received G17DT or placebo emulsion at weeks 0, 1, 3, 24, and 52. The primary end point was survival, and secondary end points were tolerability, Karnofsky performance. RESULTS: A total of 154 patients were recruited: 79 G17DT and 75 placebo. A final analysis of the intention-to-treat population, using a proportional hazards model, stratifying by disease stage and adjusting for interim analysis, gave a hazard ratio for mortality of 0.75 (95% confidence interval, 0.51-1.10, P = 0.138; G17DT/placebo). A conventional analysis without adjustment for disease stage or interim analysis, censoring for chemotherapy and excluding protocol violators, gave median survival periods of 151 (G17DT) and 82 days (placebo) (log-rank test, P = 0.03).Patients developing anti-G17DT responses (73.8%) survived longer than nonresponders or those on placebo (median survival, 176 vs 63 vs 83; log-rank test, P = 0.003). G17DT was well tolerated.

Cardiac motion recovery via active trajectory field models.

Cardiovascular researchers are constantly developing new and innovative medical imaging technologies, striving to improve the understanding, diagnosis, and treatment of cardiovascular dysfunction. Combining these sophisticated imaging methods with advancements in image understanding via computational intelligence will continue to advance the frontier of cardiovascular medicine. Recently, researchers have turned to a new class of tissue motion imaging techniques, including displacement encoding with stimulated echoes (DENSE) in cardiac magnetic resonance (cMR) imaging, to directly quantify cardiac displacement and produce accurate spatiotemporal measurements of myocardial strain, twist, and torsion. The associated analysis of DENSE cMR and other tissue motion imagery, however, represents a major bottleneck in the study of intramyocardial mechanics. In the computational intelligence area of deformable models, this paper develops an automated motion recovery technique termed active trajectory field models (ATFMs) geared toward these new motion imaging protocols, offering quantitative physiological measurements without the pains of manual analyses. This novel generative deformable model exploits both image information and prior knowledge of cardiac motion, utilizing a point distribution model derived from a training set of myocardial trajectory fields to automatically recover cardiac motion from a noisy image sequence. The effectiveness of the ATFM method is demonstrated by quantifying myocardial motion in 2-D short-axis murine DENSE cMR image sequences both before and after myocardial infarction, producing results comparable to existing semiautomatic analysis methods.