Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection.

BACKGROUND: Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse. METHODS: A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further. RESULTS: Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively. CONCLUSION: Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.

Meta-analysis of the effect of bariatric surgery on physical function.

BACKGROUND: Obesity leads to an impairment of physical function that limits the ability to perform basic physical activities affecting quality of life. Literature on the effect of bariatric surgery on physical function is confounding and generally of low quality. METHODS: A comprehensive search was undertaken using MEDLINE, Scopus (including Embase), CENTRAL, PubMed, SPORTDiscus, Scirus and OpenGrey for published research and non-published studies to 31 March 2017. Studies employing objective measurement and self-reporting of physical function before and after bariatric surgery were included. The magnitude of experimental effect was calculated in terms of the standardized mean difference (MD), and confidence intervals were set at 95 per cent to reflect a significance level of 0·05. RESULTS: Thirty studies including 1779 patients met the inclusion criteria. Physical function improved after bariatric surgery at 0-6 months (MD 0·90, 95 per cent c.i. 0·60 to 1·21; P < 0·001), more than 6 to 12 months (MD 1·06, 0·76 to 1·35; P < 0·001) and more than 12 to 36 months (MD 1·30, 1·07 to 1·52; P < 0·001). Objective assessment of physical function after bariatric surgery showed improvement at 0-6 months (MD 0·94, 0·57 to 1·32; P < 0·001), more than 6 to 12 months (MD 0·77, 0·15 to 1·40; P = 0·02) and more than 12 to 36 months (MD 1·04, 0·40 to 1·68; P = 0·001). Self-reported assessment of physical function showed similar improvements at 0-6 months (MD 0·80, 0·12 to 1·47; P = 0·02), more than 6 to 12 months (MD 1·42, 1·23 to 1·60; P < 0·001) and more than 12 to 36 months (MD 1·41, 1·20 to 1·61; P < 0·001) after a bariatric procedure. CONCLUSION: Bariatric surgery improves physical function significantly within 6 months of the procedure and this effect persists over time to 36 months after surgery, whether measured objectively or by self-reporting.

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19.

INTRODUCTION: Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients. METHODS: A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK. RESULTS: Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19. CONCLUSION: With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

All-Terrain Vehicle(ATV) Injuries - An Institutional Review Over 6 Years.

OBJECTIVE: Quad bike or all-terrain vehicle (ATV) related injuries are a significant cause of trauma and may present with severe or fatal injuries. Most of the literature describing ATV related injuries come from North America and Australasia and data from the United Kingdom is scarce despite a high prevalence of ATV use. The aim of this study was to describe our single centre experience with ATV injuries over a 6-year period from 2010 to 2015. MATERIALS AND METHODS: This is a cohort analysis of 65 patients who presented with ATV related injuries in South West Acute Hospital, UK between 2010 and 2015. RESULTS: 65 patients had ATV injuries. 34 (52%) patients were children between 0 - 17 years of age. 88% (n=57) patients were ejected from the ATV, six got trapped underneath and two had collisions. "Ejection" as a mechanism of injury was significantly more common than the other mechanisms (p<0.0001). Compliance with helmet use was low at 16% (n=10). Extremity (48%) and head and face trauma (43%) were the most common injuries. One (1.5%) patient died while 3 (4.6%) patients had major morbidity. CONCLUSION: ATV injuries are an important cause of trauma admissions and carry a significant risk of morbidity and mortality. Extremity and head trauma are the most common injuries resulting from ATV accidents. More than 50% of the injured are children. Compliance with helmet use is low and calls for legislation and public awareness strategies to reduce the impact of ATV accidents on health care.

A Single Centre Analysis of Clinical Characteristics and Treatment of Endocrine Pancreatic Tumours.

Background. Endocrine Pancreatic Tumours (PENs) are rare and can be nonfunctioning or functioning. They carry a good prognosis overall though high grade lesions show a relatively shorter survival. The aim of the current study is to describe a single centre analysis of the clinical characteristics and surgical treatment of PENs. Patients and Methods. This is a cohort analysis of 40 patients of PENs who underwent surgery at Sir Ganga Ram Hospital, New Delhi, India, from 1995 to 2013. Patient particulars, clinical features, surgical interventions, postoperative outcome, and followup were done and reviewed. The study group was divided based on grade (G1, G2, and G3) and functionality (nonfunctioning versus functioning) for comparison. Results. PENs comprised 6.3% of all pancreatic neoplasms (40 of 634). Twenty-eight patients (70%) had nonfunctioning tumours. Eighteen PENs (45%) were carcinomas (G3), all of which were nonfunctioning. 14 (78%) of these were located in the pancreatic head and uncinate process (P = 0.09). The high grade (G3) lesions were significantly larger in size than the lower grade (G1 + G2) tumours (7.0 ± 3.5 cms versus 3.1 ± 1.6 cms, P = 0.007). Pancreatoduodenectomy was performed in 18 (45%), distal pancreatectomy in 10 (25%), and local resection in 8 (20%) and nonresective procedures were performed in 4 patients (10%). Fourteen patients (35%) had postoperative complications. All G3 grade tumours which were resected had positive lymph nodes (100%) and 10 had angioinvasion (71%). Eight neoplasms (20%) were cystic, all being grade G3 carcinomas, while the rest were solid. The overall disease related mortality attributable to PEN was 14.3% (4 of 28) and for malignant PENs was 33.3% (4 of 12) after a mean follow-up period of 49.6 months (range: 2-137 months). Conclusion. Majority of PENs are nonfunctioning. They are more likely malignant if they are nonfunctioning and large in size, show cystic appearance, and are situated in the pancreatic head. Early surgery leads to good long term survival with acceptable postoperative morbidity.