bluuebunny/crossref_metadata_2025 huggingface dataset:
FTP8.13 Validation of a definition of Major Abdominal Surgery (MAS)
Authors: Courtney Alona , Dorudi Yasmin , Cosentino Daria , Cross Tim , Moonesinghe Suneetha Ramani , Dorudi Sina
Published: August 2023

Aims

To validate a previously derived definition for major abdominal surgery that has potential for widespread adoption and use in patient-driven outcome studies.

Methods

We codified our narrative definition for MAS using CCSD and OPCS-4 schedules. Data was extracted from electronic health records over a 5-year period to validate this definition by comparing relevant proxy measurements between MAS and non-MAS groups. Unsupervised machine learning, using the Partitioning Around Medoids algorithm, was used to cross-validate the definition by clustering all procedure codes into MAS and non-MAS groups based on these proxy measures.

Results

337 CCSD codes and 214 OPCS-4 codes were reviewed. Of these, 84 CCSD and 45 OPCS-4 codes were considered to be MAS, while 195 CCSD and 111 OPCS-4 codes were considered to be non-MAS. The remaining codes were excluded as they involved non-operative procedures. We extracted data on 16,353 procedures, covering 214 CCSD procedure codes over a 5 year period. There was statistically significant difference between MAS and non-MAS operations, when comparing patient age, procedure duration, length of hospital stay, percentage of ICU admissions (p<0.001 for all values). Unsupervised machine learning allocated 127 CCSD codes, that contained data on more than 10 patients, into 2 distinct clusters with percentage agreement being 87.4% and Cohen’s kappa of 0.736 between narrative definition and machine learning analysis.

Conclusions

We have arrived at a validated definition of major abdominal surgery, which can now be confirmed using a larger data set. We propose that this will prove useful in the development of comparative patient-driven outcome data.
85 The SSSLOT study: Surgery, Stent (SEMS), Stoma for Left Obstructive colonic Tumours
Authors: Kwan Jing Yi , McClean Adam , Harper Alex , Jiminez Anna , Lockwood Sonia , Yiasemidou Marina
Published: August 2023

Aim

There is no clear consensus on the optimal management of obstructed left colonic malignancy. Although SEMS as a bridge to elective surgery is considered an alternative to primary surgery, comparisons of defunctioning stoma versus stent versus surgery has yet to be explored. This is a pilot study on the management of acute left malignant colonic obstruction (LMCO) in our trust.

Methods

This is a retrospective review of the management and outcomes of LMCO in our trust from 2019-2021.

Results

19 patients were identified (72 y.o., M:F 10:9). T3:4 (8:11). 3 were rectal, 11 sigmoid, 4 were descending, and 1 transverse colon cancer. 7 had SEMS, 7 defunctioning stoma, and 5 emergency resection.

All 7 cases of SEMS were clinically and technically successful. Mean time from SEMS to definitive surgery was 49.5 days with one case not leading to surgery. There was one 30-day complication reported which was not SEMS related; 3 year mortality (3YM) was 4/7.

In the defunctioning stoma group, 2 did not proceed to surgery; 6 patients experienced complications; 3YM was 3/7. For the straight to surgery group, 5/14 of patients who had bridging-to-surgery procedure had neoadjuvant treatment; 4 complications were reported; 3YM was 1/6.

Conclusion

Although the results are limited by small numbers, a bridge-to-surgery technique is used approximately 3 times more frequently than emergency surgery, and neoadjuvant treatment is rarely employed. There would appear to be a lower 3YM with emergency surgery compared to the other interventions. Multicenter data collection will assess these preliminary findings.
92 Closed loop audit: Improving virtual clinic practice in Royal Sussex County Hospital
Authors: Nour Hussameldin Mohamed , Saleem Mohamed , Peristeri Dimitra V , Abogabal Sameh , Sajid Muhammad S
Published: August 2023

Aims

The aim of this study is to assess virtual clinics practice in Royal Sussex County Hospital comparing it to the RCS guidelines as standard as well as improving the current practice.

Methods

We undertook two cycles studying twelve consecutive clinics each cycle. These cycles aimed to assess the virtual clinics and comparing them with RCS guidelines using check-lists. A teaching session was conducted between the two cycles. In addition, RCS guidelines were handed over to surgical consultants aiding them in conduction their virtual clinic.

Results

We sampled a total of 444 patients from 24 virtual clinics (first cycle: 216, second cycle 228). Following conduction of teaching sessions and handing over guidelines , there was a significant improvement in some parameters such as obtain consent of the patient for the virtual consultation (from 70% to 100 %), explain what will happen in the virtual appointment and how long it will last (from 30% to 100 %) and If further contact is needed, confirm the patient’s agreement to be contacted remotely and explain how the patient can contact them if they have further questions (from 70% to 100 %). Introduction, history taking, management plan, conclusion and follow-up letter or email to patient and GP were satisfactory in both cycles.

Conclusion

Virtual consultations offer potential tools through which we may still be able to offer care remotely and also identify those patients who need urgent intervention, with proper education sessions Virtual clinic can be conducted safely according to RCS guidelines

Acknowledgment

First cycle presented in ASGBI 2022.
100 Utilisation of Dissections vs Prosections in Anatomical Education and its Relevance in Pursuing Surgical Training: A Comparative Study on Students' Perspectives at a Northern Irish Medical School
Authors: Roy Sakshi , Ahluwalia Arjun , Shah Muhammad Hamza
Published: August 2023

Aim

This study investigates medical students’ opinions regarding their memorisation, retention and implementation of anatomical learning by comparing prosection and dissection studies offered at the university. Furthermore, we also investigated its significance in students considering the surgical training pathway in the future.

Method

Medical students at QUB were sent a 10-item survey weighing their preference for dissection and prosection in the retention and application of anatomical knowledge along with its relevance in pursuing surgery. The survey was distributed amongst Year 1 - 5 medical students in an online format, with answers recorded over the span of two weeks.

Results

26 QUB medical students across preclinical/clinical years answered the survey, 53.85% of whom preferred dissections for identification, memorisation and employment of information regarding anatomical structures. Students who chose dissection agreed that the process offered more interaction, with deeper knowledge about spatial organ recognition. Meanwhile, prosections were chosen by students who believed focusing on isolated organs helped in mapping their knowledge to relevant learning outcomes.

Moreover, 42.11% of respondents found both learning methods helped visualise anatomical concepts outside a medical environment. However, dissection helped most students draw links between pathology and its anatomical basis. Finally, 84.21% considered dissection to play a major role in viewing surgery as a future career.

Conclusions

While there is an observable difference in respondents' perspectives, the survey indicates an overall preference for dissection in anatomical lab practices. The practice appealed to students better due to its greater interactive experience and tactile approach, with respondents agreeing that dissection mimics true surgical craftsmanship.
146 Percutaneous Cholecystostomy Management: A Quality Improvement Project
Authors: White Annabelle , Harman Holly , Worthington Tess , Wu Fiona , Klimovskij Michail
Published: August 2023

Introduction

Percutaneous Cholecystostomy (PC) drainage is used in acute calculous cholecystitis management for draining a septic source as an adjunct to antibiotic therapy, and frequently a temporising measure to interval cholecystectomy. Despite various guidelines surrounding PC insertion, there is little consensus on their subsequent management and removal – including optimal duration, investigations prior to removal, and timing of cholecystectomy.

Method

Retrospective review of all patients undergoing radiologically guided PC insertion between 1/22/21 and 2/10/22. Data collected included patient demographics, time from diagnosis to PC, duration of admission and PC in situ, investigations prior to removal, cholecystectomy, and complications.

Results

25 patients, with median 2 days from diagnosis to PC (0-25), and admission duration 6.5 days (1-25). 22 patients were discharged with PC in situ, 2 removed prior to discharge, and 1 in-hospital mortality. 33 days (1-68) median duration of PC in situ, with 11 having LFTs and 10 having cholecystogram prior to removal. 5 patients have subsequently undergone cholecystectomy, with another 5 awaiting operation date. 2 patients were readmitted following initial PC removal– both requiring further PC insertion.

Conclusion

We demonstrated considerable heterogeneity in PC management at ESHT, and subsequently introduced a consultant-body approved “Cholecystostomy Pathway” and “Cholecystostomy Passport”. This pathway outlines the journey for patients through outpatient investigations and removal – complete with ideal timeline and clinic appointments. Accompanied by the “Cholecystostomy Passport” given to patients outlining the above and providing safety netting information, we aim to standardise PC management and subsequently improve patient outcomes and experience.
147 Walled- off pancreatic necrosis mimicking a pancreatic cancer
Authors: Nawaz Ibia , Rauf Fatima , Khan Huma Sabir , Malik Naveed Akhtar , Hanif Muhammad
Published: August 2023

Introduction

Walled-off pancreatic necrosis is a late complication of acute pancreatitis and can mimic a pancreatic cancer.

Case Summary

A 20 years old male patient was referred to us with a suspicion of pancreatic mass. He gave an inconsistent history of pain epigastrium and jaundice about 3 months back. An ultrasound abdomen showed a solid mass measuring about 47 x 52mm in head of pancreas having enhanced vascularity on doppler. Computed tomography scan done showed a mass lesion of 5cm in head of páncreas, solid and enhancing in nature with no separation from duodenum. Based on radiological findings and a history of weight loss of 5 kg in 2 months, patient was referred to us with suspicion of pancreatic mass. Current admission baseline investigations were normal. CA 19-9 levels were 6.23 U/ml. Dynamic three phase CT scan of abdomen showed diffuse smooth circumferential gall bladder wall thickening without any fat stranding and preserved pericholecystic fluid planes suggestive of chronic cholecystitis. There was a hypodensity along the body of pancreas measuring 11mm in size. MRCP was done which also showed a small pancreatic cyst. After thorough discussion, a presumptive diagnosis of walled off necrosis of páncreas was made that has now regressed. Patient was assured and follow up was advised to monitor the cystic lesión.

Conclusion

Infected pancreatic necrosis may be present and can be confused with pancreatic malignancy in an early stage of development. This case highlights that awareness of the natural course of pancreatitis and infected pancreatic necrosis is important.
187 Improving adherence to anaesthetic room preoperative shaving: A surgical site infection quality improvement project
Authors: Muir Duncan , Dejsupa Chaninda , Ghani Anum , Thompson Anna , Bridegman Joseph
Published: August 2023

Introduction

The correlation between hair removal and surgical site infection (SSI) remains debated but the limited guidance suggests when hair removal is necessary it should take place in the anaesthetic room. Our local policy is for preoperative hair removal to be performed in the anaesthetic room. We completed a quality improvement project after auditing our practice.

Methods

Location of preoperative shaving in emergency and trauma theatres were recorded for 7 days. Results were presented to surgical leadership teams and SSI steering groups, and information was disseminated to surgical and anaesthetic teams. Posters specifying the appropriate location of hair removal were created. Results were re-audited after six weeks.

Results

Pre-intervention, 15 cases required preoperative hair removal. This included 9 general surgery cases, 2 urology, 1 gynaecology and 4 trauma and orthopaedics. Overall, 6/15 (40%) cases were shaved in the anaesthetic room. The rates of hair shaving in the anaesthetic room were 2/9 (22%) general surgery, 1/2 (50%) urology, 1/1 (100%) gynaecology, and 2/4 (50%) trauma. Post-intervention, 9/12 (75%) cases were shaved in the anaesthetic room. This included 7/9 (78%) general surgery, 1/2 (50%) urology, 0/0 gynaecology and 1/1 (100%) trauma and orthopaedics.

Conclusion

The rate of appropriate preoperative hair shaving in the anaesthetic room increased as a result of initial audit and intervention. Notable change was observed in general surgery in emergency theatres. Future studies should record the rate of surgical site infection, to determine the overall effect this can have on patients and should extend the assessment to elective theatre.
192 Percutaneous cholecystostomy as a definitive treatment versus bridging treatment before cholecystectomy for acute cholecystitis: a retrospective observational study
Authors: Lau Joshua , Sinha Surajit , Srinivas Gandrapu , Andrews Stuart , Bowling Kirk , Platt Timothy
Published: August 2023

Aims

In this study, we aimed to investigate the mortality and predictors of mortality of patients receiving percutaneous cholecystostomy (PC) as definitive treatment versus patients receiving PC followed by laparoscopic cholecystectomy (LC) for acute cholecystitis (AC)

Methods

The study population consisted of 48 patients receiving PC for AC (mean age 76, 68.8% male), with a median follow-up period of 22 months. Data was collected on 1,3 and 12-month mortality, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiology (ASA) score, admission bilirubin and respiratory function, and conversion to LC rates.

Results

22 patients (46.8%) received LC following PC treatment, and 26 patients (54.2%) had PC as their definitive treatment. All 22 LC patients (100%) survived at 30 days, 3 months, and 12 months. Definitive PC patients had a 30-day mortality of 30.8% (8 patients), and a 3-month and 12-month mortality of 46.2% (12 patients). The alive cohort of patients had a lower CCI (4.66 vs 5.86, p<0.094), lower ASA (2.71 vs 3.25, p<0.05), and fewer patients with respiratory dysfunction or jaundice (27.8% vs 62%) than the 30-day and 3-month mortality cohort. The LC cohort had significantly lower CCI (4.39 vs 5.57, p<0.05), lower ASA (2.61 vs 3.04, p<0.05), but more jaundice/respiratory dysfunction (50% vs 38.4%) than the PC cohort.

Conclusions

Our results suggest that patient CCI score, ASA score, admission jaundice, and respiratory dysfunction can be used as effective predictors for 30-day and 3-month mortality for patients receiving PC for AC, as well as effective adjuncts in deciding which PC patients should be considered for surgery.
227 Never reported Complication of open Right hemicolectomy -Right external iliac artery pseudoaneurysm with arterio colonic fistulae presenting as delayed postoperative anastomotic bleeding – a case report and review of Literature
Authors: Elhassan Ali Mohamed
Published: August 2023

Anastomotic bleeding is well known complication after gastrointestinal resection and anastomosis procedures. The percentage of patients experiencing this complication is between 0.5% to 9.6%. Delayed postoperative anastomotic bleeding is even more rare, herein, we report a case of pseudoaneurysm of right external iliac artery with arteriocolonic fistulae in a patient who underwent open right hemicolectomy and presented as delayed postoperative anastomotic bleeding-a complication never reported before related to this procedure.
248 Master Students' Perception and Attitude on Methods of Anatomy Teaching and Assessment, Khartoum, Sudan 2014-2020
Authors: Hassan Rawan , Awad Khalid , Hassan Razan
Published: August 2023

Aim

Anatomy is the cornerstone of medical education; anatomical knowledge is undoubtedly essential for doctors regardless of their specialty. Teaching and learning anatomy are one of the most important and challenging subjects for both teachers and students. This study aimed at improving the postgraduate teaching and assessment methodologies by eliciting the perception and attitude toward anatomy teaching approaches among anatomy master students.

Methods

A descriptive cross-sectional study was conducted among three consecutive batches of anatomy master students. A structured questionnaire was used as a tool of data collection and data was analysed using IBM statistical package for social sciences version 24 (SPSS 24).

Results

44 candidates responded to the questionnaire. Among them, 90.9% chose dissection room sessions as the best tool in attaining the intended learning outcomes. Practical dissection was the best teaching method with regards to interest 81.1%, enjoyment 70.5%, retention of information 65.9% and satisfaction 59.1%. 72.7% of the respondents think that practical dissection test was the best assessment method in fulfilling the intended learning objectives. Multiple choice questions were the most helpful in learning anatomy effectively and was the best tool for assessing knowledge.

Conclusions

The results have shown a strong positive perception towards the use of cadaveric dissection in teaching and learning anatomy. However, many did not seem to prefer lectures as a tool in anatomy teaching and learning. In addition, practical dissection test and multiple-choice questions were the best assessment methods in attaining the intended learning objectives and learning anatomy effectively respectively.
251 Trachoma in Sudan: Case Series from Two Eye Care Hospitals and a Review of the Literature
Authors: Hassan Rawan , Hassan Razan , Mohamed Sagad , Saad Fadwa , Mohamed Haidar
Published: August 2023

Background

Trachoma is a common infectious cause of blindness worldwide. Although it has largely now disappeared from developed countries, it is still endemic in many developing countries. We aimed to highlight clinical stages and common related socio-demographic and household characteristics among patients with trachoma in Sudan.

Methods

A hospital-based case series descriptive study was conducted at Makah Eye Complex and Abdalfadeel-Almaz hospital in Khartoum, Sudan. We included all Trachoma patients from all age groups attending the two eye care hospitals March-May 2015. Data was collected through clinical examination, hospital records, and face to face interview using a structured questionnaire. Also, we conducted a review of the literature to highlight the epidemiological aspect of trachoma in Sudan, using the databases of MEDLINE (PubMed) and Google Scholar.

Results

In this case series, we identified 125 patients with trachoma in the study period. Most of them were aged more than 50 years old (78.4%). Half of the participants (56%) were positive for active trachoma, 40.8% of them were having Trachomatous Trichiasis (TT), and 56% of them have Trachoma Follicles (TF). Majority of the patients have low socioeconomic status and poor personal and environmental hygiene (88%), (44%) and (74.4%), respectively.

Conclusions

Low socioeconomic status and poor personal and environmental hygiene are common socio-demographic and household characteristics among patients with trachoma. Despite the progress that has been made towards disease elimination, trachoma is still a public health problem in Sudan. Our review highlights the magnitude of trachoma and the progress towards its elimination in Sudan.
267 Perforated Meckels diverticulitis; a cautionary tale highlighting the importance of accurate vetting information in the selection and interpretation of radiological investigations
Authors: Mitchell Robert , Kulendran Myutan
Published: August 2023

Background

Failure of the vitelline duct involution process during the 7th week of gestation gives rise to the most common congenital anomaly of the GI tract; Meckel’s diverticulum. Clinical presentation is extremely variable. We present an unusual case of a perforated Meckel’s diverticulitis and a cautionary tale highlighting the importance of accurate clinical information when requesting radiological investigations.

Case report

An 18 year old gentleman presented acutely with 24 hours of rectal pain and associated fever. There were no urinary or penile symptoms. Examination revealed lower abdominal tenderness. Rectal and prostatic examination were normal. Abdominal ultrasound revealed a dilated appendix with surrounding free fluid. Diagnostic laparoscopy revealed pus in the right iliac fossa with a submerged and mildly injected appendix. A separate cause was sought – a perforated small bowel diverticulum was found in a 600mL pelvic collection. The procedure was converted to a Laparotomy with small bowel resection and side-side anastomosis plus appendicectomy and washout. Post-operative histology revealed a perforated Meckel’s diverticulitis.

Discussion

This unusual case highlights the importance of using the correct radiological investigation at the correct time for the correct clinical query. Clinical information supplied to radiologists, particularly ultrasonographer's, drastically alters the extent of examination and interpretation of imaging.

Conclusion

Providing accurate clinical information to Radiologists is key for accurate interpretation of imaging. Inaccurate information impacts the ability to arrive at the correct diagnosis, give the correct treatment and, in a surgical setting, complete the correct consent process for the patient.
275 Informed Consent for surgery: Have we learned from Montgomery v. Lanarkshire 2015
Authors: Ong Chon Sum , Ahmed Hager , Lala Anil
Published: August 2023

Introduction

Informed consent is the process in which a healthcare provider educates a patient about the risk, benefits, and alternatives of an intended procedure. However, the consequence could be detrimental if all risks were not explained appropriately to the patient.

Aim

To investigate if all relevant risks were patient-consented before elective and urgent cholecystectomy and appendicectomy.

Method

A prospective audit was conducted at a District General Hospital for 2 weeks in September 2022 by checking the consent forms of the respective procedure. Peer-reviewed leaflet produced by EIDO Healthcare was used as the standard. Intervention was done by preparing a checklist of procedural risks to be used by the consenter. The data was collected for 2 weeks in October 2022 and analysed using Microsoft Excel.

Results

For cholecystectomy (n=15), 12 were done electively and 3 were urgent. Out of the 17 common cholecystectomy risks, 9 were discussed in all consents post-intervention compared to 3 before. 6 of the risks were discussed in ³30% more consents post-intervention. Explanation of post-cholecystectomy syndrome achieved the best improvement of being discussed in 53.3% more consent. For appendicectomy (n=9), out of the common 14 risks, only 2 risks were discussed in 30% more consents post-intervention.

Conclusions

The likely explanation for the sub-optimal improvement in the appendicectomy consent process was due to urgency. The nature of the procedure might have triggered a speeding up of the consent process which consequently exposed to unintentional omission. This emphasises the importance to address difficulties with the consent process to promote patient autonomy and prevent harm.
285 Trends in Emergency General Surgery activity in a dedicated unit: impact of a 5-consultant EGS team over a 3-year period
Authors: Guy Richard , Smallwood Suzy , Gallucci Antonio , Ishak Rafik , Buckley Katherine , Pilavas Andreas
Published: August 2023

Aims

A 5-Consultant EGS team was established for all acute General Surgery admissions to a 900-bed DGH. The aim was to evaluate management, outcomes and trends over a period of almost 4 years, incorporating the COVID-19 pandemic period.

Methods

Data was collected prospectively between 01/04/2019 & 09/01/2023 and included number and source of admissions, admission decision, surgery rates and lengths of stay. Three separate time periods were compared: (A) an 11-month pre-pandemic period (B) the official pandemic lockdown period (Mar 2020-Dec 2021) (C) a 12-month post-pandemic period.

Results

Direct GP-to-Consultant telephone referral was mandatory from the start of Period B, with around 200 calls/month, resulting in significant reductions in admission rates. Median weekly admissions for Periods A, B & C were 158, 127 & 132, respectively. Corresponding mean proportions coming from Primary Care vs Emergency Department were 55% vs 31.5%, 38.1% vs 46% & 39.9 vs 41%, respectively. Data since 06/12/2021 shows that 61.6% of admissions were seen by an EGS Consultant within 4 hours. The mean proportions of patients undergoing surgery during the three periods were 19.8%, 18% and 19.2%, respectively. Median length of stay (data available after Mar 2022) was 5 days.

Conclusions

A dedicated Consultant-led EGS service with GP collaboration is associated with improved efficiency, a reduction in GP admission rates, short hospital stays and greater use of ambulatory care. Despite fewer pandemic admissions, there was no significant change in the proportion requiring surgery, reflecting appropriateness of patient selection. Regular data analysis allows service modification responsive to needs.
292 Surgical Registrar Hot Clinic - Quality Improvement Project
Authors: Rogers Michaela , Kapuge Lakith , Brunt Reece , Harries Callum , Okocha Michael , Shamali Awad
Published: August 2023

Aims

Patient seen by the on-call general surgical team who require a semi-urgent clinical assessment, imaging or an operation who are well enough to go home, are discharged with plan to come back the following day to have these done. Unfortunately, these scan are often reviewed in the afternoon having a detrimental effect on patient satisfaction and flow. A possible solution to this is having a registrar-led dedicated morning hot clinic with allocated imaging slots where these returns could be seen.

Methods

2 months worth of SAU returns were reviewed. Patient lists were reviewed and data collected including date of return, brief history and the reason for coming back. Reasons for coming back were divided into 3 categories - Clinical review, Imaging, Theatre.

Results

A total of 159 patients were brought back to SAU over 2 months. 36 patients were brought back for review, 104 patients were brought for imaging and 19 patients were brought for theatre.

Conclusion

This project identified that on average 4 patients are asked to return daily. 85% of these returns are either for clinical review or imaging. As such having dedicated slots in the radiology department between 9 and 10 and a hot clinic from 10 and 11 would streamline the current process. This will have a number of benefits including quicker turn around for patients which will improve patient satisfaction and will reduce the number of patients waiting on SAU at any given time allowing both doctors and nurses to be able to provide safe and effective care in an already stretched and demanding environment.
310 Incarcerated incisional hernias should be managed surgically where possible, despite a high incidence of obesity and comorbidity: a 7-year experience in a District General Hospital
Authors: Omar Islam , Townsend Abby , Fotiou Georgia , Khogali Moataz , Said Ilhaam , Guy Richard , Newey Luke , Williams Catrin , Jones Annabel
Published: August 2023

Aims

Incisional hernia (IH) is a common complication of major abdominal surgery. This study describes the outcomes and burden of emergency management of incisional hernias.

Methods

A retrospective single-centre observational study was conducted on all patients with an incarcerated incisional hernia over seven years. Patient demographics, comorbidities, presentation mode, radiological imaging and management were analysed. Outcome measures were: postoperative complications, need for Level 2 or 3 care, mortality rates, hospital stay, readmission rates and hernia recurrence.

Results

194 patients were identified, of whom 54 were excluded. For the 137 patients analysed, the mean age was 66.54 SD± 14.6 with a median of 67 years; 80 (58 %) were females. The mean BMI was 34.6 SD± 10.08 kg/m2.

43 % had at least one comorbidity. 69 (57.7%) patients presented with small bowel obstruction, of whom 3 (2.2%) had bowel perforation. Over two-thirds of patients (93, 67.9%) were managed surgically, with 44 (32.1%) being managed conservatively.

The significant complication (Clavien-Dindo III and over) rate was 16.1%, and the most common complications were wound-related. The 30-day and 90-day mortality rates were 6.6% and 8.8%, respectively. The mean length of stay was 12 days SD± 25. Some 19.7% needed Level 2 or 3 care, and 24.1% had unplanned readmissions, the majority of whom were in the conservatively managed group.

Conclusion

Patients with complicated IH have significant comorbidities, and many are obese. Emergency presentation of IH carries a high risk of morbidity. High readmission rates are seen in conservatively managed patients, and surgical repair should be undertaken where possible.
319 Diverticular disease of the appendix: an unusual presentation (Case report)
Authors: Bukhari Ishtiyaq , Deeknah Abdulqudus , Ghosh Soumendu , Yiannikouride Maria , Nichita Vladimir , Alaghbari Maram
Published: August 2023

Background

Appendiceal diverticular disease is not a common consideration in the diagnosis of patients presenting with atypical right lower abdominal pain. This should be considered due to a potential increased risk of perforation and appendiceal neoplasm. Furthermore there is anecdotal evidence to suggest prophylactic appendicectomy for incidental findings of appendiceal diverticular disease can prevent future complications.

Case presentation

We describe the unusual case of a 42 year old male patient presenting with intermittent recurrent right iliac fossa pain who was found to have an appendiceal mass on diagnostic laparoscopy. Following radiological imaging, colonoscopy, multidisciplinary team (MDT) discussion and proceeding to laparoscopic appendicectomy, was found to have appendiceal diverticular disease on histology.

Conclusion

Diverticulitis of the vermiform appendix is a rare but possible diagnosis and should be considered when dealing with recurrent right iliac fossa pain in middle aged population.
356 Registrar confidence levels managing paediatric surgical patients in a busy district general hospital
Authors: George Jayan , Leeman Charlie , Wafai Ahmad Hisham , Durham-Hall Antonia
Published: August 2023

Introduction

The abdominal pain pathway and appendicitis toolkit (APPAT) was developed to harmonise care across our region, reduce the negative appendicectomy rate, identify appendicitis accurately and increase the number of children undergoing a laparoscopic procedure.

Aims

Methods

Doctors were surveyed in January 2023. Two questions used Likert scales (1 to 5: not at all confident to very confident) in assessing paediatric patients. Three closed questions to assess the use of guidelines. Nine open questions to assess the network appendicitis tool. Data was initially inputted using Google Docs and analysed in Microsoft Excel.

Results

7 registrars (7/13) completed the questionnaire.

The majority of registrars felt very confident (5) assessing paediatric patients aged 8-16.

Few registrars use any guidelines or pathways when assessing a patient with abdominal pain (1/7).

Most registrars do not use a scoring system to assess for appendicitis (4/7).

No registrars were able to accurately answer all aspects of the local network tool.

No registrar was able to answer the low, medium or high-risk score of the tool.

Conclusions

Registrars feel confident assessing paediatric patients. Most registrars do not use scoring systems to assess these patients. Awareness and accuracy of the specific parameters of APPAT were low. Further awareness and education may support the management of these patients.
432 Returning to Surgical training. Are we meeting the need?
Authors: Richards Eleanor , Murphy Claire
Published: August 2023

Aims

The association of time out of training (TOOT) with skills fade is well documented. Despite the establishment of Supported Return to Training (SRTT) in 2017, engagement from Surgical trainees is suboptimal. We sought to evaluate this.

Methods

An online survey of Yorkshire Surgical trainees was conducted in January 2022. Results were analysed as were Yorkshire SRTT data for the past 2 years.

Results

Of 22 respondents, 18 had had time out, 3 were planning it and 3 considering it in future. SRTT was used by 52.6%, 21% felt it did not meet their needs whilst 15.8% were unaware of SRTT.

This is reflected in the regional HEE data. In the previous 2 years 85 surgical trainees had taken TOOT but only 22 (26%) had engaged with the SRTT process, compared with 60% of Obstetrics and Gynaecology (O&G) trainees and 87% of Anaesthetic trainees. Analysis of the reasons for TOOT showed that surgical trainees most commonly took time out for research (OOPR) (28%) or parental leave (28%) whilst 67% of Anaesthetics and 49% of O&G trainees had time out for parental leave.

Conclusions

Despite having higher numbers of returning trainees, engagement with the SRTT process from the school of surgery is poor. This is likely multifactorial, reflecting the demographics of what is perceived as a less family friendly specialty, failure to recognise or acknowledge skills fade among OOPR trainees and an existing offering that is not fit for purpose. A collaborative exploration of these issues is required to address this.
472 Right-sided diaphragmatic hernia causing gastric outlet obstruction 1 month after trauma
Authors: Alfardan Nadya , Fernandes Roland , Thomas Janine
Published: August 2023

Diaphragmatic hernias arising from trauma are rare, and scarcely present in a delayed manner. This case report highlights a case of delayed presentation of a right-sided post-traumatic hernia in a 73-year-old woman following a fall. This report sheds light on the diagnostic peculiarities and management. The woman presented with a 3-day history of abdominal pain and coffee-ground vomiting. This followed a fall a month ago. Computed Tomography confirmed the diagnosis of a gastric outlet obstruction secondary to a right-sided diaphragmatic rupture. At surgery, the herniated abdominal contents were reduced, and the diaphragmatic defect fixed. The postoperative recovery was unremarkable and the patient discharged on day 4. This case highlights that diaphragmatic hernias should be considered as differential diagnoses following recent trauma.
602 A simple and timely intervention can optimise patient’s anaemia before resectional surgery for Colorectal cancer
Authors: Shafiq Umar , Agarwal Anil , Boulos Christopher
Published: August 2023

Aims

Anaemia at the time of colorectal resection for cancer adversely affects outcomes. We performed an audit to quantify anaemia at pre-assessment. We incorporated an intervention of iron infusion at the point of diagnostic endoscopy for suspected cancers with anaemia. We assessed the improvement of anaemia in these patients at pre-assessment.

Methods

Patient records and blood results were used to determine haemoglobin levels and any treatment given for anaemia from referral to surgery. These included 53 anaemic patients in the pre-intervention group and 8 anaemic patients so far in the post-intervention group. The effect of the intervention was analysed.

Results

Pre-intervention 62.4% of patients undergoing right hemicolectomy were anaemic at pre-assessment. 32.1% had a Hb <100 g/L; 47.1% of these were treated.

In the other group, 50% of anaemic patients had a Hb of <100 g/L at colonoscopy; 75% of these patients improved their Hb at pre-assessment to >100 g/L after receiving the iron infusion.

Conclusion

The treatments to correct anaemia in the control group were varied and inconsistent. It's routine that the colorectal nurses are informed of cancer diagnosis at the time of diagnostic endoscopy. The intervention used was for them to arrange iron infusion for patients found to be anaemic on a recent FBC. This intervention was easily incorporated in the patient pathway and required no extra resources. The infusion allowed sufficient time for the anaemia to improve before the operation. This simple and timely intervention can be widely implemented, and we recommend its use.
Acute cardiovascular complications of immune-mediated systemic inflammatory diseases
Authors: Weber Brittany N , Garshick Michael , Abbate Antonio , Youngstein Taryn , Stewart Garrick , Bohula Erin , Plein Sven , Mukherjee Monica
Published: August 2023

Immune-mediated systemic inflammatory conditions (IMIDs) are associated with an increased risk of atherosclerosis and adverse cardiovascular (CV) events secondary to pathogenic inflammation and derangements in the innate and adaptive immune responses inherent to the underlying rheumatic diseases. As the intersection of cardio-rheumatology continues to expand, a multi-disciplinary approach must be considered to optimize clinical outcomes and long-term survival. This review will highlight acute cardiac manifestations of systemic inflammatory diseases and propose a clinically relevant framework for diagnosis, management, and the role of integrated multimodality imaging.
Anatomical feasibility of a ‘semi-custom’ unibody single-branch endograft in previous zone 2 thoracic endovascular aortic repair
Authors: Leone Nicola , Andreoli Francesco , Bartolotti Luigi A M , Migliari Mattia , Baresi Giovanni F , Saitta Giuseppe , Silingardi Roberto , Gennai Stefano
Published: August 2023

OBJECTIVES

The aim of this study was to evaluate the suitability of a subclavian unibody single-branch endograft among patients treated with thoracic endovascular aortic repair (TEVAR) in landing zone 2 (LZ2).

METHODS

This is a pre-clinical, single-centre, real-world, all-comers, retrospective cohort study. Patients treated with TEVAR in LZ2 with an available preoperative computed tomography angiography were included. The primary outcome was the anatomical feasibility of the Castor endograft in patients receiving endovascular treatment in LZ2 between 1999 and 2022. Secondary outcomes were: a comparison of feasible and unfeasible patients; frequencies and description of exclusion causes; non-feasibility risk factor analysis; and analysis of the stent graft configurations necessary to treat 75% of the patients. A logistic regression model was used to find associations between baseline morphological data and non-feasibility.

RESULTS

A total of 473 procedures were performed and 72 patients fulfilling inclusion criteria were included. The mean distance between the left carotid artery and left subclavian artery (or between innominate artery and bovine trunk) was 12.4 ± 5.2 mm and its average diameter was 33.0 ± 10.6 mm. The pre-vertebral left subclavian artery’s diameter and length were 11.3 ± 2.5 and 38.7 ± 10.8 mm. Forty-nine (68.1%) patients were suitable for Castor implantation. Twenty-one configurations were required to treat 75% of feasible patients and might be lowered to 12 configurations applying less strict criteria.

CONCLUSIONS

The Castor endograft was anatomically feasible in several patients requiring TEVAR in LZ2. Three-quarters of feasible patients could be treated with a reasonable number of configurations, paving the path for future off-the-shelf applications.
Nurses, doctors, and mortality: the effectiveness of early health professionals in rural Finland, 1880–1938
Authors: Saaritsa Sakari , Simanainen Eero , Ristola Markus
Published: August 2023

This article estimates the mortality effects of introducing modern health professionals in rural Finnish municipalities in the years 1880 to 1938 using panel data with approximately 25,000 observations over 423 population clusters. Our results show that ambulatory nurses had a more significant impact on mortality than municipal doctors. The effect of doctors depended on their proximity to the population. Qualitative evidence suggests that a superior capacity to influence behavior in communities mattered more than treatment or medical knowledge in the pre-biomedical context. Doctors consequently advocated for the hiring of more nurses. Their estimated contribution to mortality decline still remained modest.
Perivascular adipose tissue as a source of therapeutic targets and clinical biomarkers
Authors: Antoniades Charalambos , Tousoulis Dimitris , Vavlukis Marija , Fleming Ingrid , Duncker Dirk J , Eringa Etto , Manfrini Olivia , Antonopoulos Alexios S , Oikonomou Evangelos , Padró Teresa , Trifunovic-Zamaklar Danijela , De Luca Giuseppe , Guzik Tomasz , Cenko Edina , Djordjevic-Dikic Ana , Crea Filippo
Published: August 2023

Obesity is a modifiable cardiovascular risk factor, but adipose tissue (AT) depots in humans are anatomically, histologically, and functionally heterogeneous. For example, visceral AT is a pro-atherogenic secretory AT depot, while subcutaneous AT represents a more classical energy storage depot. Perivascular adipose tissue (PVAT) regulates vascular biology via paracrine cross-talk signals. In this position paper, the state-of-the-art knowledge of various AT depots is reviewed providing a consensus definition of PVAT around the coronary arteries, as the AT surrounding the artery up to a distance from its outer wall equal to the luminal diameter of the artery. Special focus is given to the interactions between PVAT and the vascular wall that render PVAT a potential therapeutic target in cardiovascular diseases. This Clinical Consensus Statement also discusses the role of PVAT as a clinically relevant source of diagnostic and prognostic biomarkers of vascular function, which may guide precision medicine in atherosclerosis, hypertension, heart failure, and other cardiovascular diseases. In this article, its role as a ‘biosensor’ of vascular inflammation is highlighted with description of recent imaging technologies that visualize PVAT in clinical practice, allowing non-invasive quantification of coronary inflammation and the related residual cardiovascular inflammatory risk, guiding deployment of therapeutic interventions. Finally, the current and future clinical applicability of artificial intelligence and machine learning technologies is reviewed that integrate PVAT information into prognostic models to provide clinically meaningful information in primary and secondary prevention.
Using ChatGPT and Google Bard to improve the readability of written patient information: a proof of concept
Authors: Moons Philip , Van Bulck Liesbet
Published: August 2023

Patient information materials often tend to be written at a reading level that is too advanced for patients. In this proof-of-concept study, we used ChatGPT and Google Bard to reduce the reading level of three selected patient information sections from scientific journals. ChatGPT successfully improved readability. However, it could not achieve the recommended 6th-grade reading level. Bard reached the reading level of 6th graders but oversimplified the texts by omitting up to 83% of the content. Despite the present limitations, developers of patient information are encouraged to employ large language models, preferably ChatGPT, to optimize their materials.
Role Spillover: Roles’ Impacts across Contexts and the EU’s Struggle for Arctic Council Observer Status
Authors: Busch Aslak Veierud
Published: August 2023

The way an international actor acts in one context impacts its ability to play a role in other contexts. Expanding on role theoretical insights, I develop a concept of role spillover to account for the ways in which roles interact across contexts. Acting in accordance with expectations in one context might not benefit an actor in another context; it can either support or impede an actor’s ability to play its preferred role elsewhere. I demonstrate this through a case study of the European Union (EU)’s bid for observer status at the Arctic Council, which has been left in limbo despite observing the Council’s work de facto for over 15 years. The EU’s issues with achieving permanent observer status can be explained by spillover from the EU’s role in animal welfare debates and its role as a strategic competitor to Russia. In both cases, the EU’s ability to take on its preferred role in the Arctic was hindered by role play elsewhere.
Hawks versus Doves: Who Leads American Foreign Policy in the US Congress?
Authors: Bendix William , Jeong Gyung-Ho
Published: August 2023

The combination of partisan polarization and controversial military engagements has produced contentious debates over US foreign policy in Congress. Who has been winning these debates and exerting greater influence over the development of security and defense bills, hawkish or dovish legislators? The literature offers competing answers—on the one hand, arguing that hawks enjoy policy advantages because of Congress’s commitment to US hegemony and, on the other, claiming that doves gain policy openings because of shifting partisan and security conditions. To determine the influence of hawkish versus dovish legislators, we examine congressional actions on all defense spending bills from 1971 to 2016. Specifically, we track roll call votes to see which legislators enjoy the greatest support for their measures. We find that hawks have disproportionate influence over the content of defense bills, whether Republicans or Democrats are in control, and whether the United States is at war or enjoying relative peace.
The Mitochondrial Genome of the Holoparasitic PlantThonningia sanguineaProvides Insights into the Evolution of the Multichromosomal Structure
Authors: Zhou Shuaixi , Wei Neng , Jost Matthias , Wanke Stefan , Rees Mathew , Liu Ying , Zhou Renchao
Published: August 2023

Multichromosomal mitochondrial genome (mitogenome) structures have repeatedly evolved in many lineages of angiosperms. However, the underlying mechanism remains unclear. The mitogenomes of three genera of Balanophoraceae, namely Lophophytum, Ombrophytum, and Rhopalocnemis, have already been sequenced and assembled, all showing a highly multichromosomal structure, albeit with different genome and chromosome sizes. It is expected that characterization of additional lineages of this family may expand the knowledge of mitogenome diversity and provide insights into the evolution of the plant mitogenome structure and size. Here, we assembled and characterized the mitogenome of Thonningia sanguinea, which, together with Balanophora, forms a clade sister to the clade comprising Lophophytum, Ombrophytum, and Rhopalocnemis. The mitogenome of T. sanguinea possesses a multichromosomal structure of 18 circular chromosomes of 8.7–19.2 kb, with a total size of 246,247 bp. There are very limited shared regions and poor chromosomal correspondence between T. sanguinea and other Balanophoraceae species, suggesting frequent rearrangements and rapid sequence turnover. Numerous medium- and small-sized repeats were identified in the T. sanguinea mitogenome; however, no repeat-mediated recombination was detected, which was verified by Illumina reads mapping and PCR experiments. Intraspecific mitogenome variations in T. sanguinea are mostly insertions and deletions, some of which can lead to degradation of perfect repeats in one or two accessions. Based on the mitogenome features of T. sanguinea, we propose a mechanism to explain the evolution of a multichromosomal mitogenome from a master circle, which involves mutation in organellar DNA replication, recombination and repair genes, decrease of recombination, and repeat degradation.