bluuebunny/crossref_metadata_2025 huggingface dataset:
EP 633 - Outcomes of Patients with Liver Metastases from Colorectal Cancer who Mostly Presented as Emergencies (Obstruction and Perforation) In a District General Hospital From 2014 To 2021
Authors: Amankwah Dennis , Ezeoke Chidimma , Shamsu Zaman , Annan Pangeni , Chowdhury Ashim , Cooke Joanne
Published: September 2024

This abstract was published in Volume 110, Supplement 10, December 2023 ASGBI Emergency General Surgery Symposium. 1st November 2023. Glasgow, UK, and can be accessed at https://academic.oup.com/bjs/article/110/Supplement_10/znad388.013/7455145
EP165 - It is not just a perianal wart! A rare case of perianal lesion
Authors: Ng Zoe Zhen Yi , Pal Shreya , Chaston Nicola , Shrestha Ashish
Published: September 2024

Perianal skin lesion is a common presentation with a wide range of differentials, including thrombosed external haemorrhoids, perianal abscess, perianal warts, lipoma and sebaceous cysts. Malignant lesions such as squamous cell carcinoma are uncommon but should be considered. Hereby, we present a diagnostically challenging case of a benign looking perianal lesion that ultimately revealed a rare condition.

A 50-year old lady presented with a one-year history of perianal lump accompanied with intermittent pain, fresh bleeding and pus-like discharge. A digital rectal examination revealed a well-demarcated 4mm fleshy skin lesion, 2cm from anal verge at 7 o’clock position without surrounding area of inflammation. No lymph nodes were palpable on both groins. Differentials as mentioned above including an infected granuloma and fistula in-ano were considered. Pelvic MRI revealed a well-demarcated, benign-looking subcutaneous lesion. The lesion was excised under general anaesthesia and interestingly, the histopathology report revealed a diagnosis of Hidradenoma Papilliferum (HP) with no dysplasia or malignancy. Patient recovered well, reassured with the above findings and discharged home.

HP is an uncommon, benign tumour that occurs in the anogenital region. It is more prevalent in Caucasian middle-aged females, as illustrated in our case. A definite diagnosis necessitates histopathological examination. The management includes a local excision of the lesion, and it is associated with good prognosis, with low chances of recurrence or malignant transformation.

HP, although rare, should be included in the differentials of a perianal lump. A surgical excision or diagnostic biopsy should be performed at minimum.
EP241 - Managing Cervical Spine fracture in a district general hospital
Authors: Laulloo Sufia , Elrefaiy Ahmed , Laulloo Faqih , Kumar Vish
Published: September 2024

Introduction

Cervical spinal injury affects 2–3% of trauma patients and accounts for 8.2% of all trauma-related deaths. Respiratory complications are cited as the primary cause of mortality with a 14 - >27 % rate in patients aged more than 65 years old.

Aim

Produce a clear set of guidelines in an aim to reduce mortality in patients > 65 years presenting with cervical spine fracture.

Method

Data was retrospectively collected for patients aged >65 between September 2021 and August 2022 in a district general hospital. Patients with confirmed cervical spine injury were included in the study. Data was collated and analysed using Excel.

Results

36 patients presented to ED with acute cervical spine fracture. 22 (61%) were female and 14 (39%) male with an age range of 66-98 years old. 31 (84%) patients were discussed with a tertiary centre. Complications ranged from constipation, delirium, DVT/PE, chest infections (n=5, 36%) to spinal shock (n= 3, 27%). 11 (30.6%) patients presenting with a c-spine fracture died within 30 days of admission.9 (25%) patients had an outpatient appointment booked in a tertiary centre and 13 (36%) were seen locally in the fracture clinic. 14 (39%) patients did not have any follow ups planned.

Conclusions

To mitigate in-hospital complications and improve outcomes, shared care with orthopaedics, geriatrics, and physiotherapy is being proposed for this group of patients. It would be beneficial to compare the data from the local network and aim at publishing an up-to-date set of robust guidelines.
EP264 - Dermatofibrosarcoma protuberance of the perianal region
Authors: Drmota Jan , Suseeharan Melanie , Chowdhury Ashim
Published: September 2024

Introduction

Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade sarcoma affecting dermis and subcutaneous fat. Typically presents as slow-growing lump on the trunk, extremities or head and neck.(1) It can be locally aggressive with a high recurrence rate.(2) Only 6 reported cases of DFSP in peri-anal region.

Case Description

A 26-year-old male presented with slow-growing peri-anal lump for over a year with intermittent localised pain and episodes of bleeding. No other symptoms or trauma to peri-anal area noted. No relevant medical or surgical history. Examination revealed an irreducible two-by-five by one-centimetre semi-pedunculated perianal lump extending from the seven o’clock to eleven o’clock position. It was firm and tethered to the skin.

Case Description

Flexible sigmoidoscopy was normal. Excision biopsy histology reported diffuse infiltration of spindle cells with storiform pattern of growth without clear margins. Immunohistochemistry analysis expressed CD34 with minimal focal expression of SMA and variable Ki-67 proliferation indexed up to 15-20% in most active areas. SOX10, S100, desmin, factor XIIIA, MNF116 and CD31 were negative. Diagnosis was DFSP. Local lower gastrointestinal multi-disciplinary arranged urgent imaging and referral to tertiary centre. Magnetic resonance imaging of the pelvis identified no definite underlying localised restricted diffusion or solid enhancing nodule. Wide local excision at tertiary centre with histopathology confirmed clear margins.

Conclusion

Patient is under follow-up locally and at the tertiary. Urgency and a singular episode of stool incontinence was reported at two-weeks follow-up which subsequently normalised. He is currently under 3-6 monthly reviews with repeat MRI prior to next appointment. Patient has returned to normal activities.
EP267 - Patient with Pneumomediastinum and Pneumoperitoneum – Importance of Human Factors
Authors: Lakshmipathy Gokul R , Ball William
Published: September 2024

Clinical assessment

70-year-old lady presents with one-day history of dyspnoea, chest and abdominal pain. She was recently discharged following a three-week hospital admission with fall related traumatic rib fractures and hospital acquired pneumonia. Her abdomen was soft and non-tender. CT scan with oral and IV contrast demonstrates pneumomediastinum and pneumoperitoneum with connection at diaphragmatic crura.

Management

Patient was managed conservatively however two days after admission her CRP climbed to 150 and clinical suspicion remained high. Repeat CT scan over the weekend demonstrated increase in the pneumoperitoneum and decrease in the pneumomediastinum with a collection around sigmoid colon. Trainee raised concern to consultant and a laparotomy was done. Operative findings showed perforated sigmoid colon with faeculent peritonitis of unclear cause. Hartmann’s procedure was done and patient continued post recovery in ITU.

Discussion

This case demonstrates the complex varying presentations of our elderly co-morbid population. The presence of air in thoracic and abdominal cavities with unknown cause weeks after the fall was suspicious. Hence, the team communicated well from top-down and likewise from weekday to weekend. Low threshold for escalation and high index of suspicion enabled a re-scan which proved to be life-saving for this patient. Identifying complicated cases where errors can occur is a critical first step. Clear communication among staff, accurate documentation and addressing the patient concerns enabled the surgical team to navigate the complex disease process and ensure safe patient care.
EP360 - Pitfalls in the management of transgender patients: a case report and discussion
Authors: Saraee Danial , Khadka Subodh , Kaur Geetinder
Published: September 2024

Introduction

There has been an increase in the number of transgender individuals in the population. In a clinical setting, this introduces potential patient safety issues from misidentification of biological sex, particularly in emergency scenarios. We report one such patient.

Case report

A 21-year-old ‘male’ patient presented with right iliac fossa pain. No surgical history was reported by the patient or GP records. Repeat medication included Testosterone gel. Bloods showed raised amylase though the clinical picture suggested appendicitis so a CT scan was done. This was reported normal but also identified normal sized uterus/ovaries! Following a sensitive discussion with the patient, ‘they’ revealed that ‘they’ were born biologically female and were on gender-affirming hormone-therapy. The patient was successfully managed conservatively.

Discussion

Our case report highlights the potential risks of misidentification of biological sex in an acute-abdomen scenario. Misdiagnosis is most critical - all gynaecological causes of abdominal pain (e.g. PID/ life- threatening ectopic-pregnancy) were missed. Due to the risk of ionizing radiation to unborn children, CT require the pregnancy status of patients with childbearing capacity, prior to the scan: this therefore should include transgender ‘males’ who have not undergone sex-reassignment surgery. There are also patient safety/ comfort issues with admission in single- sex wards.

Conclusion

It is important to identify transgender patients in order to avoid misdiagnosis and hence mismanagement. Taking detailed history including medication will help with this, as some transgender individuals may not volunteer details regarding their biological sex. Sensitive communication is vital to avoid any feeling of discrimination/stigmatisation.
EP363 - Idiopathic Granulomatous Mastits
Authors: Modi Vidita , Nirhale Dakshayani , Dnyanmote Anuradha
Published: September 2024

Aim

Idiopathic granulomatous mastitis (IGM) of breast is a rare condition with unknown aetiology with an incidence of 2.4 per 10,000. Treating this condition has often been a challenge and hence, this study aims at comparing the different treatment outcomes of recurrent IGM.

Method

A prospective study was conducted in our hospital. All the recurrent breast abscess with induration and biopsy proven granulomatous mastitis were included in this study for a study period of 2 years.

Result

12 patients were included in the study and were divided into two groups : recurrent breast abscess with induration of size A) less than 3 cms and B) ones with size more than 3 cms. Patients in group A underwent Wide local excision of the abscess along with induration and patients in group B underwent surgery followed by steroid therapy. Both the groups were followed up for a year and group B showed no recurrence while group A came with recurrent abscess again and had to undergo surgery followed by steroid therapy after which no recurrence was seen after one year follow up.

Conclusion

All patients of IGM require steroid therapy along with surgery for better outcome.
EP454 - Left Paraduodenal Hernia and Large Bowel Obstruction: A Case Report
Authors: Broadhurst Damian , Campbell Sandra , Jarral Fazain , Tolan Damian , Baker Richard
Published: September 2024

Aims

Internal hernias are uncommon and difficult to diagnose clinically. Of these, a paraduodenal hernia is the most common, but remains a rare condition. Cases reported in the literature are few and often describe small bowel obstruction as a result of small bowel herniation into the left paraduodenal space and lesser sac. Here we describe a case of left paraduodenal hernia resulting in large bowel obstruction.

Method

Written consent from the patient has been obtained to present the case and associated radiological and intra-operative images.

A 50 year old male with no surgical history presented to the general surgical team via the emergency department with a 12 hour history of epigastric pain, vomiting, abdominal distension and 24 hours history of absolute constipation.

CT showed a large bowel obstruction with a transition point in the mid transverse colon with a swirling of the mesentery and large bowel concerning for left paraduodenal hernia.

Results

Open laparotomy was the preferred approach. There was gross dilatation of the large bowel with a competent ileocaecal valve. The hepatic flexure was found herniating into the lesser sac under the ligament of Treitz. This was reduced and the large bowel decompressed via the appendix. The narrow based small bowel mesentery was expanded by dividing the mesenteric parietal peritoneum. The large defect was closed with interrupted non-absorbable sutures. The patient made an unremarkable post-operative recovery.

Conclusion

This is a rare pathology with interesting surgical anatomy and we present its radiological and intraoperative findings and operative management strategy.
EP467 - Bowel obstruction due to colonic lithobezoar in a patient with PICA
Authors: Hussain Mohammad Rizwan , Holcroft Philip , Qureshi Mohammed Tayab
Published: September 2024

A 16-year-old girl was admitted with complaints of abdominal distension, severe pain, vomiting, chest discomfort, and an inability to pass gas. She disclosed a history of PICA, regularly consuming brick and cement. She had no significant medical history but reported suffering from constipation for over two years. Physical examination revealed a markedly distended, tender abdomen with hyper-resonance. Digital rectal examination detected soft, breakable stool in the rectum.

A chest X-ray demonstrated massive bowel distension, causing lung compression. Clinical impression was of bowel obstruction secondary to constipation, leading to NG tube insertion, NBM status, and analgesia administration.

A CT abdomen and pelvis confirmed a markedly distended rectum with impacted faeces, proximal faecal loading, and colon dilatation consistent with severe pseudo-obstruction. Other abdominal organs were compressed but otherwise normal, with no signs of ischemia, free air, or free fluid. Patient was taken to emergency theatre for examination under anaesthesia and manual evacuation. Six litres of stool were manually evacuated, along with removal of ingested stone-like substances, leading to suspicion of lithobezoar. This was followed by a four-litre saline washout.

Postoperatively, patient received regular enemas, laxatives, and monitoring. She spent three days in the Intensive Care Unit due to persistent metabolic acidosis, necessitating ventilatory support. Afterward, she was transferred to the surgical ward, where she was monitored overnight before being discharged with laxatives and dietary advice. Patient was referred to dietitians for addressing her PICA and eating habits, with plans for psychiatric follow-up initiated through a referral from her GP.
EP551 - Assessment of Surgical Management for Mild and Moderate Acute Gallstone Pancreatitis in Accordance with AUGIS Guidelines: A Clinical Audit
Authors: Tan Eunice P J , Ng Shou Kee , Ismail Mohamed , Khan Khurram S
Published: September 2024

Aim

Acute Gallstone Pancreatitis (AGSP) presents as a surgical emergency with diverse clinical outcomes. The guidelines from the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) recommend inpatient laparoscopic cholecystectomy (LC) during the index admission or within two weeks for surgically fit patients in cases of mild to moderate AGSP. This study examines the surgical management of AGSP, evaluating adherence to AUGIS guidelines.

Methods

All patients admitted to a single surgical unit who had MRCP for AGPS from September 2020 to September 2022 were included. Electronic case notes were reviewed for demographics, comorbidities, radiological results, whether they had LC and reasons for not proceeding to LC. Severity of AGSP were graded using CT severity index. Those with severe AGSP were excluded.

Results

116 patients were identified; one was excluded. Median age was 59 years (IQR 46-73) and 79 (68.9%) were female. Median length of stay was 5.8 days (IQR 3.7-8.2).

19 (16.5%) patients had inpatient LC, 42 (36.5%) had outpatient LC, 4 (3.5%) patients declined LC, 10 (8.7%) patients were not surgically fit and in 40 (34.8%) patients there was no documentation of why LC not carried out. The median Charlson Comorbidity Index for patients where there was no documentations for not proceeding with LC was 4.5 (IQR 2.3-5.8).

Conclusion

Our study highlights suboptimal compliance with national guideline. It is essential that patients with AGSP undergo inpatient LC or receive prompt outpatient LC to mitigate the risk of recurrent AGSP. Thorough documentation becomes imperative in cases where LC is not scheduled.
EP568 - A rare case of necrotizing fasciitis caused by Streptococcus Anginosus and Staphylococcus Lugdunensis
Authors: Venkata Sujashree Yadala
Published: September 2024

Necrotizing fasciitis (NF) is a rare soft tissue infection involving the fascial planes, causing rapid and extensive tissue destruction. We present a unique case of NF in a patient with poor glycemic control caused by atypical pathogens.

A 66-year-old female with a recent biopsy for a wart-like lesion developed a wound infection, with greenish-black exudate. Initial observations were: temperature: 39.4 degrees, heart rate: 105, GCS: 15/15. Physical examination revealed a grossly filiform lesion below her abdominal apron measuring 7cm in diameter.

The patient was empirically treated with IV Co-Amoxiclav. Abnormal biochemistry results are shown below. Microbiological analysis revealed Streptococcus Anginosus, anaerobes and Staphylococcus Lugdunensis. CT abdomen revealed extensive inflammatory changes with gas and fluid collection and enlarged pelvic and inguinal lymph nodes. Two urgent surgical explorations and debridements, with meticulous wound care using negative pressure wound dressings (Prevena) were done. Intravenous Gentamicin, Benzylpenicillin, Clindamycin, Metronidazole and Flucloxacillin were administered for six weeks. The patient's clinical status gradually improved.

Streptococcus Anginosus, that is part of the Streptococcus Milleri group and Staphylococcus Lugdunensis, a coagulase-negative Staphylococci (CoNS) are commensal organisms of the oral and gastrointestinal tracts. These organisms possess virulence factors that facilitate tissue invasion and destruction, causing an aggressive course of NF. This case highlights the importance of considering atypical pathogens, especially in patients with predisposing factors such as diabetes and obesity. Early recognition, prompt surgical intervention and a multidisciplinary approach are essential for improving outcomes in these cases.TestResultWhite Blood Cells (WBC)22,200 [WBCs per microliter]Sodium123 [mmol/L]Chloride88 [mmol/L]C-reactive protein (CRP)318 [mg/L]Blood Glucose19.3 [mmol/L]
EP584 - The standard of evening handover in the acute surgical department of a single regional centre: a closed-loop audit
Authors: Tiwari Abhinav , Hayat Muhammad , Everett Katherine , Howse Frances
Published: September 2024

Aims

Handover is an important period that represents a potential risk to patient safety. The Royal College of Surgeons of England (RCSEng) have published guidelines on safe handover practice. The aim of this closed-loop two-cycle audit was to ensure general surgery patients at a single regional centre were handed over according to RCSEng guidelines.

Method

Evening handovers were prospectively audited between May 2023 to July 2023 using a proforma adapted from the RCSEng guidelines. A questionnaire relating to junior doctors’ views on the night handover was electronically disseminated prior to the first cycle. The intervention was an educational guide for foundation doctors on how to effectively hand over surgical patients, based on the RCSEng guidelines. P-values were calculated using a Mann-Whitney U test.

Results

15 handovers were audited in the first cycle; of 84 patients handed over, 31% (26/84) met the RCSEng handover ‘minimum’ standard. 13 handovers were audited in the second cycle; 84 patients were handed over, the ‘minimum’ standard rate increased to 67% (56/84) (p=0.003). There were 25 responses to the questionnaire, 92% (23/25) were by foundation doctors, 48% (12/25) volunteered wanting more teaching on handovers.

Conclusions

Introduction of an educational handover guide is a useful method to improve the quality of surgical handovers, particularly in regional centres that may have a more complex case mix. This guide was later introduced as part of the ‘induction pack’ for foundation doctors rotating into surgery.
EP621 - Surgical waiting times at a busy general surgical unit at a district hospital oin NHS
Authors: Arifuzaman Mohammed
Published: September 2024

Aims

To understand the general surgical waiting times at NMGH. To estimate the degree of mismatch among the original booking consultant and performing surgeon. To accurately assess the median waiting times for each type of surgery.

Methods

Retrospective observational study. Data collected include date of surgery, date of listing for surgery, consultant listing for surgery and name of surgeon performing procedure, MRN, age, sex and type of surgery. Times calculated from the original listing for surgery in the clinic or during inpatient and actual date of surgery.

Results

Total patients included in the study were 330. Overall median delay for all the surgical cases was 345.5 days (49.35 weeks). 173 female patients and 157 male patients were included. Patients’ records were checked for any cancellations or refusal for surgery, but most did not present any reason for delay and hence the date of booking and surgery done were recorded.

Conclusion

Overall colorectal waiting time at NMGH is median 393.5 days (56.2 weeks), mean time of 298.6 days (42.6 weeks) which is higher than MFT mean time of 26 weeks. Overall, for colorectal cases, about 62 % of times, the booking Consultant is the operating surgeon. Overall General Surgery waiting time at NMGH is median 356.6 days (50.9 weeks), mean 318 days (45.4 weeks) which is higher than MFT mean waiting time of 33 weeks. Median waiting time for lap chole is 369.5 days (52.7 weeks), mean 317.6 days (45.3 weeks) which is within the NHS standards of 18 to 52 weeks (1). West Suffolk NHS foundation Trust has published the mean waiting time of 53 weeks.
Cardiogenic shock in phaeochromocytoma multisystem crisis: a case report
Authors: Go Yun Yun , Ng Audrey Jing Ting , Balakrishnan Iswaree Devi , Tiwari Raj Vikesh , Tong Aaron Kian Ti , Lee Lianne Ai Ling , Keh Yann Shan , Tay Donovan
Published: September 2024

Background

Phaeochromocytoma multisystem crisis (PMC) is characterized by labile blood pressures (extremes of hypo- and/or hypertension) and multiorgan failure as a result of catecholamine excess. Initial stabilization requires pharmacological and/or mechanical circulatory support, followed by the institution of antihypertensives to correct the underlying pathophysiology.

Case summary

A previously well 40-year-old male developed a sudden onset of breathlessness. On presentation, he was in shock with multiorgan failure. He required intubation, mechanical ventilation, dual inotropic support, and renal replacement therapy. Bedside echocardiogram showed a severely impaired left ventricular ejection fraction (LVEF) of 25%. Coronary angiography revealed normal coronary arteries. In view of raised inflammatory markers and transaminitis, a computed tomography abdomen/pelvis was performed. An incidental left adrenal mass was found. Further work-ups revealed raised plasma metanephrine and normetanephrine, 24-h urine epinephrine, and norepinephrine. A cardiac magnetic resonance (CMR) showed myocardial inflammation and reverse Takotsubo pattern of regional wall motion abnormality (RWMA). The diagnosis of cardiogenic shock and stress cardiomyopathy secondary to PMC was made. He was subsequently initiated on α- and β-blockers and goal-directed medical therapy for heart failure. A 68Ga-DOTATATE scan showed avid tracer uptake of the left phaeochromocytoma. An interval CMR 3 weeks from presentation showed near normalization of the LVEF and RWMA. He underwent a successful laparoscopic left adrenalectomy and was antihypertensive-free since.

Discussion

The clinical suspicion for PMC as the cause of cardiogenic shock requires astute clinical judgement, while the management requires an understanding of the underlying pathophysiology that calls for multidisciplinary inputs.
Y and mitochondrial chromosomes in the heterogeneous stock rat population
Authors: Okamoto Faith , Chitre Apurva S , Missfeldt Sanches Thiago , Chen Denghui , Munro Daniel , Aron Allegra T , Beeson Angela , Bimschleger Hannah V , Eid Maya , Garcia Martinez Angel G , Han Wenyan , Holl Katie , Jackson Tyler , Johnson Benjamin B , King Christopher P , Kuhn Brittany N , Lamparelli Alexander C , Netzley Alesa H , Nguyen Khai-Minh H , Peng Beverly F , Tripi Jordan A , Wang Tengfei , Ziegler Kendra S , Adams Douglas J , Baud Amelie , Carrette Lieselot L G , Chen Hao , de Guglielmo Giordano , Dorrestein Pieter , George Olivier , Ishiwari Keita , Jablonski Monica M , Jhou Thomas C , Kallupi Marsida , Knight Rob , Meyer Paul J , Solberg Woods Leah C , Polesskaya Oksana , Palmer Abraham A
Published: September 2024

Genome-wide association studies typically evaluate the autosomes and sometimes the X Chromosome, but seldom consider the Y or mitochondrial (MT) Chromosomes. We genotyped the Y and MT Chromosomes in heterogeneous stock (HS) rats (Rattus norvegicus), an outbred population created from 8 inbred strains. We identified 8 distinct Y and 4 distinct MT Chromosomes among the 8 founders. However, only 2 types of each nonrecombinant chromosome were observed in our modern HS rat population (generations 81–97). Despite the relatively large sample size, there were virtually no significant associations for behavioral, physiological, metabolome, or microbiome traits after correcting for multiple comparisons. However, both Y and MT Chromosomes were strongly associated with the expression of a few genes located on those chromosomes, which provided a positive control. Our results suggest that within modern HS rats there are no Y and MT Chromosomes differences that strongly influence behavioral or physiological traits. These results do not address other ancestral Y and MT Chromosomes that do not appear in modern HS rats, nor do they address effects that may exist in other rat populations, or in other species.
Stop antibiotics when you feel better? Opportunities, challenges and research directions
Authors: Borek A J , Ledda A , Pouwels K B , Butler C C , Hayward G , Walker A S , Robotham J V , Tonkin-Crine S
Published: September 2024

Shortening standard antibiotic courses and stopping antibiotics when patients feel better are two ways to reduce exposure to antibiotics in the community, and decrease the risks of antimicrobial resistance and antibiotic side effects. While evidence shows that shorter antibiotic treatments are non-inferior to longer ones for infections that benefit from antibiotics, shorter courses still represent average treatment durations that might be suboptimal for some. In contrast, stopping antibiotics based on improvement or resolution of symptoms might help personalize antibiotic treatment to individual patients and help reduce unnecessary exposure. Yet, many challenges need addressing before we can consider this approach evidence-based and implement it in practice. In this viewpoint article, we set out the main evidence gaps and avenues for future research.
Within-population variation in preference functions reveals substantial among-female disagreement in mate assessment
Authors: Stratman Kane , Höbel Gerlinde
Published: September 2024

The mate choice behaviours of females can greatly affect patterns of reproductive success in males and influence the evolution of sexually selected male traits. Population-level estimates of display preferences may provide an accurate estimate of the strength and direction of selection by female choice if all females in the population show homogeneous preferences. However, population-level estimates may yield misleading estimates if there is within-population variation in mate preferences. While it is increasingly clear that the latter situation is common in nature, empirical data on the magnitude of variation in female preferences are required to improve our current understanding of its potential evolutionary consequences. We explored variations in female preference functions for 3 male call properties in a treefrog. We document substantial within-population variation not only in peak preferences but also in preference function shape (open, closed, flat), with at best 62% of females sharing a preference function shape with the respective population curve. Our findings suggest that population curves may accurately capture the direction of sexual selection, but depending on the properties of the constituting individual functions they may over- or underestimate the strength of selection. Particularly population estimates suggesting weak selection may in fact hide the presence of individual females with strong but opposing preferences. Moreover, due to the high within-population variation in both peak preferences and preference function shapes, the population functions drastically underestimate the predicted variation in male mating success in the population.
A randomized controlled trial to test the efficacy of a brief Triple P discussion group to increase healthy feeding practices and reduce risk factors for infant obesity
Authors: Gelmini Agnes , Tellegen Cassandra L , Morawska Alina
Published: September 2024

Objective

Test the efficacy of a brief 2-hr parenting intervention in increasing protective factors against and reducing risk factors for infant obesity.

Method

A 2 (Baby Healthy Living Triple P vs. care-as-usual) × 3 (baseline, postintervention, 6-month follow-up) design was used. Eighty-two parents of 4- to 18-month-old infants meeting at least two risk factors for early childhood obesity (e.g., parent/child overweight, low education level) were randomized to intervention (n = 42) or control group (n = 40). Parents questionnaires and child weight status was measured.

Results

Results showed an intervention effect on a primary outcome, early feeding practices (restrictive: d = 0.44, 95% CI [−0.01,0.88], pressuring: d = 0.11, 95% CI [−0.32,0.54], nonresponsive behaviors: (d = 0.32, 95% CI [−0.11,0.75]), and on a secondary outcome, feeding beliefs (d = 0.29, 95% CI [−0.14,0.73]). No beneficial impact was found on other primary outcomes (responsiveness in feeding: quantity d = 0.50, 95% CI [−0.03,1.03]) and nutritive d = 0.52, 95% CI [−0.03,1.07], mealtime environment: d = 0.35, 95% CI [−0.78,0.08], self-efficacy in responsive feeding: d = 0.21, 95% CI [−0.22,0.64]), or secondary outcomes (parental self-efficacy: d = 0.08, 95% CI [−0.50,0.35]), parent emotional eating (d = 0.01, 95% CI [−0.43,0.43]), food restraint (d = 0.42, 95% CI [−0.85,0.02]), and body satisfaction (d = 0.01, 95% CI [−0.43,0.43]) and child weight status (d = 0.11, 95% CI [−0.54,0.32]).

Conclusions

Promising though limited support was demonstrated for a brief, low-intensity program to help parents in the prevention of obesity for infants at risk.
Treatment-related survival patterns in diffuse intrinsic pontine glioma using a historical cohort: A report from the European Society for Pediatric Oncology DIPG/DMG Registry
Authors: Baugh Joshua N , Veldhuijzen van Zanten Sophie , Fiocco Marta , Colditz Niclas , Hoffmann Marion , Janssens Geert O , Valentini Chiara , Hargrave Darren , Wiese Maria , von Bueren André O , Karremann Michael , Perwein Thomas , Nussbaumer Gunther , Benesch Martin , Sturm Dominik , Gielen Gerrit H , Krause Mechthild , Eyrich Matthias , Hoving Eelco W , Bison Brigitte , van Vuurden Dannis G , Kramm Christof M
Published: September 2024

Background

Our aim is to investigate the association of treatment with survival in patients with diffuse intrinsic pontine glioma (DIPG) by examining 6 historical treatment paths.

Methods

We retrospectively analyzed data from 409 patients with radiologically centrally reviewed DIPG, sourced from the German Society of Pediatric Oncology and Hematology HIT-HGG trial database and the SIOPE-DIPG/DMG Registry. Survival outcomes were estimated using the Kaplan–Meier method, and univariable and multivariable Cox proportional hazard models were estimated to study treatment effects.

Results

The median overall survival (OS) from diagnosis was 11.2 months (95% confidence interval [CI], 10.5–11.9). Patients who by choice received no frontline treatment had an OS of 3.0 months (95% CI, 2.0–4.0), while those treated with radiation therapy (RT) alone had a median OS of 10.4 months (95% CI, 9.1–11.8). Those receiving RT combined with chemotherapy had the longest median OS of 11.7 months (95% CI, 10.8–12.6). The median post-progression survival (PPS) was 4.1 months (95% CI, 3.5–4.7). Patients who relapsed and did not receive treatment had a PPS of 2.2 months (95% CI, 1.8–2.6), while those treated with chemotherapy alone had a PPS of 4.4 months (95% CI, 3.7–5.0), and those who underwent reirradiation, with or without chemotherapy, had the longest survival after relapse of 6.6 months (95% CI, 5.3–8.0). Treatment differences remained significant in multivariable analysis adjusted for age and symptom duration in both diagnosis and relapse setting.

Conclusions

This study shows increased survival outcomes associated with radiation and chemotherapy treatment or a combination thereof, at diagnosis and relapse, in a historical DIPG cohort.
Alice Walker
Authors: Medine Carolyn , Watts Chera Jo
Published: September 2024

Alice Malsenior Tallulah-Kate Walker was born on 9 February 1944, in Putnam County, just outside of Eatonton, Georgia, as the youngest of eight children to her parents Willie Lee and Minnie Tallulah. Walker boasts a long and distinguished career, as an internationally recognized novelist, poet, essayist, and activist. She was awarded the 1983 Pulitzer Prize for The Color Purple, the first African American woman to be so honored. The novel also won the National Book Award. Walker is well-known for her stunning autobiographical essay collection, In Search of Our Mothers’ Gardens, which included some of her work originally published in Ms. magazine. In this volume, she, with African women writers, coined and extended the use of the concept “Womanist,” which is used across disciplines. She also revived the work of Zora Neale Hurston. In addition, she is one of the first African American Buddhists to publish work in that religion. She began to practice yoga and meditation, her journals indicate, around 1979 and openly to practice Buddhism in her fifties, though she had studied it for many years. Walker has published seventeen novels and short story collections, twelve non-fiction works, including collections of essays and poetry, and several children’s books. Her life has been documented by Pratibha Parmar in the documentary Beauty in Truth (2013). Walker’s activist work has been controversial, particularly for her criticism of female circumcision in Warrior Marks: Female Genital Mutilation and the Sexual Binding of Women (1993), co-authored with Pratibha Parmar, who also filmed a documentary on the issue. Also, some criticize her support of the cause of the Palestinians. Nevertheless, her work is loved, not just by academics, but by many loyal readers. She has influence both in and beyond the academy and is respected in literary, feminist, activist, and many other circles. Alice Walker’s influence cannot be summed up: her work is immense, as is her spirit.
Incompatibility of Y-site-administered drugs: the case of acyclovir and ciprofloxacin
Authors: Labrosse Dorine , Flacher Lugan , Bachelart Thomas , Boumendjel Ahcène
Published: September 2024

Objectives

Multiple drug administration is a common practice in hospitals and clinics. This is the case when multiple pathologies are treated. In this context, frequently, antivirals and antibiotics are co-administrated either simultaneously or sequentially ignoring potential incompatibilities. In this study, we focused on an antiviral (acyclovir) and an antibiotic (ciprofloxacin) compatibility/incompatibility when they are co-administrated.

Methods

In this study, we focused on the effect of drug ratio, pH, and delay by implementing robust high-performance liquid chromatography methods to determine the main factors leading to potential modification of concentration of one of the two drugs in the mixture.

Key findings

The results showed that acyclovir is quantitatively recovered in all conditions related to pH, concentration, and time (up to 24 hours). However, ciprofloxacin is strongly altered depending on the acidic and basic conditions, the quantity of ciprofloxacin used, and the time after mixing the two drugs. The most valuable piece of information is that the ratio of acyclovir/ciprofloxacin is crucial.

Conclusions

The volume ratio of acyclovir/ciprofloxacin (prepared at 2 mg/ml each) should be calculated and managed to provide at least two-fold quantity of acyclovir versus ciprofloxacin or at least nine-fold quantity of ciprofloxacin versus acyclovir to maintain the administrated doses and prevent physicochemical interactions.
Developing a shared language: a proposed guide to frame early implementation science collaboration discussions
Authors: Best Stephanie , Peters Sanne , Guccione Lisa , Francis Jillian , Klaic Marlena
Published: September 2024

Miscommunication between health care practitioners and implementation researchers can lead to a mismatch of expectations and understandings, resulting in wasted research and frustration. Conversely, combining the expertise and knowledge of those working in health care practice and implementation research can deliver context informed research questions and appropriate study designs. Achieving this ambition requires a shared language. We sought to develop a guide to identify a common language to constructively explore nascent implementation research concepts. We set up a working group, comprising of implementation researchers, health care practitioners and operational managers, to work through ideas generation, debate and a consensus process to generate and refine a discussion guide. The resultant guide steps health care practitioners and implementation researchers through a three-phase enquiry - Question 1: What is the implementation question? Question 2: What is the proposed implementation solution? And Question 3: How can the investigation of this idea be resourced? At each step, the health care practitioner and implementation researcher collaborate to include theory and practice and rigorously work through the question to build implementation on evidence and to promote diverse stakeholder engagement. The next steps for this study will be operationalising the discussion guide, as an interactive tool. Future evaluation, to test effectiveness, acceptability and feasibility will be designed with health care practitioners and implementation researchers.
Lactobacillus delbrueckii alleviates lipopolysaccharide‐induced muscle inflammation and atrophy in weaned piglets associated with inhibition of endoplasmic reticulum stress and protein degradation
Authors: Zhong Songshi , Sun Zhiyuan , Tian Qiyu , Wen Wei , Chen Fengming , Huang Xingguo , Li Yinghui
Published: September 2024

Pro‐inflammatory cytokines in muscle play a pivotal role in physiological responses and in the pathophysiology of inflammatory disease and muscle atrophy. Lactobacillus delbrueckii (LD), as a kind of probiotics, has inhibitory effects on pro‐inflammatory cytokines associated with various inflammatory diseases. This study was conducted to explore the effect of dietary LD on the lipopolysaccharide (LPS)—induced muscle inflammation and atrophy in piglets and to elucidate the underlying mechanism. A total of 36 weaned piglets (Duroc × Landrace × Large Yorkshire) were allotted into three groups with six replicates (pens) of two piglets: (1) Nonchallenged control; (2) LPS‐challenged (LPS); (3) 0.2% LD diet and LPS‐challenged (LD+LPS). On d 29, the piglets were injected intraperitoneally with LPS or sterilized saline, respectively. All piglets were slaughtered at 4 h after LPS or saline injection, the blood and muscle samples were collected for further analysis. Our results showed that dietary supplementation of LD significantly attenuated LPS‐induced production of pro‐inflammatory cytokines IL‐6 and TNF‐α in both serum and muscle of the piglets. Concomitantly, pretreating the piglets with LD also clearly inhibited LPS‐induced nuclear translocation of NF‐κB p65 subunits in the muscle, which correlated with the anti‐inflammatory effects of LD on the muscle of piglets. Meanwhile, LPS‐induced muscle atrophy, indicated by a higher expression of muscle atrophy F‐box, muscle RING finger protein (MuRF1), forkhead box O 1, and autophagy‐related protein 5 (ATG5) at the transcriptional level, whereas pretreatment with LD led to inhibition of these upregulations, particularly genes for MuRF1 and ATG5. Moreover, LPS‐induced mRNA expression of endoplasmic reticulum stress markers, such as eukaryotic translational initiation factor 2α (eIF‐2α) was suppressed by pretreatment with LD, which was accompanied by a decrease in the protein expression levels of IRE1α and GRP78. Additionally, LD significantly prevented muscle cell apoptotic death induced by LPS. Taken together, our data indicate that the anti‐inflammatory effect of LD supply on muscle atrophy of piglets could be likely regulated by inhibiting the secretion of pro‐inflammatory cytokines through the inactivation of the ER stress/NF‐κB singling pathway, along with the reduction in protein degradation.
The Effect of Spaced Repetition on Learning and Knowledge Transfer in a Large Cohort of Practicing Physicians
Authors: Price David W. , Wang Ting , O’Neill Thomas R. , Morgan Zachary J. , Chodavarapu Prasad , Bazemore Andrew , Peterson Lars E. , Newton Warren P.
Published: September 2024

Purpose

Spaced repetition is superior to repeated study for learning and knowledge retention, but literature on the effect of different spaced repetition strategies is lacking. The authors evaluated the effects of different spaced repetition strategies on long-term knowledge retention and transfer.

Method

This prospective cohort study, conducted from October 1, 2020, to July 20, 2023, used the American Board of Family Medicine Continuous Knowledge Self-Assessment (CKSA) to assess learning and knowledge transfer of diplomates and residents. Participants were randomized to a control group or 1 of 5 spaced repetition conditions during 5 calendar quarters (January 1, 2021, to March 31, 2022). Participants in the spaced repetition groups received 6 repeated questions once or twice. Incorrectly but confidently answered questions were prioritized for repetition, with decreasing priority for questions answered incorrectly with lesser confidence. All participants received 6 rewritten questions corresponding to their initial questions chosen for repetition in quarter 10 (second quarter of calendar year 2023).

Results

A total of 26,258 family physicians or residents who completed the CKSA in the baseline period were randomized. Spaced repetition was superior to no spaced repetition for learning at quarter 6 (58.03% vs 43.20%, P < .001, Cohen d = 0.62) and knowledge transfer at quarter 10 (58.33% vs 52.39%, P < .001, Cohen d = 0.26). Double-spaced repetitions were superior to single-spaced repetitions for learning (62.24% vs 51.83%, P < .001, Cohen d = 0.43) and transfer (60.08% vs 55.72%, P < .001, Cohen d = 0.20). There were no meaningful differences in learning or transfer between repetition strategy chosen in the single- or double-repetition groups.

Conclusions

This study affirms the value of spaced repetition in improving learning and retention in medical education and ongoing professional development.
Depth of anesthesia monitoring: an argument for its use for patient safety
Authors: Brook Karolina , Agarwala Aalok V. , Li Fenghua , Purdon Patrick L.
Published: September 2024

Purpose of review

There have been significant advancements in depth of anesthesia (DoA) technology. The Anesthesia Patient Safety Foundation recently published recommendations to use a DoA monitor in specific patient populations receiving general anesthesia. However, the universal use of DoA monitoring is not yet accepted. This review explores the current state of DoA monitors and their potential impact on patient safety.

Recent findings

We reviewed the current evidence for using a DoA monitor and its potential role in preventing awareness and preserving brain health by decreasing the incidence of postoperative delirium and postoperative cognitive dysfunction or decline (POCD). We also explored the evidence for use of DoA monitors in improving postoperative clinical indicators such as organ dysfunction, mortality and length of stay. We discuss the use of DoA monitoring in the pediatric population, as well as highlight the current limitations of DoA monitoring and the path forward.

There is evidence that DoA monitoring may decrease the incidence of awareness, postoperative delirium, POCD and improve several postoperative outcomes. In children, DoA monitoring may decrease the incidence of awareness and emergence delirium, but long-term effects are unknown. While there are key limitations to DoA monitoring technology, we argue that DoA monitoring shows great promise in improving patient safety in most, if not all anesthetic populations.
Safety amid the scalpels: creating psychological safety in the operating room
Authors: Cohen Jonathan B. , Feldman-Brillembourg Jennifer A. , Cheng Jason , Rangrass Govind
Published: September 2024

Purpose of review

We briefly review the concept of psychological safety and discuss the actions that can create it in the anesthesiologist's work environment.

Recent findings

The interest in psychological safety has grown in popularity since the publication of Amy Edmondson's book The Fearless Organization in 2018. While the concept and its benefits are described in the healthcare literature, the specific actions necessary to create it are often not.

To ensure patient safety, we want members of the teams we lead to be comfortable sharing emerging problems that they see before we become aware of them. As educators, we want trainees to approach us when they do not understand something and openly participate and contribute without the fear of how others will perceive them. These scenarios require an environment of psychological safety – the ability to ask for help, admit mistakes, and be respectfully forthright with unpopular beliefs without the fear of being ostracized or ignored. Methods for creating an environment of psychological safety will be discussed.
Plantar Flap Imbrication and Mobilization: A Technique for the Correction of Floating Toes
Authors: Vlasak Alex Loren , Reddy Akshay R. , Lagrew Delaney Joseph , Toussaint Rull James
Published: September 2024

The Weil osteotomy is a common procedure used to address length discrepancies in the metatarsal cascade. The most widely reported complication from this procedure is a floating toe. While other studies have described approaches to reduce the likelihood of the deformity occurring intraoperatively, there is paucity in the literature about soft tissue techniques that can be used to correct this deformity. We report a novel surgical technique to correct the floating toe after Weil osteotomy by creating a plantar flap imbrication to mobilize soft tissues.

Level of Evidence:

Level V—Diagnostic.