WUTH publication: Removal of breast implants as primary treatment for autoimmune/inflammatory syndrome induced by adjuvants

Citation: Scandinavian Journal of Rheumatology. 2022, Sep 30, 1-2
Author: S Ramakrishnan, A Abbas, N Jordan 

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WUTH publication: Safety and effectiveness of ustekinumab in elderly Crohn's disease patients

Citation: European Journal of Gastroenterology and Hepatology. 2022, 34(11), 1132-39
Author: Joseph Fiske, Eleanor Liu, Jimmy K Limdi, Thomas E Conley, Tristan Townsend, Mike Davies, Robert Brockwell, Daniyal Baig, Sherif Abdelbadiee, Anastasia Uney, Angela Liaros, Waqas Gaba, Philip J Smith, Paul K Flanagan, Sreedhar Subramanian
Abstract: Objective: Anti-tumour necrosis factor (TNF) agents are associated with increased infection risk among elderly IBD patients, but little is known about non anti-TNF biologics in this cohort. We examined the safety and effectiveness of ustekinumab in elderly Crohn's patients.

Methods: This retrospective multi-centre cohort study included Crohn's patients ≥60-years old who commenced ustekinumab. We recorded Harvey-Bradshaw index (HBI), concomitant steroid therapy, treatment persistence and new infections or malignancies. Primary outcome was serious infections requiring hospitalisation.

Results: Seventy patients were included, with median age of 68 years. 43 (61.4%) had prior anti-TNF exposure, and 15 (21.4%) vedolizumab. Median treatment duration was 12 months, totalling 84 patient-years. Nine serious infections were reported, incidence 106.7/1000 patient-years. Systemic steroids were associated with increased risk of serious infections [odds ratio (OR) 7.83, 95% confidence interval (CI): 1.44-44.32, P = 0.02]. There were 27 "non-serious" infections; 321.4/1000 patient-years. Charlson co-morbidity index (OR 1.49, 95% CI: 1.05-2.12, P = 0.03) and steroid exposure (OR 44.10, 95% CI: 1.75-1112.10, P = 0.02) increased non-serious infection risk (P < 0.05). Mean HBI improved from 8.13 to 4.64 at 6 months and 4.10 at last follow up (P < 0.0001). 12-month treatment persistence was 55.7% (N = 39); 34 (48.6%) were steroid-free.

Conclusion: Ustekinumab was safe and effective in a cohort of elderly Crohn's disease patients. Infections were mostly mild, not resulting in therapy discontinuation. Serious infection risk was comparable to previously reported rates with anti-TNF agents. Steroid exposure was associated with an increased serious infection risk.

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WUTH publication: Pregnancy and neonatal outcomes of COVID-19: The PAN-COVID study

Citation: European Journal of Obstetrics, Gynecology and Reproductive Biology. 2022, 276, 161-7
Author: E Mullins, A Perry, J Banerjee, J Townson, D Grozeva, R Milton, N Kirby, R Playle, T Bourne, C Lees, PAN-COVID Investigators
Abstract: Objective: To assess perinatal outcomes for pregnancies affected by suspected or confirmed SARS-CoV-2 infection.
Methods: Prospective, web-based registry. Pregnant women were invited to participate if they had suspected or confirmed SARS-CoV-2 infection between 1st January 2020 and 31st March 2021 to assess the impact of infection on maternal and perinatal outcomes including miscarriage, stillbirth, fetal growth restriction, pre-term birth and transmission to the infant.
Results: Between April 2020 and March 2021, the study recruited 8239 participants who had suspected or confirmed SARs-CoV-2 infection episodes in pregnancy between January 2020 and March 2021. Maternal death affected 14/8197 (0.2%) participants, 176/8187 (2.2%) of participants required ventilatory support. Pre-eclampsia affected 389/8189 (4.8%) participants, eclampsia was reported in 40/ 8024 (0.5%) of all participants. Stillbirth affected 35/8187 (0.4 %) participants. In participants delivering within 2 weeks of delivery 21/2686 (0.8 %) were affected by stillbirth compared with 8/4596 (0.2 %) delivering ≥ 2 weeks after infection (95 % CI 0.3-1.0). SGA affected 744/7696 (9.3 %) of livebirths, FGR affected 360/8175 (4.4 %) of all pregnancies. Pre-term birth occurred in 922/8066 (11.5%), the majority of these were indicated pre-term births, 220/7987 (2.8%) participants experienced spontaneous pre-term births. Early neonatal deaths affected 11/8050 livebirths. Of all neonates, 80/7993 (1.0%) tested positive for SARS-CoV-2.
Conclusions: Infection was associated with indicated pre-term birth, most commonly for fetal compromise. The overall proportions of women affected by SGA and FGR were not higher than expected, however there was the proportion affected by stillbirth in participants delivering within 2 weeks of infection was significantly higher than those delivering ≥ 2 weeks after infection. We suggest that clinicians' threshold for delivery should be low if there are concerns with fetal movements or fetal heart rate monitoring in the time around infection. The proportion affected by pre-eclampsia amongst participants was not higher than would be expected, although we report a higher than expected proportion affected by eclampsia. There appears to be no effect on birthweight or congenital malformations in women affected by SARS-CoV-2 infection in pregnancy and neonatal infection is uncommon. This study reflects a population with a range of infection severity for SARS-COV-2 in pregnancy, generalisable to whole obstetric populations.
Keywords: COVID; Fetal; Fetal growth restriction; Infection; Neonatal; Perinatal; Pregnancy; SARS-CoV-2; Stillbirth.

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WUTH publication: The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections

Citation: Journal of Wound Care. 2022, 31(8), 683-88
Author: Bradley Pittam, Ruby Chumber, Gaurav Vashisht, Sophie Miller, Christina O'Dowd, Thomas Ledson, Upendram Srinivas-Shankar
Abstract: Objective: People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD.
Method: This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome.
Results: A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment.
Conclusion: HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI.
Declaration of interest: The authors have no conflicts of interest to declare.
Keywords: diabetes; diabetic foot infection; haemodialysis; intravenous antibiotics; vancomycin; vascular complications; wound; wound bed; wound care; wound dressing; wound healing.

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WUTH publication: The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

Citation: International Journal of Surgery. 2022, 104, 106766. Epub 2022 Jul 13.
Author: Islam Omar, Karl Miller, Brijesh Madhok, Bassem Amr, Rishi Singhal, Yitka Graham, Sjaak Pouwels, Mohammad Abu Hilal, Sandeep Aggarwal, Irfan Ahmed, Ali Aminian, Basil Jaser Ammori, Tan Arulampalam, Altaf Awan, José María Balibrea, Aneel Bhangu, Richard Raymond Brady, Wendy Brown, Manish Chand, Ara Darzi, Talvinder Singh Gill, Ramen Goel, Bussa R Gopinath, Mark van Berge Henegouwen, Jacques M Himpens, David Daniel Kerrigan, Misha Luyer, Christian Macutkiewicz, Julio Mayol, Sanjay Purkayastha, Raul Jacobo Rosenthal, Scott Alan Shikora, Peter Kenneth Small, Neil James Smart, Mark A Taylor, Tehemton E Udwadia, Tim Underwood, Yirupaiahgari Ks Viswanath, Neil Thomas Welch, Steven D Wexner, Michael Samuel James Wilson, Des C Winter, Kamal K Mahawar
Abstract: Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.
Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.
Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.
Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.
Keywords: Ergonomics; Gastrointestinal surgery; Guidelines; Hepatobiliary; Laparoscopic surgery; Minimally invasive; Patient safety; Surgical training.

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WUTH publication: Complications in Device Therapy: Spectrum, Prevalence, and Management

Citation: Current Heart Failure Reports. 2022 Aug 6. Online ahead of print.
Author: J Llewellyn, D Garner, A Rao 
Abstract: Purpose of review: Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications.
Recent findings: Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.
Keywords: Complications; Device therapy; Management.

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WUTH publication: A BURST-BAUS consensus document for best practice in the conduct of scrotal exploration for suspected testicular torsion: the Finding consensus for orchIdopeXy In Torsion (FIX-IT) study

Citation: BJU International. 2022 Jun 10. Online ahead of print.
Author: Keiran D Clement, Alexander Light, Aqua Asif, Vinson Wai-Shun Chan, Sinan Khadhouri, Taimur T Shah, Frederick Banks, Trevor Dorkin, Christopher P Driver, Vinnie During, Nia Fraser, Maximilian J Johnston, Marc Lucky, Vaibhav Modgil, Asif Muneer, Arie Parnham, Ian Pearce, Majed Shabbir, Manoj Shenoy, Duncan J Summerton, Shabnam Undre, Alun Williams, Steven MacLennan, Veeru Kasivisvanathan, FIX-IT collaborators
Abstract: Objectives: To produce a best practice consensus guideline for the conduct of scrotal exploration for suspected testicular torsion using formal consensus methodology.
Materials and methods: A panel of 16 expert urologists, representing adult, paediatric, general, and andrological urology used the RAND/UCLA Appropriateness Consensus Methodology to score a 184 statement pre-meeting questionnaire on the conduct of scrotal exploration for suspected testicular torsion. The collated responses were presented at a face-to-face online meeting and each item was rescored anonymously after a group discussion, facilitated by an independent chair with expertise in consensus methodology. Items were scored for agreement and consensus and the items scored with consensus were used to derive a set of best practice guidelines.
Results: Statements scored as with consensus increased from Round 1 (122/184, 66.3%) to Round 2 (149/200, 74.5%). Recommendations were generated in ten categories: consent, assessment under anaesthetic, initial incision, intraoperative decision making, fixation, medical photography, closure, operation note, logistics and follow-up after scrotal exploration. Our statements assume that the decision to operate has already been made. Key recommendations in the consent process included the discussion of the possibility of orchidectomy and the possibility of subsequent infection of the affected testis or wound requiring antibiotic therapy. If after the examination under anaesthesia, the index of suspicion of testicular torsion is lower than previously thought, then the surgeon should still proceed to scrotal exploration as planned. A flow chart guiding decision making dependent on intraoperative findings has been designed. If no torsion is present on exploration and the bell clapper deformity is absent, the testis should not be fixed. When fixing a testis using sutures, 3 or 4-point is acceptable and non-absorbable sutures are preferred.
Conclusions: We have produced consensus recommendations to inform best practice in the conduct of scrotal exploration for suspected testicular torsion.
Keywords: Fixation; Orchidopexy; Scrotal exploration; Surgical Technique; Testicular Torsion

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WUTH publication: The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias

Citation: European Journal of Trauma and Emergency Surgery. 2022 Jun 21. Online ahead of print.
Author: Walid Ibrahim, Jeremy Wilson, Conor Magee 
Abstract: Purpose: Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia.
Methods: A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay.
Results: Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0 h vs 13.0 h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014).
Conclusions: Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .
Keywords: Abdominal wall; Acute symptomatic; CT; Hernia; Preoperative.

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WUTH publication: The diagnostic value and accuracy of ultrasound in diagnosing hydatidiform mole: A systematic review and meta-analysis of the literature

Citation: Radiography. 2022, 28(4), 897-905
Author: I Newhouse, A Spacey, B Scragg, K Szczepura 
Abstract: Introduction: Hydatidiform moles are the most common type of gestational trophoblastic disease. Internationally the incidence of hydatidiform moles is 1-2:1000 pregnancies. Early detection of women with hydatidiform moles is preferential, as these women are at a higher risk of developing other gestational trophoblastic disease. Despite Ultrasound being the most common modality used to diagnose hydatidiform moles, its diagnostic value and accuracy throughout all trimesters remains uncertain. Thus, the aim of this review was to explore and evaluate the diagnostic value and accuracy of Ultrasound in diagnosing hydatidiform mole throughout all trimesters of pregnancy.
Methods: The databases MEDLINE and CINAHL were searched between 2004 and 2021. Included studies were quality assessed using the Mixed Methods Appraisal Tool.
Results: A total of 8 studies were included. The narrative synthesis identified four themes: Misdiagnosis, Complete and Partial molar pregnancy, Operator dependency and Gestational age. The meta-analysis highlighted although the sensitivity of ultrasound for diagnosing hydatidiform moles is relatively low at 52.2%, the specificity was high at 92.6%.
Conclusion: While histological examination remains the gold standard for detecting hydatidiform moles, our review made evident that ultrasound is a beneficial diagnostic tool in the detection of Hydatidiform moles, especially alongside other diagnostic investigations. This review has highlighted and collated the main barriers and facilitators to diagnosing hydatidiform moles using ultrasound.
Implication for practice: Findings suggest that although sonographic detection of hydatidiform moles remains a diagnostic challenge, seeking a second opinion or repeating scans before making a final diagnosis should be embedded into clinical practice.
Keywords: Complete molar; Gestational trophoblastic disease; Hydatidiform mole; Partial molar; Ultrasound.

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WUTH publication: Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy

Citation: Surgical Endoscopy. 2022 Jun 9. Online ahead of print.
Author: Matta Kuzman, Khalid Munir Bhatti, Islam Omar, Hany Khalil, Wah Yang, Prem Thambi, Nader Helmy, Amir Botros, Thomas Kidd, Siobhan McKay, Altaf Awan, Mark Taylor, Kamal Mahawar
Abstract: Background: There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure.
Methods: A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media.
Results: 638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy.
Conclusions: This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.
Keywords: Cholecystectomy; Cholecystitis; Gallbladder surgery; Gallstone disease; Gallstone pancreatitis; Obstructive jaundice; Variation in practice.

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WUTH publication: Clinical management of community-acquired meningitis in adults in the UK and Ireland in 2017: a retrospective cohort study on behalf of the National Infection Trainees Collaborative for Audit and Research (NITCAR)

Citation: BMJ Open. 2022, 12(7), e062698
Author: Jayne Ellis, David Harvey, Sylviane Defres, Arjun Chandna, Eloisa MacLachlan, Tom Solomon, Robert S Heyderman, Fiona McGill, National Audit of Meningitis Management (NAMM) group
Abstract: Objectives: To assess practice in the care of adults with suspected community-acquired bacterial meningitis in the UK and Ireland.
Design: Retrospective cohort study.
Setting: 64 UK and Irish hospitals.
Participants: 1471 adults with community-acquired meningitis of any aetiology in 2017.
Results: None of the audit standards, from the 2016 UK Joint Specialists Societies guideline on diagnosis and management of meningitis, were met in all cases. With respect to 20 of 30 assessed standards, clinical management provided for patients was in line with recommendations in less than 50% of cases. 45% of patients had blood cultures taken within an hour of admission, 0.5% had a lumbar puncture within 1 hour, 26% within 8 hours. 28% had bacterial molecular diagnostic tests on cerebrospinal fluid. Median time to first dose of antibiotics was 3.2 hours (IQR 1.3-9.2). 80% received empirical parenteral cephalosporins. 55% ≥60 years and 31% of immunocompromised patients received anti-Listeria antibiotics. 21% received steroids. Of the 1471 patients, 20% had confirmed bacterial meningitis. Among those with bacterial meningitis, pneumococcal aetiology, admission to intensive care and initial Glasgow Coma Scale Score less than 14 were associated with in-hospital mortality (adjusted OR (aOR) 2.08, 95% CI 0.96 to 4.48; aOR 4.28, 95% CI 1.81 to 10.1; aOR 2.90, 95% CI 1.26 to 6.71, respectively). Dexamethasone therapy was weakly associated with a reduction in mortality in both those with proven bacterial meningitis (aOR 0.57, 95% CI 0.28 to 1.17) and with pneumococcal meningitis (aOR 0.47, 95% CI 0.20 to 1.10).
Conclusion: This study demonstrates that clinical care for patients with meningitis in the UK is not in line with current evidence-based national guidelines. Diagnostics and therapeutics should be targeted for quality improvement strategies. Work should be done to improve the impact of guidelines, understand why they are not followed and, once published, ensure they translate into changed practice.
Keywords: BACTERIOLOGY; Diagnostic microbiology; INTERNAL MEDICINE; Infectious disease/HIV; Molecular diagnostics; Protocols & guidelines.

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WUTH publication: Small bowel obstruction caused by a fibrotic bow-string appendix: a consequence of non-operative management of acute appendicitis

Citation: Annals of the Royal College of Surgeons of England. 2022 May 31. Online ahead of print.
Author: J Banks, P Shuttleworth, N Day, R Guy 
Abstract: A 73-year-old woman presented with small bowel obstruction that failed to settle with conservative management. Over the previous 2 years she had presented twice with computed tomography scan-proven acute appendicitis with localised perforation of the appendix tip. In view of medical comorbidities, she was treated non-operatively with clinical and radiological resolution on each occasion, but on the third presentation laparoscopy was undertaken for non-resolving small bowel obstruction and the non-inflamed appendix itself was identified as a fibrous band causing compression of the distal ileum and complete small bowel obstruction. Following division and appendicectomy, the patient made an uneventful recovery. This case illustrates the potential consequence of repeated appendiceal inflammation and non-operative management and may be seen increasingly as this approach is widely adopted during the COVID-19 pandemic.
Keywords: Acute appendicitis; Non-operative management; Small bowel obstruction.

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WUTH publication: Patient worry and concern associated with referral on the two-week suspected head and neck pathway

Citation: British Dental Journal. 2022 Jul 5;1-5. Online ahead of print.
Author: Catherine E P Rowlands, Peter James, Derek Lowe, Simon N Rogers
Abstract: Introduction Patient worry and concern of cancer adds to the latent distress associated with referral on the two-week suspected pathway (2WW). For oral cancer, as the conversion rate is in the region of 5-10%, the majority of people will have needless cause for concern.Aim This study aims to report how worried/concerned patients were that the reason for referral might mean that they had cancer and to relate to referral characteristics.Materials/methods All patients referred on the 2WW to two oral and maxillofacial departments in the three months from January to March 2021 were sent a one-off anonymised study-specific post-consultation survey.Results In total, 107 of 353 patients responded to the survey (30%). The response rate increased notably in the older group (p <0.001). The cancer conversion rate overall was 5.4% (19/353), stratified as 2.4% (4/167) for general dental practitioner and 8.1% (15/186) for general medical practitioner (p = 0.02). When asked how worried/concerned they were that the reason for referral might have been for cancer, the response was 'very much' (34%, 33/98), and 'somewhat' (24%, 24/98). Concerns tended to be higher in women and those under 40.Conclusions In recognition of the proportion of patients on the 2WW pathway without cancer who have 'very much worry and concern', it is appropriate to explore ways to alleviate this anxiety, and the best means to achieve this needs careful consideration.

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WUTH publication: Effect of contrast administration on the renal function of predialysis patients undergoing fistuloplasty

Citation: Journal of Vascular Surgery. 2022 Jun 13, S0741-5214(22), 01648-2. Online ahead of print.
Author: Panagiota Birmpili, Thomas Pearson, Ewa Magdalena Zywicka, James Jackson, Ramasubramanyan Chandrasekar
Abstract: Objective: The aim of this study was to investigate if administration of iodinated contrast during endovascular interventions in arteriovenous fistula (AVF) in patients not requiring dialysis (predialysis patients) (1) negatively affects their renal function and (2) if oral hydration has a protective effect.
Methods: All pre-dialysis patients who underwent endovascular interventions in AVF between August 2010 and April 2019 were included in the study. During the procedures, 35 to 50 mL of Iodixanol were administered. A pre-hydration protocol was introduced in March 2015. Data were grouped before and after this date. The difference between pre- and post-contrast estimated glomerular filtration rate (eGFR) and the difference between the eGFR of hydrated and non-hydrated groups were calculated.
Results: Eighty-four patients who underwent 151 procedures were included in the study. In 60.3% of procedures, a mean decrease of 1.35 mL/min/1.73 m2 in eGFR was noted (95% confidence interval [CI], 1.02-1.69 mL/min/1.73 m2), whereas in 35.1% of procedures, there was a mean increase of 1.06 mL/min/1.73 m2 (95% CI, 0.84-1.28 mL/min/1.73 m2). The mean difference between pre- and post-procedure eGFR was -0.44 mL/min/1.73 m2 (95% CI, -0.72 to -0.16 mL/min/1.73 m2; P = .002). Oral hydration was associated with a smaller mean change in eGFR of -0.32 mL/min/1.73 m2 (95% CI, -0.62 to -0.03 mL/min/1.73 m2) compared with the non-hydrated group, with mean change of -0.47 mL/min/1.73 m2 (95% CI, -0.91 to -0.03 mL/min/1.73 m2), but this was not statistically significant (P = .586).
Conclusions: This study demonstrates that administration of up to 50 mL of iodinated contrast for endovascular interventions in AVF in predialysis patients has minimal adverse effect on the eGFR with questionable clinical significance. In addition, oral hydration before and after the procedure has only a mild protective effect against a decrease in eGFR.
Keywords: Arteriovenous fistula; Chronic renal insufficiency; Contrast-induced acute kidney injury; Endovascular; Hemodialysis; Iodinated contrast.

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WUTH publication: Knowledge mobilization in critical care and the evolving communication role of nurses

Citation: Nursing in Critical Care. 2022 Jul 6. Online ahead of print.
Author: Sioban Kelly, Jayne Garner, Victoria Treadway, Girendra Sadera
Abstract: Background: The importance of appropriate communication skills within a health care setting rests upon the need for effective information sharing. When successful, this provides a supportive working environment for staff and has a positive impact on patient care and outcomes.

Aims: The purpose of this study was to explore how knowledge/evidence is acquired, shared, and applied in the Critical Care (CC) environment for staff and patients/family members.

Study design: A qualitative approach was used, consisting of semi-structured interviews and focus groups. Data analysis was conducted using an iterative thematic approach.

Results: Data collected prior to the COVID-19 pandemic from United Kingdom (UK) critical care workers (N = 46), patients, and family members (N = 21) identified four communication roles performed by the nursing staff: team member; diplomat; translator and friend.

Conclusions: It was evident that without suitable training and support, the stresses and demands placed upon the nurses could lead to disenfranchisement and burnout.

Relevance to clinical practice: These findings are relevant and timely given the impact of the pandemic, highlighting the need for accessible and alternate communication strategies to support nurses by reducing stress, moral distress and increasing psychological safety. Improved communication can provide tailored information for staff and patients/family improving the CC experience for all.

Keywords: collaboration; critical care; nurse communication; patient care.

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WUTH publication: The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

Citation: International Journal of Surgery. 2022 Jul 13, 104, 106766. Online ahead of print
Author: Islam Omar, Karl Miller, Brijesh Madhok, Bassem Amr, Rishi Singhal, Yitka Graham, Sjaak Pouwels, Mohammad Abu Hilal, Sandeep Aggarwal, Irfan Ahmed, Ali Aminian, Basil Jaser Ammori, Tan Arulampalam, Altaf Awan, José María Balibrea, Aneel Bhangu, Richard Raymond Brady, Wendy Brown, Manish Chand, Ara Darzi, Talvinder Singh Gill, Ramen Goel, Bussa R Gopinath, Mark van Berge Henegouwen, Jacques M Himpens, David Daniel Kerrigan, Misha Luyer, Christian Macutkiewicz, Julio Mayol, Sanjay Purkayastha, Raul Jacobo Rosenthal, Scott Alan Shikora, Peter Kenneth Small, Neil James Smart, Mark A Taylor, Tehemton E Udwadia, Tim Underwood, Yirupaiahgari Ks Viswanath, Neil Thomas Welch, Steven D Wexner, Michael Samuel James Wilson, Des C Winter, Kamal K Mahawar
Abstract: Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.
Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.
Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.
Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.
Keywords: Ergonomics; Gastrointestinal surgery; Guidelines; Hepatobiliary; Laparoscopic surgery; Minimally invasive; Patient safety; Surgical training.

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Pop-Up Library

It's Knowledge and Library Services National Awareness Week. Come along to our pop-up library today in the restaurant. Liam will be there to answer any questions this afternoon at 1.30pm until 2.30pm

WUTH publication: Partial tear of the distal biceps tendon: Current concepts

Citation: Journal of Orthopaedics. 2022, 32, 18-24
Author: Zaid Hamoodi , Joanna Winton, Vijaya Bhalaik 
Abstract: Background: Patients with partial rupture of the distal biceps tendon can present with vague elbow pain and weakness. Understanding of the anatomy and aetiology of this disease is essential to management. Patients can present with a single or multiple traumatic events or with a chronic degenerative history. On clinical examination, patients will have an intact tendon making the diagnosis more challenging. Clinicians, therefore, should have a high index of suspicion and should actively look for this pathology.
Objectives and rationale: This review aims to discuss the current evidence in managing partial rupture of the distal biceps tendon with a suggested treatment algorithm.
Conclusion: Several clinical tests have been described in the literature including resisted hook test, biceps provocation test, and TILT sign. However, the diagnosis is usually confirmed by a magnetic resonance scan with the arm positioned in elbow flexion, shoulder abduction, and forearm supination and commonly known as FABS MR. Partial tendon tears that involve less than 50% of the tendon can be successfully managed conservatively. Tears that include more than 50% of the tendon are more likely to fail conservative management and would benefit from surgical intervention. It is crucial, however, to involve the patient in the decision making, which is based on their objectives and needs.
Keywords: Anatomy; Diagnosis; Distal biceps tendon; Management; Partial tear.

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WUTH publication: Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke

Citation: European Heart Journal. 2022 May 13, ehac245. Online ahead of print.
Author: Gregory Y H Lip, Deirdre A Lane, Radosław Lenarczyk, Giuseppe Boriani, Wolfram Doehner, Laura A Benjamin, Marc Fisher, Deborah Lowe, Ralph L Sacco, Renate Schnabel, Caroline Watkins, George Ntaios, Tatjana Potpara
Abstract: The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient 'journey' or 'patient pathway,' supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: • A: Appropriate Antithrombotic therapy. • B: Better functional and psychological status. • C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
Keywords: Delivery of care; Heart disease; Integrated care; Patient pathways; Stroke.

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WUTH publication: Safety of Bariatric Surgery in ≥ 65-Year-Old Patients During the COVID-19 Pandemic

Citation: Obesity Surgery. 2022 May 5, 1-13. Online ahead of print
Author: Rishi Singhal, Islam Omar, Brijesh Madhok, Yashasvi Rajeev, Yitka Graham, Abd A Tahrani, Christian Ludwig, Tom Wiggins, Kamal Mahawar, GENEVA Collaborators
Abstract: Background: Age ≥ 65 years is regarded as a relative contraindication for bariatric surgery. Advanced age is also a recognised risk factor for adverse outcomes with Coronavirus Disease-2019 (COVID-19) which continues to wreak havoc on global populations. This study aimed to assess the safety of bariatric surgery (BS) in this particular age group during the COVID-19 pandemic in comparison with the younger cohort.
Methods: We conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups - patients ≥ 65-years-old (Group I) and patients < 65-years-old (Group II). The two groups were compared for 30-day morbidity and mortality.
Results: There were 149 patients in Group 1 and 6923 patients in Group II. The mean age, preoperative weight, and BMI were 67.6 ± 2.5 years, 119.5 ± 24.5 kg, and 43 ± 7 in Group I and 39.8 ± 11.3 years, 117.7±20.4 kg, and 43.7 ± 7 in Group II, respectively. Approximately, 95% of patients in Group 1 had at least one co-morbidity compared to 68% of patients in Group 2 (p = < 0.001). The 30-day morbidity was significantly higher in Group I (11.4%) compared to Group II (6.6%) (p = 0.022). However, the 30-day mortality and COVID-19 infection rates were not significantly different between the two groups.
Conclusions: Bariatric surgery during the COVID-19 pandemic is associated with a higher complication rate in those ≥ 65 years of age compared to those < 65 years old. However, the mortality and postoperative COVID-19 infection rates are not significantly different between the two groups.
Keywords: Metabolic surgery; Obesity; Older patients; Resuming elective surgery; SARS-CoV-2.

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WUTH publication: Alterations of mucosa-attached microbiome and epithelial cell numbers in the cystic fibrosis small intestine with implications for intestinal disease

Citation: Scientific Reports. 2022, 12(1), 6593
Author: Jennifer Kelly, Miran Al-Rammahi, Kristian Daly, Paul K Flanagan, Arun Urs, Marta C Cohen, Gabriella di Stefano, Marcel J C Bijvelds, David N Sheppard, Hugo R de Jonge, Ursula E Seidler, Soraya P Shirazi-Beechey
Abstract: Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Defective CFTR leads to accumulation of dehydrated viscous mucus within the small intestine, luminal acidification and altered intestinal motility, resulting in blockage. These changes promote gut microbial dysbiosis, adversely influencing the normal proliferation and differentiation of intestinal epithelial cells. Using Illumina 16S rRNA gene sequencing and immunohistochemistry, we assessed changes in mucosa-attached microbiome and epithelial cell profile in the small intestine of CF mice and a CF patient compared to wild-type mice and non-CF humans. We found increased abundance of pro-inflammatory Escherichia and depletion of beneficial secondary bile-acid producing bacteria in the ileal mucosa-attached microbiome of CFTR-null mice. The ileal mucosa in a CF patient was dominated by a non-aeruginosa Pseudomonas species and lacked numerous beneficial anti-inflammatory and short-chain fatty acid-producing bacteria. In the ileum of both CF mice and a CF patient, the number of absorptive enterocytes, Paneth and glucagon-like peptide 1 and 2 secreting L-type enteroendocrine cells were decreased, whereas stem and goblet cell numbers were increased. These changes in mucosa-attached microbiome and epithelial cell profile suggest that microbiota-host interactions may contribute to intestinal CF disease development with implications for therapy.

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WUTH publication: An Uncommon Presentation of Fracture-dislocation of the 4th and 5th Carpometacarpal Joints with Volar Displacement and its Management

Citation: Journal of Orthopaedic Case Reports. 2021, 11(9), 24-28
Author: Nikhil Jawaharlal, Vasanthakumar Ramsingh, Vijaya Bhalaik 
Abstract: Introduction: Carpo-metacarpal joint fracture-dislocations are rare injuries. They constitute less than 1% of all hand injuries [1]. They often go unnoticed [2]. Of these, dorsal fracture-dislocations on the ulnar side are more commonly seen [3] because of the greater stabilizing dorsal structures. Volar fracture-dislocations are very rare and difficult to diagnose for which, one should have a keen eye on.
Case report: This is a case of a 51-year-old female with a closed injury to her wrist. With clinical suspicion and appropriate radiographs fracture-dislocation of the 4th and 5th carpometacarpal joints with volar displacement was diagnosed. She underwent closed reduction and percutaneous Kirschner wire fixation, followed by 6 weeks of immobilization. At the final follow-up in 4 months, the patient was noted to have a satisfactory outcome following intense physiotherapy.
Conclusion: Fourth and fifth carpometacarpal joint fracture-dislocations of the fingers are unique; their diagnosis can be challenging and often overlooked [4], which if missed can have very poor outcomes. The functional prognosis depends on the precocity of diagnosis and appropriate reduction and vigorous rehabilitation.
Keywords: Carpometacarpal joint; fracture-dislocation; volar displacement; wrist injury.

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WUTH publication: Subspecialist abdominal wall reconstruction services in Canada

Citation: Canadian Journal of Surgery. 2022, 65(2), E264-E265
Author: Simon T Adams, Michael Harington 
Abstract: SummaryRecent years have seen considerable increases in both the demand for, and complexity of, ventral hernia repairs. This has led to calls for abdominal wall surgery to become a recognized subspecialty in the United States and Europe, with some centres responding by forming specialized, multidisciplinary teams for abdominal wall reconstruction. At present, however, no Canadian city has followed suit. In this article, we outline the major arguments underlying the drive toward the centralization of complex abdominal wall services. 

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WUTH publication: The British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

Citation: The bone & joint journal. 2022, 104-B(4), 510-18 
Author: Daniel C Perry, Barbara Arch, Duncan Appelbe, Priya Francis, Joanna Craven, Fergal P Monsell, Paula Williamson, Marian Knight, BOSS collaborators 
Abstract: Aims: The aim of this study was to evaluate the epidemiology and treatment of Perthes' disease of the hip.
Methods: This was an anonymized comprehensive cohort study of Perthes' disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children's hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.
Results: Overall, 371 children (396 hips) were newly affected by Perthes' disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years.
Conclusion: Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510-518.
Keywords: Avascular necrosis; BOSS; Cohort; Epidemiology; Incidence; Legg-Calvé-Perthes; Legg-calve-perthes disease; Osteonecrosis; Patient-reported outcome measures (PROMs); Perthes; clinicians; cohort studies; epidemiology; hip disease; hips; orthopaedic surgery; radiological outcomes; randomized controlled trials. 

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WUTH publication: The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain

Citation: The bone & joint journal. 2022, 104-B(4), 519-28 
Author: Daniel C Perry, Barbara Arch, Duncan Appelbe, Priya Francis, Joanna Craven, Fergal P Monsell, Paula Williamson, Marian Knight, BOSS collaborators 
Abstract: Aims: The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE).
Methods: This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.
Results: A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define 'at risk'. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE.
Conclusion: The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519-528.
Keywords: Avascular necrosis; BOSS; Cohort study; Epidemiology; Incidence; Patient-reported outcome measures (PROMs); SCFE; SUFE; Slipped capital femoral epiphysis; Slipped capital femoral epiphysis (SCFE); Slipped upper femoral epiphysis; avascular necrosis; clinicians; deformity; hip(s); open reduction and internal fixation; orthopaedic surgery; prophylactic fixation; randomized controlled trials. 

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WUTH publication: Which outcomes should be used in future bronchiolitis trials? Developing a bronchiolitis core outcome set using a systematic review, Delphi survey and a consensus workshop

Citation: BMJ Open. 2022, 12(3), e052943 
Author: A Rosala-Hallas, Ashley P Jones, Paula R Williamson, Emma Bedson, Vanessa Compton, Ricardo M Fernandes, David Lacy, Mark David Lyttle, Matthew Peak, Kentigern Thorburn, Kerry Woolfall, Clare Van Miert, Paul S McNamara 
Abstract: Objectives: The objective of this study was to develop a core outcome set (COS) for use in future clinical trials in bronchiolitis. We wanted to find out which outcomes are important to healthcare professionals (HCPs) and to parents and which outcomes should be prioritised for use in future clinical trials.
Design and setting: The study used a systematic review, workshops and interviews, a Delphi survey and a final consensus workshop.
Results: Thirteen parents and 45 HCPs took part in 5 workshops; 15 other parents were also separately interviewed. Fifty-six items were identified from the systematic review, workshops and interviews. Rounds one and two of the Delphi survey involved 299 and 194 participants, respectively. Sixteen outcomes met the criteria for inclusion within the COS. The consensus meeting was attended by 10 participants, with representation from all three stakeholder groups. Nine outcomes were added, totalling 25 outcomes to be included in the COS.
Conclusion: We have developed the first parent and HCP consensus on a COS for bronchiolitis in a hospital setting. The use of this COS will ensure outcomes in future bronchiolitis trials are important and relevant, and will enable the trial results to be compared and combined.
Trial registration number: ISRCTN75766048.
Keywords: bronchiolitis; core outcome sets; paediatrics. 

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WUTH publication: Is There a Role for Antifungal Prophylaxis in Patients Undergoing Penile Prosthesis Surgery? A Systematic Review

Citation: Urologia Internationalis. 2022, 1-7. Online ahead of print.  
Author: Zain Siddiqui, Ian Pearce, Vaibhav Modgil
Abstract: Objective: The aim of this study is to review the literature on the use of antifungal prophylaxis in penile prosthesis (PP) surgery and provide a summary on its efficacy as an adjunct to current prophylactic regimes in patients undergoing PP surgery.
Materials and methods: PubMed, Medline, and EMBASE databases were systematically searched up to May 2020. All included studies were analysed and the information extracted included author, title of study, year of publication, type of study, journal of publication, and main findings regarding post PP implantation fungal infections.
Results: Nine relevant studies were included in this review, comprising retrospective single-centre studies and retrospective multicentre studies ranging from 2017 to 2020. Fungal infections were found responsible for 11.1% of all PP infections, with a greater risk in patients with diabetes, obesity, and from warmer climates. Current American Urological Association (AUA) and European Association of Urology (EAU) prophylaxis guidelines do not incorporate the use of antifungals. Trials of antifungal prophylaxis regimes combined with antibiotic prophylaxis have demonstrated a reduction in PP fungal infections.
Conclusions: Fungal infections represent a significant proportion of implant infections and therefore antifungal prophylaxis is warranted. Future studies comparing the efficacy of traditional antibiotic prophylaxis as set out by AUA/EAU with novel prophylaxis regimes including the addition of an antifungal may provide more definitive guidance on this issue. Until then antifungal prophylaxis in all patients undergoing PP procedures may provide a significant cost-effect benefit.
Keywords: Candida; Fungal; Infection; Penile prosthesis; Prophylaxis.

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World Book Day

Happy world book day from everyone in McArdle Library!

Today above all days we welcome you to come into the library and experience our extensive fiction collection in our read and relax section!

WUTH publication: Negative Appendicectomy Rate: Incidence and Predictors

Citation: Cureus. 2022, 14(1), e21489. eCollection 2022 Jan.
Author: Khaled Noureldin, Ali Asgar Hatim Ali, Mohamed Issa, Heer Shah, Bolu Ayantunde, Abraham Ayantunde 
Abstract: Introduction Acute appendicitis is a common emergency surgical presentation. The gold standard treatment is surgery. Like any surgical procedure, appendicectomy is associated with complications. Negative appendicectomy (NA) can occur, and its incidence is 15%-39%. This study aimed to evaluate the rate and predictors of NA in a cohort. Patients and methods A retrospective study over a year through which data of patients who underwent emergency appendicectomies were collected and analyzed. The absence of inflammatory process and/or other significant pathology in the appendix was considered negative for appendicitis. An utter definition of NA was the absence of inflammatory cells in the appendix. The NA rate (NAR) was calculated using the standard criteria (NAR-SDC) and the strict criteria (NAR-STC). The routine laboratory parameters for diagnosing acute appendicitis on admission were collected. Increased inflammatory markers in the form of leucocytosis of total WBC > 11,000 per mm, elevated CPR > 5 mg/L, and isolated elevated total serum bilirubin > 20 µmol/L, were suggestive of acute appendicitis. Results Three hundred and seventy-two patients were included, 179 males and 193 females with a median age were 27 (5-94) years. The median duration of symptoms and waiting time to surgery were two days and one day, respectively. The mean admission WBC, C-reactive protein (CRP) and serum bilirubin levels were 12,600 (3,000-38,000)/mm3, 66.9 (1-323) mg/L and 12.7 (4-38) µmol/L respectively. Laparoscopic appendicectomy was performed in 93.5% of patients with a conversion rate of 4.6%. NAR-SDC was 10.2% and NAR-STC was 25.8%. NAR was significantly higher in females than males (39.4% versus 11.1%; p-value 0.0001). Patients with NA were younger (p-value 0.0001), had lower mean total WBC (p-value 0.014), CRP (p-value 0.0001) and total serum bilirubin (p-value 0.0001) levels on admission. Conclusion NA is still a major problem in the management of patients with acute right lower abdominal pain. Our NAR compared favourably with reported rates. Female gender, duration of symptoms more than three days, and lower total WBC were independent predictors of NA.
Keywords: emergency appendicectomy; incidence of negative appendicitis; negative appendicectomy; outcome of appendicectomy; pain right iliac fossa; predictors of negative appendicectomy. 

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WUTH publication: Development, implementation and evaluation of an early warning system improvement programme for children in hospital: the PUMA mixed-methods study

Citation: Health and Social Care Delivery Research. 2022
Author: Davina Allen, Amy Lloyd, Dawn Edwards, Aimee Grant, Kerenza Hood, Chao Huang, Jacqueline Hughes, Nina Jacob, David Lacy, Yvonne Moriarty, Alison Oliver, Jennifer Preston, Gerri Sefton, Richard Skone, Heather Strange, Khadijeh Taiyari, Emma Thomas-Jones, Robert Trubey, Lyvonne Tume, Colin Powell, Damian Roland 
Abstract: Background: The Paediatric early warning system Utilisation and Morbidity Avoidance (PUMA) study was commissioned to develop, implement and evaluate a paediatric track-and-trigger tool for widespread adoption. Following findings from three systematic reviews, revised aims focused on implementation of a whole-systems improvement programme.
Objectives: (1) Identify, through systematic review, the following: evidence for core components of effective paediatric track-and-trigger tools and paediatric early warning systems, and contextual factors consequential for paediatric track-and-trigger tool and early warning system effectiveness. (2) Develop and implement an evidence-based paediatric early warning system improvement programme (i.e. the PUMA programme). (3) Evaluate the effectiveness of the PUMA programme by examining clinical practice and core outcomes trends. (4) Identify ingredients of successful implementation of the PUMA programme.
Review methods: The quantitative reviews addressed the following two questions: how well validated are existing paediatric track-and-trigger tools and their component parts for predicting inpatient deterioration? How effective are paediatric early warning systems (with or without a tool) at reducing mortality and critical events? The qualitative review addressed the following question: what sociomaterial and contextual factors are associated with successful or unsuccessful paediatric early warning systems (with or without tools)?
Design: Interrupted time series and ethnographic case studies were used to evaluate the PUMA programme. Qualitative methods were deployed in a process evaluation.
Setting: The study was set in two district general and two tertiary children’s hospitals.
Intervention: The PUMA programme is a paediatric early warning system improvement programme designed to harness local expertise to implement contextually appropriate interventions.
Main outcome measures: The primary outcome was a composite metric, representing children who experienced one of the following in 1 month: mortality, cardiac arrest, respiratory arrest, unplanned admission to a paediatric intensive care unit or unplanned admission to a high-dependency unit. Paediatric early warning system changes were assessed through ethnographic ward case studies.
Results: The reviews showed limited effectiveness of paediatric track-and-trigger tools in isolation, and multiple failure points in paediatric early warning systems. All sites made paediatric early warning system changes; some of the clearer quantitative findings appeared to relate to qualitative observations. Systems changed in response to wider contextual factors.
Limitations: Low event rates made quantitative outcome measures challenging. Implementation was not a one-shot event, creating challenges for the interrupted time series in conceptualising ‘implementation’ and ‘post-intervention’ periods.
Conclusions: Detecting and acting on deterioration in the acute hospital setting requires a whole-systems approach. The PUMA programme offers a framework to support ongoing system-improvement work; the approach could be used more widely. Organisational-level system change can affect clinical outcomes positively. Alternative outcome measures are required for research and quality improvement.
Future work: The following further research is recommended: a consensus study to identify upstream indicators of paediatric early warning system performance; an evaluation of OUTCOME approach in other clinical areas; an evaluation of supernumerary nurse co-ordinator role; and an evaluation of mandated system improvement.
Study registration: This study is registered as PROSPERO CRD42015015326.
Funding: This project was funded by the National Institute for Health Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information. 

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WUTH publication: Gaps in the Care of Open Fractures: An Indian Scenario

Citation: Indian Journal of Orthopaedics. 2021, 56(2), 280-88. eCollection 2022 Feb
Author: Rohit Jindal, Mehar Dhillon, Naveen Mittal, Arushi Aggarwal, Anubhav Malhotra, Sudhir Kumar Garg 
Abstract: Background/purpose: There is a distinct lack of published studies evaluating the reasons for delay in definitive treatment of open fractures. This study aimed to determine the specific factors causing delay in the timely treatment of open fractures from the time of injury and to analyse the quality of treatment performed at the pre-hospital level.
Methods: In total, 250 consecutive patients with open fractures were assessed for time to surgery from injury and admission. The referred patients were analysed for distance of travel, level of referring hospital and appropriateness of care. The reasons for delay in terms of infrastructural- and patient-related factors were analysed individually and in combination.
Results: There were 37 direct patients (Group A) and 213 referred patients (Group B). Inappropriate care was present in 172 out of 213 (80.8%) referred patients. In total, 84% patients travelled more than 50 kms. The definitive surgery in referred patients was likely to be significantly delayed with regard to time from injury (29.84 vs 44.84 h, p ≤ 0.02). After admission, the time to surgery was greater than 24 h in 102 patients. Multivariate regression analysis determined that associated injuries and lack of fitness for surgery caused greater delay than non-availability of operation theatre or intensive care unit bed.
Conclusion: Delayed referral, inadequate pre-hospital care and delay in surgery due to patient- and infrastructural-related issues at tertiary centre were identified as critical gaps in open fracture care in India. The importance of appropriate basic knowledge about management of open fractures should be emphasized at all structural level of care.
Keywords: Delay (> 24 h) in management; Open fractures; Pre-hospital care; Referral network. 

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WUTH publication: Skin Graft Versus Local Flaps in Management of Post-burn Elbow Contracture

Citation: Cureus. 2021, 13(12), e20768. eCollection 2021 Dec
Author: Mohamed Issa, Marwa Badawi, George Bisheet, Mahmoud Makram, Abdelhamed Elgadi, Ayyat Abdelaziz, Khaled Noureldin 
Abstract: Introduction Contracture is a pathological scar tissue resulting from local skin tissue damage, secondary to different local factors. It can restrict joint mobility, resulting in deformity and disability. This study aimed to investigate the outcomes of skin grafts compared to local flaps to reconstruct post-burn elbow contractures. These parameters included regaining function, range of movement, recurrence, and local wound complications. Methodology A retrospective study reviewed 21 patients for elbow reconstruction over 12 months. Only patients with post-burn elbow contracture were included. Other causes, including previous corrective surgery, associated elbow stiffness, and patients who opted out of post-operative physiotherapy, were excluded. Patients were categorized according to the method of coverage into three groups: graft alone (G1), local flap (G2), or combined approach (G3). Results Females were three times at higher risk to suffer a burn injury, while almost half of the cases were children. Scald injury represented 81% of burn causes. G1,2,3 were used in 47.6%, 42.9% and 9.5% of cases retrospectively. The overall rate of infection was 28.6%. Hundred percent graft taken was recorded in 83.3 % of cases; however, flap take was 91.1%. After 12 months of follow-up, re-contracture was 60% and 22.8% in G1 and G2; however, the satisfaction rate was 70% and 100% in both groups retrospectively. The overall satisfaction was 85.7% in all groups. Conclusion Grafts and local flaps are reasonable options for post contracture release; however, flaps are superior. Coverage selection depends on the lost tissue area and exposure of underlying deep structures. Physiotherapy and patient satisfaction are crucial in the outcomes.
Keywords: burn injury; contracture release; elbow contracture; flaps and grafts; physiotherapy; postburn contracture; split-thickness skin graft (stsg). 

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WUTH publication: Evaluation of the Sublay Mesh Repair Outcomes in Different Types of Ventral Hernia

Citation: Cureus. 2021, 13(12), e20590. eCollection 2021 Dec
Author: Mohamed Issa, Khaled Noureldin, Abdelhamed Elgadi, Ayyat Abdelaziz, Marwa Badawi, Mahmoud Makram 
Abstract: Introduction: Ventral hernia repair is one of the challenging surgical operations over time. Several surgical techniques for mesh repair have been described (onlay, inlay, sublay, and underlay repairs). It is suggested that sublay mesh repair has the lowest recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyze the pros and cons of the sublay mesh in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Hospital stay, acute postoperative complications, and the recurrence rate were the main areas of investigation.
Methods: A retrospective study on 79 patients with ventral hernias who were operated on with sublay mesh repair between January 2015 and December 2018 was conducted. Patients were admitted through the elective route. The study included fit patients with first-time ventral hernias (primary and incisional). Recurrent hernia, patients with decompensated cardiopulmonary disorders, and bleeding disorders were excluded from the project. The project pro forma includes patient's demographics, operative details, length of stay, postoperative complications, and follow-up up to 12 months.
Results: All patients underwent open mesh repair using the sublay technique. The ventral hernia was five times more common in females than males. The mean age of presentation was 44.8 years old. The mean operating time was 67 minutes and a one-day hospital stay. Paraumblical and incisional hernias represented the majority of cases. The component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in two cases (2.5%). Only six cases (6.3%) developed wound-related complications, while two cases (2.5%) had a recurrence.
Conclusion: The sublay mesh repair is a perfect choice for the repair of ventral abdominal hernia. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.
Keywords: abdomen ventral hernia; component separation technique; incisional ventral hernia; mesh repair; postoperative complications; recurrence rate; sublay meshplasty. 

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WUTH publication: Clinical Characteristics of COVID-19 Patients in a Regional Population With Diabetes Mellitus: The ACCREDIT Study

Citation: Frontiers in endocrinology. 2022 Jan 13. eCollection 2021
Author: Daniel Kevin Llanera, Rebekah Wilmington, Haika Shoo, Paulo Lisboa, Ian Jarman, Stephanie Wong, Jael Nizza, Dushyant Sharma, Dhanya Kalathil, Surya Rajeev, Scott Williams, Rahul Yadav, Zubair Qureshi, Ram Prakash Narayanan, Niall Furlong, Sam Westall, Sunil Nair 
Abstract: Objective: To identify clinical and biochemical characteristics associated with 7- & 30-day mortality and intensive care admission amongst diabetes patients admitted with COVID-19.
Research design and methods: We conducted a cohort study collecting data from medical notes of hospitalised people with diabetes and COVID-19 in 7 hospitals within the Mersey-Cheshire region from 1 January to 30 June 2020. We also explored the impact on inpatient diabetes team resources. Univariate and multivariate logistic regression analyses were performed and optimised by splitting the dataset into a training, test, and validation sets, developing a robust predictive model for the primary outcome.
Results: We analyzed data from 1004 diabetes patients (mean age 74.1 (± 12.6) years, predominantly men 60.7%). 45% belonged to the most deprived population quintile in the UK. Median BMI was 27.6 (IQR 23.9-32.4) kg/m2. The primary outcome (7-day mortality) occurred in 24%, increasing to 33% by day 30. Approximately one in ten patients required insulin infusion (9.8%). In univariate analyses, patients with type 2 diabetes had a higher risk of 7-day mortality [p < 0.05, OR 2.52 (1.06, 5.98)]. Patients requiring insulin infusion had a lower risk of death [p = 0.02, OR 0.5 (0.28, 0.9)]. CKD in younger patients (<70 years) had a greater risk of death [OR 2.74 (1.31-5.76)]. BMI, microvascular and macrovascular complications, HbA1c, and random non-fasting blood glucose on admission were not associated with mortality. On multivariate analysis, CRP and age remained associated with the primary outcome [OR 3.44 (2.17, 5.44)] allowing for a validated predictive model for death by day 7.
Conclusions: Higher CRP and advanced age were associated with and predictive of death by day 7. However, BMI, presence of diabetes complications, and glycaemic control were not. A high proportion of these patients required insulin infusion warranting increased input from the inpatient diabetes teams.
Keywords: COVID-19; CRP; diabetes; mortality; observational study; risk factors. 

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WUTH publication: Nutritional Complications After Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: A Comparative Systematic Review and Meta-Analysis

Citation: Cureus. 2022, 14(1), e21114. eCollection 2022 Jan
Author: Mohamed Tourky, Mohamed Issa, Mohamed A Salman, Ahmed Salman, Hossam El-Din Shaaban, Ahmed Safina, Abd Al-Kareem Elias, Ahmed Elewa, Khaled Noureldin, Ahmed Abdelrahman Mahmoud, Ahmed Dorra, Mohamed Farah, Mahmoud Gebril, Mujahid Gasemelseed Fadlallah Elhaj, Hesham Barbary
Abstract: A systematic review and meta-analysis were carried out involving studies that compared the nutritional complications of Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB); these included the incidence of malnutrition as well as deficiencies of other nutritional elements, such as total protein, albumin, calcium and iron. A comprehensive search strategy was implemented in PubMed, Embase, and the Cochrane Library. Effect sizes included the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs), as well as mean differences (MDs) and 95% CIs of the percentage total weight loss (%TWL) and excess weight loss percentage (%EWL). Thirteen studies were included (12,964 patients, 66.27% females, 53.82% underwent OAGB). At the longest follow-up period (≥3 years), OAGB was associated with significantly higher %TWL (MD=5.41%, 95%CI, 1.52 to 9.29) and %EWL (MD=13.81%, 95%CI, 9.60 to 18.02) compared to RYGB. However, OAGB procedures were associated with malnutrition (OR=3.00, 95%CI, 1.68 to 5.36, p<0.0001), hypoalbuminemia (OR=2.38, 95%CI, 1.65 to 3.43, p<0.0001), hypoproteinemia (OR=1.85, 95%CI, 1.09 to 3.14, p=0.022), anemia (OR=1.38, 95%CI, 1.08 to 1.77, p=0.011), and hypocalcemia (OR=1.78, 95%CI, 1.01 to 3.12, p=0.046). On subgroup analyses, the proportions of anemia and hypoalbuminemia remained significantly higher at longer follow-up periods and in studies published in Asia. Despite the favorable weight loss profile, the unfavorable nutritional consequences of OAGB merits further investigations to explore the malabsorptive element, ethnic variation, and the role of biliopancreatic limb length. 

Keywords: comparative; gastric bypass; hypoalbuminemia; malnutrition; one-anastomosis gastric bypass; roux-en-y. 

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WUTH publication: Physical activity recommendations pre and post abdominal wall reconstruction: a scoping review of the evidence

Citation: Hernia. 2022 Jan 13. Online ahead of print
Author: S T Adams, N H Bedwani, L H Massey, A Bhargava, C Byrne, K K Jensen, N J Smart, C J Walsh 
Abstract: Purpose: There are no universally agreed guidelines regarding which types of physical activity are safe and/or recommended in the perioperative period for patients undergoing ventral hernia repair or abdominal wall reconstruction (AWR). This study is intended to identify and summarise the literature on this topic.
Methods: Database searches of PubMed, CINAHL, Allied & Complementary medicine database, PEDro and Web of Science were performed followed by a snowballing search using two papers identified by the database search and four hand-selected papers of the authors' choosing. Inclusion-cohort studies, randomized controlled trials, prospective or retrospective. Studies concerning complex incisional hernia repairs and AWRs including a "prehabilitation" and/or "rehabilitation" program targeting the abdominal wall muscles in which the interventions were of a physical exercise nature. RoB2 and Robins-I were used to assess risk of bias. Prospero CRD42021236745. No external funding. Data from the included studies were extracted using a table based on the Cochrane Consumers and Communication Review Group's data extraction template.
Results: The database search yielded 5423 records. After screening two titles were selected for inclusion in our study. The snowballing search identified 49 records. After screening one title was selected for inclusion in our study. Three total papers were included-two randomised studies and one cohort study (combined 423 patients). All three studies subjected their patients to varying types of physical activity preoperatively, one study also prescribed these activities postoperatively. The outcomes differed between the studies therefore meta-analysis was impossible-two studies measured hernia recurrence, one measured peak torque. All three studies showed improved outcomes in their study groups compared to controls however significant methodological flaws and confounding factors existed in all three studies. No adverse events were reported.
Conclusions: The literature supporting the advice given to patients regarding recommended physical activity levels in the perioperative period for AWR patients is sparse. Further research is urgently required on this subject.
Keywords: Abdominal wall; Activity; Exercise; Hernia; Perioperative. 

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WUTH publication: The influence of intraoperative rectal washout on local recurrence of colorectal cancer following curative resection: a systematic review and meta-analysis

Citation: International Journal of Colorectal Disease. 2022 Jan 11. Online ahead of print
Author: Josh Solomon, Talal Majeed, Conor Magee, Jeremy Wilson 
Abstract: Purpose: To determine the effectiveness of rectal washout in preventing local recurrence of distal colorectal cancer following curative resection.
Methods: A systematic review and meta-analysis was performed after a literature search was conducted on MEDLINE, EMBASE, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the ISRCTN registry. The study was reported using PRISMA guidelines. The primary endpoint was incidence of local recurrence of cancer after distal colonic and rectal cancer surgery.
Results: After screening, 8 studies with a total sample size of 6739 patients were identified. At 5-year follow-up, local recurrence in the washout group (WO) was 6.08% compared to 9.48% in the no-washout group (NWO) group (OR 0.63, 95% CI = 0.51-0.78, Chi2 = 6.76, df = 7, p = 0.45). The relative risk reduction was 36.9%. To exclude a 36.9% relative risk reduction from 9.48 to 6.08% with a 5% significance level and 80% power a randomized control trial would require a total sample size of 1946 participants distributed equally between the two treatment arms.
Conclusion: It is safe to recommend the use of rectal washout for left sided and rectal tumour resections. It is a simple and safe step during colorectal surgery that appears to improve long-term oncological outcomes and was not reported to be associated with any complications.
Keywords: Colorectal cancer; Lavage; Local recurrence; Rectal tumour; Rectal washout; Washout. 

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WUTH publication: Reading a preoperative CT scan to guide complex abdominal wall reconstructive surgery

Citation: Hernia: the journal of hernias and abdominal wall surgery. 2022 Jan 5. Online ahead of print
Author: S T Adams, D Slade, P Shuttleworth, C West, M Scott, A Benson, A Tokala, C J Walsh 
Abstract: Computed tomography (CT) scanning is the imaging modality of choice when planning the overall management and operative approach to complex abdominal wall hernias. Despite its availability and well-recognised benefits there are no guidelines or recommendations regarding how best to read or report such scans for this application. In this paper we aim to outline an approach to interpreting preoperative CT scans in abdominal wall reconstruction (AWR). This approach breaks up the interpretive process into 4 steps-concentrating on the hernia or hernias, any complicating features of the hernia(s), the surrounding soft tissues and the abdominopelvic cavity as a whole-and was developed as a distillation of the authors' collective experience. We describe the key features that should be looked for at each of the four steps and the rationale for their inclusion.
Keywords: Abdominal wall reconstruction; Computed tomography; Imaging; Incisional hernia; Ventral hernia. 

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WUTH publication: Development, implementation and evaluation of an evidence-based paediatric early warning system improvement programme: the PUMA mixed methods study

Citation: BMC health sciences research. 2022, 22(1), 9
Author: Davina Allen, Amy Lloyd, Dawn Edwards, Kerenza Hood, Chao Huang, Jacqueline Hughes, Nina Jacob, David Lacy, Yvonne Moriarty, Alison Oliver, Jennifer Preston, Gerri Sefton, Ian Sinha, Richard Skone, Heather Strange, Khadijeh Taiyari, Emma Thomas-Jones, Rob Trubey, Lyvonne Tume, Colin Powell, Damian Roland
Abstract: Background: Paediatric mortality rates in the United Kingdom are amongst the highest in Europe. Clinically missed deterioration is a contributory factor. Evidence to support any single intervention to address this problem is limited, but a cumulative body of research highlights the need for a systems approach.
Methods: An evidence-based, theoretically informed, paediatric early warning system improvement programme (PUMA Programme) was developed and implemented in two general hospitals (no onsite Paediatric Intensive Care Unit) and two tertiary hospitals (with onsite Paediatric Intensive Care Unit) in the United Kingdom. Designed to harness local expertise to implement contextually appropriate improvement initiatives, the PUMA Programme includes a propositional model of a paediatric early warning system, system assessment tools, guidance to support improvement initiatives and structured facilitation and support. Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome was a composite metric (adverse events), representing the number of children monthly that experienced one of the following: mortality, cardiac arrest, respiratory arrest, unplanned admission to Paediatric Intensive Care Unit, or unplanned admission to Higher Dependency Unit. System changes were assessed qualitatively through observations of clinical practice and interviews with staff and parents. A qualitative evaluation of implementation processes was undertaken.
Results: All sites assessed their paediatric early warning systems and identified areas for improvement. All made contextually appropriate system changes, despite implementation challenges. There was a decline in the adverse event rate trend in three sites; in one site where system wide changes were organisationally supported, the decline was significant (ß = -0.09 (95% CI: - 0.15, - 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes.
Conclusions: System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations.
Keywords: Healthcare improvement; Paediatric early warning systems; Quality improvement. 

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