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.
Monday, 28 February 2022
WUTH publication: Negative Appendicectomy Rate: Incidence and Predictors
Friday, 18 February 2022
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.
Monday, 14 February 2022
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.
Friday, 4 February 2022
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).
Thursday, 3 February 2022
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.
Monday, 31 January 2022
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.
Thursday, 20 January 2022
WUTH publication: Nutritional Complications After Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: A Comparative Systematic Review and Meta-Analysis
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.
Friday, 14 January 2022
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.
Wednesday, 12 January 2022
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.
Friday, 7 January 2022
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.