Recent Submissions

  • Torus fractures - diagnosis and management

    Tahir, Abdullah; Naji, Omar; Khawar, Haseeb; Iqbal, Mohammad Jawaid; Iqbal, Mohammad Jawaid; Trauma and Orthopaedics; Medical and Dental; John Radcliffe Hospital; Royal Berkshire NHS Foundation Trust; Royal Cornwall Hospitals NHS Trust; Walsall Healthcare NHS Trust (MA Healthcare, 2024-05-24)
    Torus fractures are a common paediatric injury involving the distal radius. Patients typically present following a fall onto the outstretched hand, with wrist pain as their primary complaint. The principal investigation of choice is a plain radiograph of the wrist joint. These fractures should be managed with a soft-bandage and immediate discharge approach and do not require specialist follow-up. Clinicians have historically had differing views regarding optimal management of torus fractures. It is therefore important for hospital clinicians to uniformly understand the most up-to-date management of this condition. This review provides an overview of the epidemiology, anatomy, diagnosis and management, with an aim to improve outcomes.
  • Do hypoalbuminaemia increase the risk of surgical site infection in neck of femur fracture patients : a systematic review and meta-analysis

    Mostafa, Omar E; Al-Allaf, Omar; Tahir, Muaaz; Hossain, Fahad; Blackwell, John; Hossain, Fahad; Blackwell, John; Trauma and Orthopaedics; Medical and Dental; The Dudley Group NHS Foundation Trust; Walsall Healthcare NHS Trust; The Royal Orthopaedic Hospital NHS Foundation Trust (Springer, 2024-05-30)
    Serum albumin plays an important role in physiological and inflammatory haemostasis, and low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in the spine and elective arthroplasty settings, there is a paucity of evidence with regard to the effect of low serum albumin on rates of SSI following surgery for adult patients suffering from traumatic and acute hip fractures. A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials (RCTs), cohort studies, and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web software. Results were reported as odds ratios (OR) with 95% confidence intervals (CI) and statistical significance of p <0.05. An inverse variance model was used in the meta-analysis. Six retrospective studies (five cohorts and one case-control) with a total of 43,059 patients were included. 45.3% (n=19 496) had low serum albumin (<3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, although one study reported this with poor statistical significance (OR 8.74, p<0.054). Hypoalbuminemia increases the risk of most forms of surgical site infections, both superficial and deep. There is a weak conclusion to draw between the incidence of deep-space organ infections and low serum albumin.
  • Blood, sweat and tonsils : bleeding after abscess tonsillectomy for quinsy - a meta-analysis

    Mughal, Zahir; Gupta, Keshav Kumar; Yeo, Justin Jui Yuan; Metcalfe, Christopher; Weller, Matthew; Mughal, Zahir; Gupta, Keshav Kumar; Yeo, Justin Jui Yuan; Weller, Matthew; Ear, Nose and Throat; et al. (Wiley, 2024-04-13)
    Objective: Abscess tonsillectomy is performed during an active episode of quinsy. Apprehensions regarding an elevated bleeding risk have hindered its widespread acceptance. This study aims to assess the prevalence of post-tonsillectomy bleeding (PTB) associated with abscess tonsillectomy. Data sources: A search was performed on August 27, 2023 in Medline, Embase, PubMed, Cochrane CENTRAL, and Web of Science databases. Review methods: The systematic review was conducted in adherence to the PRISMA guidelines. Pooled PTB rate was determined using a meta-analysis of proportions. The JBI tool was used to assess the quality of the included studies. Results: Of the 525 search records, 18 studies met the eligibility criteria for final analysis. These comprised of retrospective single-center analyses. The pooled prevalence of PTB was 6.65% (95% C.I. 4.01-9.81), and the return-to-theatre rate was 2.35% (95% C.I. 1.48-3.37). There was no difference in PTB rate between unilateral and bilateral tonsillectomy. However, the bipolar technique was associated with a higher PTB rate compared to cold steel dissection. The overall quality of the body of evidence was moderate. Conclusion: Our study highlights the complications associated with abscess tonsillectomy. These findings contribute valuable insights into this potential treatment option for quinsy.
  • Testing for t(3;8) in MYC/BCL6 re-arranged large B cell lymphoma identifies a high risk subgroup with inferior survival

    Maybury, Bernard Douglas; James, Lisa Jane; Phillips, Neil; Venkatadasari, Indrani; Qureshi, Iman; Riley, James William Elliot; Talbot, Georgina; Moosai, Shivir; Giles, Hannah Victoria; Chadderton, Nicola; et al. (American Society of Hematology, 2024-04-22)
    A reciprocal t(3;8) BCL6::MYC fusion is common in large B cell lymphoma (LBCL) with MYC and BCL6 disruption. These pseudo-double hit cases are not adverse, whereas t(3;8) negative MYC/BCL6 lymphoma has an inferior prognosis relative to other MYC-rearranged LBCL.
  • The impact of obesity on reflux recurrence following Laparoscopic anti-reflux surgery : an evidence-based systematic review and meta-analysis

    Nadeem, Faisal; Singh, Ananya; Karim, Muhammad; Khan, Amir; Mirza, Salman; Kabir, Syed A; Nadeem, Faisal; Singh, Ananya; Karim, Muhammad; Khan, Amir; et al. (Springer, 2024-03-26)
    Gastroesophageal reflux disease (GERD) is frequently seen in the Western population. Laparoscopic anti-reflux surgery (LARS) is effective in managing this condition. Obesity is strongly associated with GERD, and with the rising rate of obesity, there is, therefore, a concurrently increasing frequency of LARS performed. We aim to review the outcomes of LARS in patients with obesity, including the recurrence of GERD symptoms and peri-operative complications. A systematic review and meta-analysis were performed for articles from June 1992 to June 2022. The literature was reviewed for outcomes of LARS in patients with obesity (BMI≥30). Eligibility criteria included specific BMI, study design, type of surgery, and outcomes. The recurrence of symptoms and peri-operative complications were assessed. Thirty-one studies were thoroughly reviewed. Nine studies (five retrospective and four prospective) were selected for meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow, which included 1,499 patients with obesity and 5,521 without. Laparoscopic Nissen fundoplication was the most common procedure performed. The recurrence of symptoms was significantly lower in patients without obesity (p=0.0001). There was no statistically significant difference between patients with and without obesity in peri-operative complications, re-intervention, and early return to theatres. A higher recurrence rate of GERD symptoms post-LARS was reported in patients with obesity. Further research is required to decrease such risks and propose different methods, such as weight loss prior to surgery or Roux-en-Y (R&Y) gastric bypass. Risks and benefits should be considered by clinicians prior to offering LARS to patients with obesity.
  • Laparoscopic cholecystectomy performed by a surgical care practitioner : a review of outcomes

    Odogwu, S; Morris, S; Addison, S; Abbott, S; Addison, Sarah; Odogwu, S; Morris, S; Abbott, S; Colorectal Surgery; Medical and Dental (Royal College of Surgeons of England, 2024-04-25)
    Introduction: Surgical care practitioners (SCPs) are non-medical workers involved in various aspects of the management of surgical patients. The role includes assisting and performing surgical procedures. More than 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever-increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP. Methods: A retrospective review of a prospectively collected database was performed. The primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission. Results: In total, 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis in 30 (17.6%) and pancreatitis in 13 (7.6%). Mean operating time was 65min (range 35-152min). Fifty-three operations were assisted by a consultant, 110 by a specialist or associate specialist grade (SAS) doctor and 7 by a core trainee (CT2). Some 139 (81.7%) patients were discharged on the day of surgery and 24 (14.1%) stayed one night in hospital. There were no major complications. Five patients required readmission, three with pain and two with port site infections. There were no conversions or transfusions required. Conclusions: There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach, SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP. Keywords: Cholecystectomy, laparoscopic; Clinical nurse specialist; Development, staff; Nurse practitioner.
  • Combined Charcot hindfoot and midfoot reconstruction using internal fixation method-surgical technique and single surgeon series

    Kavarthapu, Venu; Guduri, Venugopal; Hester, Thomas; Guduri, Venugopal; Trauma and Orthopaedics; Medical and Dental; King's College Hospital,; University of Southern Denmark; Walsall Healthcare NHS Trust (AME Publishing Company, 2023-01-15)
    Isolated midfoot and hindfoot Charcot reconstruction using internal fixation is increasingly a common procedure in multidisciplinary diabetic foot units, and the surgical techniques using internal fixation have well been described. However, about a third of Charcot deformities that require surgical limb salvage present with the involvement of midfoot and hindfoot. Surgical reconstruction of a combined hindfoot and midfoot deformity is an evolving technique and technically challenging. We present the surgical technique of deformity correction and stabilisation using internal fixation, developed by the senior author (VK), and present the outcomes. All patients that had undergone combined hindfoot and midfoot reconstruction to address a limb threatening deformity due to Charcot neuroarthropathy, performed by the senior author, with a minimum follow-up of 12 months, have been included in this study. The principles of surgical reconstruction included adequate pre-operative optimisation of the patient, sequential deformity correction and stabilisation of the hindfoot followed by midfoot using the principle of long-segment rigid internal fixation with optimal bone opposition. Standard post-operative regime, including offloading, has been used in all patients. A total of 34 patients (35 feet) had undergone combined midfoot and hindfoot Charcot reconstruction between January 2009 and December 2019. Active ulcers were noted in 13 feet at the time of the procedure. Eleven reconstructions were performed as two-stage procedures due to the presence of active infection. At a mean follow-up of 53 months, 11/13 ulcer healed, and 32 patients (33 feet) were full weightbearing in surgical shoes or a brace at the latest follow-up. Bone fusion was noted in 28 feet in the hindfoot region and 32 feet in the midfoot. Metal work failure was noted in 5 feet requiring removal in 3 feet. Revision procedures were required in 4 patients. Our newly described technique of combined hindfoot and midfoot Charcot has provided functional limb salvage in majority of presentations, with an acceptable level of complications, at a medium-term follow-up of 53 months.
  • Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

    Kermansaravi, Mohammad; Chiappetta, Sonja; Parmar, Chetan; Shikora, Scott A; Prager, Gerhard; LaMasters, Teresa; Ponce, Jaime; Kow, Lilian; Nimeri, Abdelrahman; Kothari, Shanu N; et al. (Nature Research, 2024-02-11)
    Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.
  • The characteristics and predictors of mortality in periprosthetic fractures around the knee

    Nasser, Ahmed A H H; Sidhu, Manpreet; Prakash, Rohan; Mahmood, Ansar; Osman, Khabab; Chauhan, Govind S; Nandra, Rajpal; Dewan, Varun; Davidson, Jerome; Al-Azzawi, Mohammed; et al. (British Editorial Society of Bone and Joint Surgery, 2024-02-01)
    Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.
  • Myc/Bcl6 double hit lymphoma negative for T(3;8) Bcl6::Myc fusion Is associated with inferior survival, in contrast with T(3;8) positive pseudo‐double hit lymphoma

    Maybury, B. D.; James, L.; Chadderton, N.; Dowds, J.; Venkatadasari, I.; Riley, J.; Qureshi, I.; Talbot, G.; Giles, H. V.; Phillips, N. J.; et al. (Wiley, 2023-06)
    MYC/BCL6 DOUBLE HIT LYMPHOMA NEGATIVE FOR T(3;8) BCL6::MYC FUSION IS ASSOCIATED WITH INFERIOR SURVIVAL, IN CONTRAST WITH T(3;8) POSITIVE PSEUDO-DOUBLE HIT LYMPHOMA B Introduction: b A small proportion of large B cell non-Hodgkin lymphoma (NHL) has I MYC i and I BCL6 i rearrangements, detectable by fluorescence in-situ hybridisation (FISH) break-apart probes. Cases of I MYC/BCL2 i double-hit lymphoma without I BCL6 i rearrangement were excluded.
  • Aspirin as an adjuvant treatment for cancer: feasibility results from the Add-Aspirin randomised trial

    Joharatnam-Hogan, Nalinie; Cafferty, Fay; Hubner, Richard; Swinson, Daniel; Sothi, Sharmila; Gupta, Kamalnayan; Falk, Stephen; Patel, Kinnari; Warner, Nicola; Kunene, Victoria; et al. (Elsevier, 2019-08-30)
    Background: Preclinical, epidemiological, and randomised data indicate that aspirin might prevent tumour development and metastasis, leading to reduced cancer mortality, particularly for gastro-oesophageal and colorectal cancer. Randomised trials evaluating aspirin use after primary radical therapy are ongoing. We present the pre-planned feasibility analysis of the run-in phase of the Add-Aspirin trial to address concerns about toxicity, particularly bleeding after radical treatment for gastro-oesophageal cancer. Methods: The Add-Aspirin protocol includes four phase 3 randomised controlled trials evaluating the effect of daily aspirin on recurrence and survival after radical cancer therapy in four tumour cohorts: gastro-oesophageal, colorectal, breast, and prostate cancer. An open-label run-in phase (aspirin 100 mg daily for 8 weeks) precedes double-blind randomisation (for participants aged under 75 years, aspirin 300 mg, aspirin 100 mg, or matched placebo in a 1:1:1 ratio; for patients aged 75 years or older, aspirin 100 mg or matched placebo in a 2:1 ratio). A preplanned analysis of feasibility, including recruitment rate, adherence, and toxicity was performed. The trial is registered with the International Standard Randomised Controlled Trials Number registry (ISRCTN74358648) and remains open to recruitment. Findings: After 2 years of recruitment (October, 2015, to October, 2017), 3494 participants were registered (115 in the gastro-oesophageal cancer cohort, 950 in the colorectal cancer cohort, 1675 in the breast cancer cohort, and 754 in the prostate cancer cohort); 2719 (85%) of 3194 participants who had finished the run-in period proceeded to randomisation, with rates consistent across tumour cohorts. End of run-in data were available for 2253 patients; 2148 (95%) of the participants took six or seven tablets per week. 11 (0·5%) of the 2253 participants reported grade 3 toxicity during the run-in period, with no upper gastrointestinal bleeding (any grade) in the gastro-oesophageal cancer cohort. The most frequent grade 1-2 toxicity overall was dyspepsia (246 [11%] of 2253 participants). Interpretation: Aspirin is well-tolerated after radical cancer therapy. Toxicity has been low and there is no evidence of a difference in adherence, acceptance of randomisation, or toxicity between the different cancer cohorts. Trial recruitment continues to determine whether aspirin could offer a potential low cost and well tolerated therapy to improve cancer outcomes.
  • Exploring the mechanisms behind autologous lipotransfer for radiation-induced fibrosis : a systematic review

    Pattani, Nikhil; Sanghera, Jaspinder; Langridge, Benjamin J; Frommer, Marvin L; Abu-Hanna, Jeries; Butler, Peter; Sanghera, Jaspinder; General Surgery; Medical and Dental; Epsom and St Helier NHS Trust; Walsall Healthcare NHS Trust; Royal Free Hospital; University College London; University of Oxford (Public Library of Science, 2024-01-25)
    Aim: Radiation-induced fibrosis is a recognised consequence of radiotherapy, especially after multiple and prolonged dosing regimens. There is no definitive treatment for late-stage radiation-induced fibrosis, although the use of autologous fat transfer has shown promise. However, the exact mechanisms by which this improves radiation-induced fibrosis remain poorly understood. We aim to explore existing literature on the effects of autologous fat transfer on both in-vitro and in-vivo radiation-induced fibrosis models, and to collate potential mechanisms of action. Method: PubMed, Cochrane reviews and Scopus electronic databases from inception to May 2023 were searched. Our search strategy combined both free-text terms with Boolean operators, derived from synonyms of adipose tissue and radiation-induced fibrosis. Results: The search strategy produced 2909 articles. Of these, 90 underwent full-text review for eligibility, yielding 31 for final analysis. Nine conducted in-vitro experiments utilising a co-culture model, whilst 25 conducted in-vivo experiments. Interventions under autologous fat transfer included adipose-derived stem cells, stromal vascular function, whole fat and microfat. Notable findings include downregulation of fibroblast proliferation, collagen deposition, epithelial cell apoptosis, and proinflammatory processes. Autologous fat transfer suppressed hypoxia and pro-inflammatory interferon-γ signalling pathways, and tissue treated with adipose-derived stem cells stained strongly for anti-inflammatory M2 macrophages. Although largely proangiogenic initially, studies show varying effects on vascularisation. There is early evidence that adipose-derived stem cell subgroups may have different functional properties. Conclusion: Autologous fat transfer functions through pro-angiogenic, anti-fibrotic, immunomodulatory, and extracellular matrix remodelling properties. By characterising these mechanisms, relevant drug targets can be identified and used to further improve clinical outcomes in radiation-induced fibrosis. Further research should focus on adipose-derived stem cell sub-populations and augmentation techniques such as cell-assisted lipotransfer.
  • Assessing asymmetrical tonsils in children : an evidence-based review for primary care

    Mughal, Zahir; Jangan, Akash; Ahmad, Ahmar; Turner, Nick; Mughal, Faraz; Mughal, Zahir; Jangan, Akash; Ahmad, Ahmar; Turner, Nick; Ear, Nose and Throat; et al. (Royal College of General Practitioners, 2024-01-25)
    No abstract available.
  • Component separation repair of incisional hernia : evolution of practice and review of long-term outcomes in a single center

    Odogwu, S O; Magsi, A M; Spurring, E; Malik, M; Kadir, B; Cutler, K; Abdelrahman, S; Prescornita, C; Li, E; Odogwu, SO; et al. (Springer, 2024-01-12)
    Purpose: To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center. Methods: This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients. Results: 89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date. Conclusion: Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.
  • Identifying preoperative predictors for 24-hour discharge after elective hip and knee arthroplasties

    Murrell, James; Khadabadi, Nikhil Aravind; Moores, Thomas; Hossain, Fahad; Murrell, James; Khadabadi, Nikhil Aravind; Moores, Thomas; Hossain, Fahad; Trauma and Orthopaedics; Medical and Dental; et al. (Springer, 2023-12-23)
    Introduction The resumption of elective medical services post-pandemic has brought to the forefront the importance of outpatient arthroplasty services in promoting efficiency and mitigating hospital-acquired infections. This study aimed to identify preoperative factors that predict the success of outpatient lower limb arthroplasty surgeries. Methods Our investigation involved a retrospective review of 606 patients who underwent elective hip and knee arthroplasty. We documented variables such as the hospital length of stay, patient demographics (age and gender), Oxford Joint Scores, body mass index, socioeconomic status, American Society of Anaesthesiologists' (ASA) physical status classification, comorbid conditions, the Functional Comorbidity Index (FCI), preoperative blood test results, implant types, scheduling details of the surgery, and rates of readmission within 30 days post-surgery. A two-step analysis using univariate and multivariate regression models was performed to pinpoint preoperative indicators that could predict same-day discharge following arthroplasty. Results Forty-five patients (7.4%) were discharged within 24 hours of surgery. Early discharge did not correlate with higher rates of readmission within 30 days (p>0.05). Neither weekend nor afternoon surgeries significantly extended the length of stay beyond 24 hours (p>0.05). No significant differences in the prevalence of comorbidities, FCI scores, socioeconomic status, or preoperative blood test results were found when comparing patients discharged within 24 hours to those who stayed longer. Multivariate analysis revealed that patients younger than 65 years (relative risk (RR) 2.41; 95% confidence interval (CI) 1.02-5.74) and those receiving partial knee arthroplasty (RR 8.91; 95% CI 3.05-26.04) were more likely to be discharged within 24 hours. Conclusions Outpatient arthroplasty is a viable option, especially for individuals younger than 65 years undergoing partial knee arthroplasty, independent of other patient-related factors, comorbidities, and specifics of the hospital episode.
  • Predictors of mortality in periprosthetic fractures of the hip : results from the national PPF study

    Nasser, Ahmed Abdul Hadi Harb; Prakash, Rohan; Handford, Charles; Osman, Khabab; Chauhan, Govind Singh; Nandra, Rajpal; Mahmood, Ansar; Dewan, Varun; Davidson, Jerome; Al-Azzawi, Mohammed; et al. (Elsevier, 2023-12-01)
    Introduction: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. Methods: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. Results: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. Conclusion: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.
  • Evaluation of National Anaesthetics Teaching in Undergraduate Medicine (ENATUM)

    Kumar, Prakrit R; Wicks, Saskia K; Kumar, Ranya V; Rottenberg, Augustus; Mostafa, Omar; Gavalas, Manolis; Mostafa, Omar; Anaesthetics; Medical and Dental; East and North Hertfordshire NHS Trust; Royal Free London NHS Trust; University of Cambridge; London North West University Healthcare NHS Trust; Walsall Healthcare NHS Trust; University College London Hospital (UCLH) NHS Foundation Trust (Oxford University Press, 2023-10-17)
    Background: During a global pandemic where anaesthetists play a pertinent role in treating coronavirus 2019 (COVID-19), it is crucial to inspire medical students to consider a career in anaesthetics and perioperative care. Where anaesthetic skills are vital for all surgical foundation doctors, regardless of whether they have a rotation in anaesthetics, this study seeks to establish the current level of exposure to anaesthetics in the UK medical schools' curriculum and evaluate if the current anaesthetic undergraduate curriculum is sufficient to prepare students to pass their exams and perform the duties expected of them as future junior doctors. Methods: A 35-item structured questionnaire, registered at University College London Hospital Research & Development (R&D), was distributed amongst foundation doctors who had graduated from UK universities within the previous 3 years between August and October 2020. Results: In total, 239 participants completed the questionnaire from 34 UK medical schools. Despite 90.0% of participants being allocated an 'anaesthesia' placement, 54.0% spent <15 hours shadowing an anaesthetist throughout their medical school. Of participants, 38.5% agreed that their anaesthetic teaching was sufficient compared to teaching of other specialities, with 48.6% of students not satisfied with the teaching provided to meet anaesthetic learning outcomes set by The Royal College of Surgeons of England; 72.4% said they would have benefited from additional anaesthetic teaching, with 80.7% stating it would have increased understanding into the speciality; and 71.5% stated a short course in anaesthetics alongside undergraduate training would have been beneficial. Conclusions: Our results demonstrate that there is a lack of standardization in undergraduate anaesthetics teaching nationally and an additional undergraduate anaesthetic teaching programme is required to increase understanding and provide further insight into anaesthetics. Key messages: The emergence of the coronavirus 2019 (COVID-19) pandemic has halted undergraduate medical education, in particular perioperative medicine and surgery.Exposure to anaesthesia is already limited in the medical undergraduate curriculum, with a limited number of anaesthesia-themed foundation rotations available for junior doctors.Recent UK graduates feel that undergraduate anaesthetics education is inadequate at medical school, reporting a lack of confidence in applying undergraduate anaesthesia learning outcomes.Additional anaesthetic teaching and online teaching methods are suggested ways of improving the delivery of undergraduate anaesthetic education.Can a national, standardized anaesthetics teaching curriculum improve the undergraduate knowledge base of anaesthesia?
  • The British Orthopaedic Oncology Management (BOOM) audit

    Archer, James E; Chauhan, Govind S; Dewan, Varun; Osman, Khabab; Thomson, Calum; Nandra, Rajpal S; Ashford, Robert U; Cool, Paul; Stevenson, Jonathan; Moores, Thomas; et al. (British Editorial Society of Bone and Joint Surgery, 2023-10-01)
    Aims: Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. Methods: A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion. Results: A total of 846 patients with pelvic and appendicular MBD were analyzed, after excluding those with only spinal metastatic disease. A designated MBD lead was not present in 39% of centres (33/84). Adequate radiographs were not performed in 19% of patients (160/846), and 29% (247/846) did not have an up-to-date CT of thorax, abdomen, and pelvis to stage their disease. Compliance was low obtaining an oncological opinion (69%; 584/846) and prognosis estimations (38%; 223/846). Surgery was performed in 38% of patients (319/846), with the rates of up-to-date radiological investigations and oncology input with prognosis below the expected standard. Of the 25% (215/846) presenting with a solitary metastasis, a tertiary opinion from a MBD centre and biopsy was sought in 60% (130/215). Conclusion: Current practice in the UK does not comply with national guidelines, especially regarding investigations prior to surgery and for patients with solitary metastases. This study highlights the need for investment and improvement in care. The recent publication of British Orthopaedic Association Standards for Trauma (BOAST) defines auditable standards to drive these improvements for this vulnerable patient group.
  • Modelling a consultant workforce for the United Kingdom: needs-based planning for dental public health

    Gallagher, J E; Donaldson, M; Karki, A; Keat, R; Yeung, C A; Roberts, W; Birch, S; Listl, S; Witton, R; Roberts, William; et al. (CDH, 2023-11-30)
    Objective: To develop a needs-based workforce planning model to explore specialist workforce capacity and capability for the effective, efficient, and safe provision of services in the United Kingdom (UK); and test the model using Dental Public Health (DPH). Basic research design: Data from a national workforce survey, national audit, and specialty workshops in 2020 and 2021 set the parameters for a safe effective DPH workforce. A working group drawing on external expertise, developed a conceptual workforce model which informed the mathematical modelling, taking a Markovian approach. The latter enabled the consideration of possible scenarios relating to workforce development. It involved exploration of capacity within each career stage in DPH across a time horizon of 15 years. Workforce capacity requirements were calculated, informed by past principles. Results: Currently an estimated 100 whole time equivalent (WTE) specialists are required to provide a realistic basic capacity nationally for DPH across the UK given the range of organisations, population growth, complexity and diversity of specialty roles. In February 2022 the specialty had 53.55 WTE academic/service consultants, thus a significant gap. The modelling evidence suggests a reduction in DPH specialist capacity towards a steady state in line with the current rate of training, recruitment and retention. The scenario involving increasing training numbers and drawing on other sources of public health trained dentists whilst retaining expertise within DPH has the potential to build workforce capacity. Conclusions: Current capacity is below basic requirements and approaching 'steady state'. Retention and innovative capacity building are required to secure and safeguard the provision of specialist DPH services to meet the needs of the UK health and care systems.
  • Does omentopexy make a difference in laparoscopic sleeve gastrectomy for obesity treatment? A systematic review and meta-analysis

    Mohamedahmed, Ali Yasen Y; Hamid, Mohammed; Zaman, Shafquat; Abdalla, Hashim E; Wuheb, Ali Ahmed; Khan, Amir; Parmar, Jitesh; Khan, Amir; General Surgery; Medical and Dental; et al. (Springer, 2023-12-01)
    This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.

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