Annals of Medicine and Surgery

Print ISSN: 2049-0801
Publications
Change in the frequency of endorsement of guidelines between 2011 and 2014.
Percentage levels of endorsement of each guideline, given that the guideline has been mentioned in the instructions to authors. The labels above each bar indicate the absolute numbers. Systematic review registration has not been included, as only one journal mentioned this, and it was only recommended in this case.
List of journals included in the study.
Guidance has been published on how best to report randomised controlled trials (Consolidated Standards of Reporting Trials - CONSORT) and systematic reviews (Preferred Reporting Items for Systematic Reviews and Meta-analysis - PRISMA). In 2011, we reported a low rate of enforcement by surgery journals for submitted manuscripts to conform to these guidelines. The aim of this follow-up study is to establish whether there has been any improvement. We studied the 134 surgery journals indexed in the Journal Citation Report. The 'Instructions to Authors' were scrutinised for inclusion of the following guidance: CONSORT, PRISMA, clinical trial registration and systematic review registration. Compared to 2011, there has been an improvement in the endorsement of reporting guidance in journals' 'Instructions to Authors' in 2014, as follows: trial registration (42% vs 33%), CONSORT (42% vs 30%) and PRISMA (19% vs 10%, all p < 0.001). As in 2011, journals with a higher impact were more likely to adopt trial registration (p < 0.001), CONSORT (p < 0.001) and PRISMA (p = 0.002). Journals with editorial offices in the UK were more likely to endorse guidance compared to those outside the UK (p < 0.05). Only one journal mentioned registration for systematic reviews. Surgery journals are presently more likely to require submitted manuscripts to follow published reporting guidance compared to three years ago. However, overall concordance rates are still low, and an improvement is required to help enhance the quality of reporting - and ultimately the conduct - of randomised control trials and systematic reviews in surgery.
 
Systematic comparison of 3 publications with the current case of Gluteal Compartment Syndrome in bariatric surgery. 
Gluteal Compartment Syndrome is a rare condition caused by excessive pressure within the gluteal compartments which leads to a number of potentially serious sequelae including rhabdomyolysis, nerve damage, renal failure and death. As bariatric patients are heavy and during prolonged bariatric procedures lie in one position for extended periods of time, they are especially susceptible to developing this complication. It is therefore essential that bariatric surgeons are aware of this complication and how to minimise the chances of it occurring and how to diagnose it. We describe a case of Gluteal Compartment Syndrome in a patient following a gastric bypass and review the aetiology, pathophysiology, treatment and prevention of this complication.
 
Summary of patient presentation and planned management.
Doppler ultrasound image demonstrating subclavian vein thrombosis.
Thrombotic complications arising during the treatment of breast cancer can impact the breast reconstruction pathway. We set out to review the details of cases of thromboembolism occurring during neoadjuvant chemotherapy and peri-operatively to study the impact of the event and its management on subsequent breast reconstruction. We retrospectively reviewed the medical records of seven patients who had experienced a thrombotic event during their treatment of breast cancer between 2008 and 2012, who then proceeded to breast reconstruction. We recorded size and grade of tumour, neoadjuvant chemotherapeutic regimen, details of port insertion, planned reconstruction, thrombotic event and its management and the surgery performed and outcome. All patients received chemotherapy via central venous access and went on to present with local symptomatic thrombosis. They were managed with anticoagulant regimens at the time of mastectomy and reconstruction, which were unique for each patient. The results revealed delays to surgery and modifications to planned reconstruction. The majority of patients developing thrombotic complications go on to achieve successful reconstruction. There is significant variation in the anticoagulation management in this patient group. Identification of optimal anticoagulant regimes and the possibilities for prophylaxis may prove key in informing surgeons when planning the reconstructive process. An awareness of the effects of thrombotic events in this patient group is important in terms of developing an understanding of its impact on the performance of reconstruction, on the management of anticoagulation peri-operatively and on monitoring for post-operative complications.
 
Presenting symptoms of patients with confirmed caecal diverticulitis.
Database of patients with confirmed caecal diverticulitis.
Computed tomography of 49 year old female patient with a caecal diverticulitis (arrow illustrates inflamed diverticulum of the caecum).
Patients presenting with colonic diverticulitis: right-sided vs. left-sided.
While left sided colonic diverticular disease is common in Western countries, right sided colonic diverticular disease is rare. With increasing migration from Asia, many western countries including Australia, are now seeing more right sided diverticular disease, of which caecal diverticulitis is the commonest. This study aims to determine the incidence of caecal diverticulitis in patients presenting with colonic diverticulitis, as well as identify the symptoms and clinical features that may aid in making a pre-operative diagnosis. Data was collected using the Queen Elizabeth II Hospital medical records database identifying patients diagnosed with colonic diverticulitis and, more specifically, those with caecal diverticulitis from January 2007 to December 2013. Only those patients who had confirmed caecal diverticulitis on imaging studies or at laparoscopy on their first admission were included in this study. A total of 632 patients with colonic diverticulitis were admitted to our institution over a seven-year period, of which 13 patients had caecal diverticulitis (2.06%). Of the 13 patients, twelve were of Asian background and ten were considered young (≤50 years of age). The main complaints were right sided abdominal pain (n = 11, 84.6%) and diarrhoea (n = 5, 38.5%). Nine were diagnosed using computed tomography (n = 9/10, 90%), three on laparoscopy and one using ultrasound (n = 1/2, 50%). Ten patients were treated successfully by conservative means. A high index of suspicion in Asian patients with atypical symptoms of appendicitis, especially diarrhoea, may provide the diagnosis of caecal diverticulitis.
 
ERCP showed hilar stenosis with a neoplastic character.
ERCP showed hilar stenosis with a neoplastic character.
Ultrasound: porcelain gallbladder with a posterior acoustic shadow. Minimum intrahepatic bile duct dilatation. No ascites.
(A) CT showed exophytic growth of a vesicular mass and a calcified wall thickening. (B) Affected liver segments (IV b, V, VII, VIII) extended to the liver capsule, hepatic hilum, and gastrohepatic ligament.
Porcelain gallbladder is a very rare entity that consists of a calcification of the gallbladder wall, and is associated with carcinoma in 12.5-62% of patients, although recent studies suggest weaker association. We describe an 80-year-old woman who presented with colicky abdominal pain in the right upper quadrant, radiating to the back and associated with vomiting. Physical examination revealed jaundice, murphy's sign was negative. Hepatic-biliary tract ultrasound revealed porcelain gallbladder, she was referred to the surgical team for a scheduled cholecystectomy. A month later, she presented diffuse abdominal pain. Imaging studies showed a disseminated process affecting liver's segments, capsule, and hilum; and lungs. An aggressive surgical treatment was dismissed, and was referred to the oncology department. There is controversy in the harboring risk of malignancy of the porcelain gallbladder. While it seems that the current data points towards a lower risk of degeneration, it is also demonstrated that patients with gallbladder wall calcifications are indeed statistically at risk of gallbladder cancer. Laparoscopic cholecystectomy has become a safe and efficient approach recommended for patients with gallbladder symptoms directly related or unrelated to gallbladder wall calcifications. In this case, a pathological gallbladder, very quickly evolved into an inoperable tumor with a poor prognosis. This report heightens that with US evidence of porcelain gallbladder, an urgent CT scan should be carried out to assess an underlying malignancy, and a simple cholecystectomy should be done urgently rather than on a routine elective list to prevent possible malignant change if possible.
 
The 2012 London Olympic and Paralympic Games were widely regarded as an organisational and sporting success for the United Kingdom. Therefore, it is prudent to consider what other large, public endeavours might learn from the Games’ success. Team GB worked to develop a positive team culture based around shared values. This is something the National Health Service (NHS) could learn from, as an organisation which can appear to lack this culture. The NHS should also work harder to adopt evidence-based practices, and to adopt them quickly, as is often the case in sport. Sport is the ultimate example of transparent results reporting, and the NHS ought to consider systematic reporting of risk-adjusted performance data, which may drive improved performance. The NHS should pay attention to the experiences of successful Olympic sports with centralised centres of excellence, and to medical data which suggests that better outcomes result from centres of excellence. The NHS and wider government should look to Olympic athletes and place more emphasis on prevention of disease by encouraging positive lifestyle choices. Finally, the NHS should develop private sector partnerships carefully. We must look to gather knowledge and ideas from every area of life in pursuit of excellence in the NHS. Experience of the Olympics offers a number of instructive lessons.
 
Cataract extraction is the commonest surgical procedure performed in the UK.1 Congenital cataracts are a treatable cause of childhood visual deficit,2 with a prevalence of 6 cases per 10,000 births.3 Various morphological types present in infants, some being visually significant, including posterior polar cataracts located near the macula.4 Four decades ago, infants were managed conservatively with atropine for mydriasis allowing the child to “look around the opacity”.5 Currently, it is a predominantly surgical task, however, surgeons are facing the question of which mode of optical correction to use, either a contact lens or an intra-ocular lens.6,7 Many studies have not shown a significant difference in visual outcomes afforded by contact lens or intra-ocular lens. Other factors including the time the cataract has been visually significant, poor compliance of contact lens wear, and occlusion therapy have proven to be better determinants of visual outcome. Intra-ocular lenses are associated with a significantly higher incidence of complications including glaucoma and iris prolapse.8 Younger age at surgery is also linked to a higher rate of adverse events, especially if before six weeks of life.9 Early lensectomy is advised to prevent the cataract affecting vision for a longer period of time, which is associated with a poor prognosis.10 Surgeons should make an informed decision on whether parents are likely to comply with contact lens wear and, if not, advise them on intraocular lenses, the more appropriate option for non-compliant parents.
 
Background It is difficult to measure accurately the out-of-pocket surgical health expenditures in developing countries. The World Health Organization reports that 45% of health costs in the developing world are out-of-pocket expenditures.1 Many households often incur catastrophic costs, pushing them below the poverty line.2, 3, 4, 5, 6, 7 and 8 Methods Ovid MEDLINE literature search on out-of-pocket surgical expenditures, public health, and health systems. Results Various studies have shown that surgical services can sizably reduce premature death or disability in developing countries.9,10 A common misconception is that they are expensive; however, studies show that they are cost-effective public health measures,10 and that surgical conditions are significant public health problems.9,11 In fact, some studies suggest that select surgical interventions may be more cost-effective compared to other health interventions.12, 13 and 14 There are glaring inequalities and inequities in access to surgical services in developing countries, particularly in rural and/or marginalized populations.9,15, 16 and 17 Due to a lack of perceived importance and political advocacy, there is a lack of coverage by health systems which frequently push households below the poverty line due to catastrophic health expenditures. This has wide ranging physical, psychological, financial, and social implications to individuals and households. Surgery could also be the crucial determining factor in the achievement of Millennium Development Goals (MDGs) 4–6.18 Conclusions Surgical interventions are often a neglected public/global health topic as they are, often incorrectly, deemed as high-cost. Health systems strengthening to increase provision and access to surgical interventions are vital to save lives, prevent disability, provide a social safety net, and aid in the achievement of the MDGs.
 
We report the procedural results of an Operation Hernia mission in La Concordia, Ecuador, learning points as well as the difficulties we faced whilst delivering high-quality, low-cost surgery to the local population. During the 6-day mission, we performed 74 hernia repair operations on 72 patients. 41% of the 74 hernia repairs were umbilical, 39% inguinal (either unilateral or bilateral), 12% incisional, 5% epigastric, 3% femoral, and 1% lumbar. 53% of all hernias were reducible, and 88% were primary repairs. At 2 weeks follow-up, there were no mortalities, and a 3.9% complication rate (3 patients). The mission was an excellent training opportunity for all involved; surgical decision-making skills, as well as theatre-management were key in the mission's success. We faced challenges on various levels during the mission, and these can be divided into problems with preliminary mission groundwork, as well as operating and anaesthetic facilities. While there are no simple remedies for some of the issues we identified, we believe that many of these problems can be overcome with adequate preparation and organisation. Hence, we would like to contribute our findings to the growing evidence base on delivering voluntary medical or surgical services to developing countries. We hope our insights can be used to inform future missions or projects and be used to improve the quality of care delivered to patients worldwide.
 
Aim: The laparoscopic inguinal hernia repair has gained significant interest over the years as an alternative to the conventional open technique as a result of its faster recovery time, reduced postoperative pain and numbness. However the recurrence rates are in the order of 2.3% compared to the 1.3% quoted for the equivalent open approach. Much of these recurrences occur either caudal to the fold created in the mesh once in-situ or lateral to the border of the mesh. This technique aims to address both these areas of concern using an additional strip of mesh across the centre to brace the mesh and create a bolster to maintain mesh stability. Methods: The technique involves cutting a 2 cm strip from the 15x15 cm mesh which is laid length-ways over the remaining 13x15 cm mesh, keeping the longest dimension in the medial to lateral plane, and loosely tacked. The strip over hangs the lateral border of the mesh to control the lateral space. Recurrence rates were evaluated from a prospectively collected data series as well as outcomes collected from a questionnaire over a 10 year period between January 2001 and October 2011. Primary outcomes were confirmed hernia recurrence requiring surgical repair. Results: Four hundred ninety-one patients underwent laparoscopic totally extraperitoneal (TEP) hernia repair with outcomes including recurrence rates were retrospectively examined through a prospectively collected database. Subsequently 400 patients were sent a validated questionnaire. 246 responded (62% response rate). One recurrence (0.3%), which occurred 4 years after the original laparoscopic repair, was described across the series. Conclusion: The use of the additional mesh strip potentially reduces TEP hernia recurrence rates beyond simply the benefits of the learning curve. Although, questionnaires are notoriously inaccurate, the value and consistency between both evaluation techniques suggests that this level of reduction is significant to warrant further prospective trials.
 
A 68-year-old man is referred to the colorectal clinic by his GP. He has lost 10 kg in weight over the last two months. He also noticed that his bowel motions have been loose and sometimes contain blood. You review the full blood count and faecal occult blood test the GP requested. What should you do next?
 
You see an 81-year-old man in the emergency department. He has been troubled by abdominal and back pain that has been worsening over the last two days. He has smoked 20 cigarettes a day for the last 60 years. On examination his heart rate is 110 beats per minute and his blood pressure is 130/80 mmhg. He is tender over the central abdomen and you feel a pulsatile mass above the umbilicus. You request a CT scan of the abdomen.
 
Global trends in ESBL-producing Enterobacteriaceae*: SMART study 2005–2010 [22]. * Includes ESBL-positive E. coli, K. pneumoniae and K. oxytoca
Prevalence of ESBL producers among E. coli and K. pneumoniae isolates from IAIs in 11 Asia–Pacific countries in 2010 [18]. Reprinted from Int J Antimicrob Agents, Volume 40 Supplement, Huang CC, et al., Impact of revised CLSI breakpoints for susceptibility to third-generation cephalosporins and carbapenems among Enterobacteriaceae isolates in the Asia–Pacific region: results from the Study for Monitoring Antimicrobial Resistance Trends (SMART), 2002–2010, S4–S10, 2012, with permission from Elsevier.
Regional epidemiological data and resistance profiles are essential for selecting appropriate antibiotic therapy for intra-abdominal infections (IAIs). However, such information may not be readily available in many areas of Asia and current international guidelines on antibiotic therapy for IAIs are for Western countries, with the most recent guidance for the Asian region dating from 2007. Therefore, the Asian Consensus Taskforce on Complicated Intra-Abdominal Infections (ACT-cIAI) was convened to develop updated recommendations for antibiotic management of complicated IAIs (cIAIs) in Asia. This review article is based on a thorough literature review of Asian and international publications related to clinical management, epidemiology, microbiology, and bacterial resistance patterns in cIAIs, combined with the expert consensus of the Taskforce members. The microbiological profiles of IAIs in the Asian region are outlined and compared with Western data, and the latest available data on antimicrobial resistance in key pathogens causing IAIs in Asia is presented. From this information, antimicrobial therapies suitable for treating cIAIs in patients in Asian settings are proposed in the hope that guidance relevant to Asian practices will prove beneficial to local physicians managing IAIs.
 
of the scanning of RFID-tagged surgical sponges in 20 swine; positive pre- dictive value and negative predictive value. 
Background Counting the sponges is an important step in surgical procedures. A miscount may impact the patient's health, and it also has legal implications for the surgeon. This is an experimental study evaluating radio-frequency technology used in the perioperative period to identify surgical sponges left in the peritoneal cavity of swine. Methods Radio-frequency labeled-disc identification tags were sewn into 40 surgical towels. Twenty labels had the ability to emit radio-frequency waves, and 20 labels were inert to radio-frequency identification. Twenty adult pigs that underwent laparotomy and randomly received two surgical sponges were scanned by a radio-frequency identification antenna. Results This method presented a positive predictive value of 100% and 100% specificity and sensitivity, as all of the tagged surgical sponges were detected. Conclusion Radio-frequency identification has been proved to be a useful method for the identification of surgical sponges within the abdominal cavities of swine.
 
Background There are various assessment methods that allow the evaluation of skills acquisition in microsurgery simulation training such as global rating scores and check lists. The present scoring systems are used to analyse the process of conducting an anastomosis. This paper presents a novel quantitative method based on assessing the intimal surface of the anastomosis to analyse the end product. Method 24 candidates were recruited for a five day microsurgical skills acquisition course. The cohort ranged from undergraduate medical students to experts microsurgeons. On days three and five, the trainees performed two assessment anastomoses on cryopreserved rat aortas (average diameter = 1.75 millimeter). These were cut open to expose the intimal surface of the anastomosis and a high magnification photo was taken. The photos were then analysed using ImageJ. The perfect anastomosis was defined as having equidistant insertion points, equal suture lengths across the anastomosis line, and a single axis meaning that there is no torsion in the vessel edges. In turn, 4 parameters were measured: 1) distance between the proximal insertion points, 2) distance between the distal insertion points, 3) length of sutures placed, 4) number of axes. Using these parameters, a 10 component scoring system was produced by a 3 point linkert scale giving 0, 5, and 10 points for scores between the range of 0–50th, 51st to 75th and above the 75th centile respectively. The maximum score achievable is 100. Results The thresholds of this scoring system were defined based on the population performance. In our cohort the scores ranged from 0–95. This system demonstrated both concurrent and construct validity (p < 0.05). Conclusion This novel scoring system satisfies an area of microsurgical skills acquisition assessment that has not yet been covered in great depth. The system allows objective assessment of the anastomosis's quality thus paving the way for identifying clinical safe threshold of microsurgery simulated training. In the future we can correlate this system to physiological anastomosis outcome measures such as patency rate and other methods of microsurgery assessment skills to establish the predictive validity of this system in discriminating trainees who have reached clinically competent standards in microsurgery.
 
Background Acute burns are relatively common. The incidence, outcomes, and factors related to mortality need to be identified in order to create a useful guideline. The purpose of this study was to define the factors that affect mortality and outcome of burns patients treated in the intensive care unit (ICU). Methods In this study, 47 cases between November 2004 and August 2012 were included. Patients less than 16 years of age (n = 26) were excluded. Studied variables were age, burn ratio, degree of burn, APACHE II score, Glasgow Coma Scale (GCS), length of stay (LOS) in ICU, airway condition on arrival to ICU, albumin level at admission, arrival time to ICU, mechanical ventilation (MV) time if done, crystalloid and colloid levels given to the patient in ICU. Additionally, interventions during the stay such as central venous catheter (CVC), intravenous arterial catheter (IAC), Foley catheter, intubation, and nasogastric tube (NGT) were recorded. These variables were compared with survival for patients. Fluid resuscitation was managed using the Parkland Formula. Results We compared factors which might have an effect on survival for burn patients in the ICU. The mean burn ratio of patients who did not survive was 53.5%, this compared to 33.4% for the patients who survived (p = 0.038). The mean GCS for patients who survived and died were 13.43 and 9.79, respectively (p = 0.01). The mean APACHE II scores for non-surviving and surviving patients were 21.29 and 15.43, respectively (p = 0.03). The mean mechanical ventilation time for patients who survived and died were 20.57 and 106.67 hours respectively (p = 0.025). The mean albumin levels at admission for surviving and non-surviving patients were 2.81 and 2.26 g/dl respectively (p = 0.014). Factors that showed no significant relationship to survival included: amount of crystalloid or colloid solutions provided (p = 0.674 and p = 0.298 respectively), arrival time to ICU (p = 0.478), length of stay in ICU (p = 0.475), degree of burn (p = 0.110), and the mean age of the patient on admission(p = 0.911). Because of burns related to jugular region, five dead patients could not have CVC and NGT, as interventions needed. Conclusion GCS, APACHE II score, burn ratio, MV time, and albumin levels at admission are significant markers of likely survival in burns patients treated in ICU. In all deceased patients, intubation was undertaken, but was ineffective. The width of the area burned and the region of burn both highly affected the interventions undertaken.
 
This editorial examines the problem of predatory publishers and how they have negatively affected scholarly communication. Society relies on high-quality, peer-reviewed articles for public policy, legal cases, and improving the public health. Researchers need to be aware of how predatory publishers operate and need to avoid falling into their traps. The editorial examines the recent history of predatory publishers and how they have become prominent in the world of scholarly journals.
 
a. T1 weighted MRI post-gadolinium showing the spiculated 20 mm mass within the mesentery. This lesion is arrowed. b. T2 weighted MRI also illustrating the speculated 20 mm mass within the mesentery. The lesion is arrowed. c. CT of the mesentery mass that was taken 1 month after the MRI in a and b. The lesion is arrowed.
Timeline of events.
a. this indicates the chromogranin stain that was used. It is dark which indicates that the chromogranin was taken up readily by the neuroendocrine tumour. b. this indicates the carcinoid tumour within the sigmoid colon.
This indicates the presence of carcinoid through the muscularis mucosa within the small bowel lumen.
Histology showing the sigmoid adenocarcinoma. ‘A’ marks glandular forming tissue which is indicative of adenocarcinoma.
INTRODUCTION Gastropancreato-neuroendocrine tumours (GETs) are rare, especially when they occur alongside colorectal adenocarcinoma. Furthermore, multiple GETs occurring within the small bowel are less frequent with only two cases described within the literature. PRESENTATION OF CASE A healthy 58-year old woman presented with severe gastrointestinal pain and faecal incontinence. Family history revealed consanguineous parents and a brother who had recently died of a gastric GET. First biopsy showed a sigmoid adenocarcinoma. Histology of the resected sigmoid revealed both adenocarcinoma and GET. After this, she presented with small bowel obstruction secondary to multiple ileal and jejunal GETs, also treated with resection. All imaging modalities gave no evidence of extra-intestinal metastasis. The patient received multiple operations and chemotherapy but died 18 months after the original presentation. DISCUSSION A case of such persistent and multiple small bowel GET without extra-intestinal metastasis has yet to be reported within the literature. GETs are rare and typically asymptomatic with a small proportion giving the classical carcinoid syndrome. Surgery is usually reserved for smaller GETs with high five-year survival. Despite this, surgery and chemotherapy were performed and both proved to be ineffective. Furthermore, a genetic basis for GETs is supported in this case with her brother suffering a similar fatal tumour. CONCLUSION This case highlights a rare GET that has a likely underlying familial origin. It illustrates the non-specific presentation of these tumours and the importance of taking a thorough family history. It also demonstrates that these tumours can be fatal even in the absence of extra-intestinal metastasis.
 
Resected tracheal section of the stenosed segment. 
Computed tomography of the patient depicting tracheal stenosis 3 cm below the vocal cords. 
Tracheal stenosis refers to a reduction in the size of the tracheal lumen and can be due to a myriad of reasons, but the most common remains trauma. In iatrogenic situations, internal trauma is the most likely culprit, resulting from prolonged intubation. Our case reviews a patient who developed severe tracheal stenosis (90% reduction in lumen size) within a month of a threeday- long intubation, and presented to the emergency room with dyspnea, orthopnea, and stridor. Tracheal reconstruction with resection of the stenosed segment and end-to-end anastomosis was done. The patient returned a month later with re-stenosis, and underwent tracheal dilatation. Subsequently, he was discharged with a tracheostomy with no problems thereafter.
 
Selected randomized controlled trials evaluating the effect of neostigmine in ACPO.
Clinical significance of neostigmine for ACPO.
Process of study selection.
Introduction: Acute colonic pseudo-obstruction (ACPO) is an uncommon condition that occasionally develops in hospitalized patients with serious underlying ailments. Its early recognition is essential to reduce life-threatening complications. Few low-powered randomized clinical trials (RCTs) have confirmed the effectiveness of neostigmine for treatment. Aim: To analyse the effectiveness and main side effects of neostigmine in the treatment of ACPO. Experimental: A literature search was performed for all published RCTs, reporting on neostigmine as treatment for ACPO. Results: Four studies fulfilled the inclusion criteria, evaluating 127 patients: treatment group = 65, control group = 62. Neostigmine effectiveness to resolve ACPO with only one dose was 89.2% versus 14.65% (P
 
Possible errors in RCTs, adapted from Keirse et al. 9 
A recent paper1 has highlighted the use of randomised controlled trials (RCTs) as a basis for creating and implementing policies by the United Kingdom government. However, RCTs are potentially difficult, costly, and complex. Therefore, this paper explores what public policy-makers can learn from medicine's extensive experience with RCTs so that public policy may be both cost-effective and efficacious. The first RCT in the health sector is often accredited to Sir A Bradford Hill, who randomised patients to a control arm and to a streptomycin arm to treat tuberculosis in 1948.2 However, history is pitted with earlier examples of controlled trials including the biblical Book of Daniel and James Lind's scurvy trial of 1747.2 Since then, RCTs have become a staple research tool in the health sector. They provide high quality evidence by using a randomised control group to compare to the intervention group being tested, removing bias and ensuring the intervention itself, and not other factors, exerts an effect upon the results. RCTs aim to establish a causal link between interventions and outcomes. As such, they are used extensively to assess the usefulness of drugs, interventions, and changes in practice. As they have aided the health sector, business, and many other areas of society, should they also be used systematically to aid policy-makers?
 
Molecular mechanism of NCAM action [7].
Adhesive interactions are important for cell trafficking, differentiation, function and tissue differentiation. Neural cell adhesion molecule (NCAM) is involved in a diverse range of contact-mediated interactions among neurons, astrocytes, oligodendrocytes, and myotubes. It is widely but transiently expressed in many tissues early in embryogenesis. Four main isoforms exist but there are many other variants resulting from alternative splicing and post-translational modifications. This review discusses the actions and association of N-CAM and variants, PSA CAM. L1CAM and receptor tyrosine kinase. Their interactions with the interstitial cells of Cajal- the pacemaker cells of the gut in the manifestation of gut motility disorders, expression in carcinomas and mesenchymal tumours are discussed.
 
Childhood obesity is an increasingly prevalent problem, associated with obesity later in life, and a sequalae of health problems such as metabolic syndrome and an increased risk of coronary heart disease. Poor nutrition and a lack of physical activity are said to be causes of obesity development, with genetic factors and heritability also implicated. However, there are established, identifiable risk factors associated with the future development of obesity, both in childhood, and adolescence. These include parental weight before pregnancy, gestational weight gain, pre-pregnancy maternal smoking, as well as numerous socioeconomic factors.1, 2, 3 and 4 Studies have also shown that once obese, children can find it very difficult to lose the excess weight,5 with long-term management methods having shown poor efficacy.5 Therefore, preventative strategies are becoming a high priority to battle the ever-increasing epidemic of childhood obesity. This study by Morandi et al. 6 is the first longitudinal study to analyse the predictive properties of early life risk factors for obesity, and propose a subsequent predictive algorithm to identify newborns most at risk of becoming obese in childhood and adolescence. Morandi et al.’s study aimed to develop a clinically useful formula, which could be used to identify the risk of future obesity in newborns, thereby enabling more efficient implementation of prevention strategies.6 The lifetime Northern Finland Birth Cohort 1986 (NFBC 1986) was used to form predictive equations for both childhood and adolescent obesity, based on established risk factors: parental BMI, birth weight, maternal gestational weight gain, and socioeconomic factors. A genetic score was also created based on 39 BMI/obesity-associated polymorphisms. Validation studies were performed on both a retrospective cohort of children from Veneto, Italy, and a prospective cohort of children from Massachusetts, USA.
 
Background characteristics and clinical data of all patients.
Laparoscopic port sites for adrenalectomy. In laparoscopic adrenalectomy, the scope was placed between the operator's hands. The operator manipulated C and D ports in Case 1, and B and D ports in Cases 2 and 3, respectively. The first assistant manipulated the B port in Case 1, and A and E ports in Case 2. A port was used in Case 3 to facilitate liver and gall bladder retraction by the first assistant.
Macroscopic and microscopic findings of a typical case (a) A section of the surface of the resected tumor with a 5-cm diameter showed a mixture of tan-brown and pale yellow areas with abundant cells and fat, respectively. (b) Microscopically, the section showed characteristics of myelolipoma with mature fat and hematopoietic elements such as megakaryocytes (black arrow; hematoxylin and eosin, ×200). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Imaging findings of a typical right adrenal myelolipoma. (a) Computed tomography shows a right adrenal tumor, measuring up to 5.0 cm in diameter with approximately – 80 Hounsfield units, which is suggestive of fat. (b) In-phase (left) and out-of-phase (right) gradient-echo magnetic resonance imaging reveals a right adrenal tumor (white arrow) with a partial fatty component.
Introduction Earlier reports of laparoscopic adrenalectomy (LA) for adrenal myelolipoma are limited. Presentation of case Between June 2000 and September 2012, we performed right adrenal resections using LA and open adrenalectomy (OA) in patients with myelolipoma (n = 3 and n = 3, respectively). Then, we evaluated patients' background characteristics and short- and long-term outcomes for both groups. The median maximum diameters of tumors were 3.5 (3.0–4.4) cm and 7.1 (7.0–9.5) cm for the LA and OA groups, respectively. The median durations of the operation were 152 (117–188) min and 218 (153–230) min, and the median blood loss volumes were 50 (20–160) mL and 290 (62–1237) mL in the LA and OA groups, respectively. The median postoperative lengths of hospital stay were 4 (4–4) days and 11 (11–13) days for the LA and OA groups, respectively. Conversion from LA to an open approach during surgery was not necessary in any of the cases. Additionally, perioperative morbidity and mortality were not observed. Discussion The limitation of this study is its methodological design; it is a case series and not a matched-control study, which would be difficult to conduct owing to the rare nature of adrenal myelolipoma. However, we esteem that LA will become widespread in the future because it is feasible, cosmetic, and less invasive. Conclusion LA was a safe, feasible, and effective approach to adrenal myelolipoma, assisted by advancement in preoperative imaging diagnostic techniques.
 
The United States Preventive Services Task Force (USPSTF) has recently released an updated, evidence-based, recommendation for the screening and management of obesity in adults.1 These new recommendations reinforce the significant impact of obesity upon health services, and raise critical questions concerning the future of its management in reducing long-term sequelae. Although the remit of the recommendations lie within the US, they should be considered in the context of the global nature of obesity.2 These new USPSTF guidelines stress important themes applicable to obesity management policies and guidelines worldwide. This article aims to summarise the findings and recommendations outlined by the USPSTF, including its strengths and limitations. These will be considered in the context of respective recommendations from the American Heart Association (AHA)3 and the American Medical Association, and internationally from the UK's National Institute for Health and Clinical Excellence (NICE),4 2006 Canadian clinical practice guidelines,5 Australia's National Health and Medical Research Council (NHMRC),6 and the World Health Organisation (WHO).7
 
Major complications in surgery affect up to 16% of surgical procedures. Over the past 50 years, many patient safety initiatives have attempted to reduce such complications. Since the formation of the National Patient Safety Agency in 2001, there have been major advances in patient safety. Most recently, the production and implementation of the Surgical Safety Checklist by the World Health Organisation (WHO), a checklist ensuring that certain ‘never events’ (wrong-site surgery, wrong operation etc.) do not occur, irrespective of healthcare allowance. In this review, a summary of recent advances in patient safety are considered – including improvements in communication, understanding of human factors that cause mistakes, and strategies developed to minimise these. Additionally, the synthesis of best medical practice and harm minimisation is examined, with particular emphasis on communication and appreciation of human factors in the operating theatre. This is based on the resource management systems developed in other high risk industries (e.g. nuclear), and has also been adopted for other high risk medical areas. The WHO global movement to reduce surgical mortality has been highly successful, especially in the healthcare systems of developing nations where mortality reductions of up to 50% have been observed, and reductions in patient complications of 4%. Incident reporting has long been a key component of patient safety and continues to be so; allowing reflection and improved guideline formation. All patients are placed at risk in the surgical environment. It is crucial that this risk is minimised, whilst optimising the patient's outcome. In this review, recent advances in perioperative patient safety are examined and placed in context.
 
Annual incidence, mortality and gastric cancer surgery statistics in Scottish Hospitals including SASM notifications of surgical deaths 1996–2005.
Adverse events in all patients who died during a surgical admission with gastric cancer from 1996–2005.
Adverse events in patients who died during a surgical admission with gastric cancer after gastrectomy from 1996–2005.
Adverse events in patients who died during a surgical admission with gastric cancer after palliative surgery from 1996–2005.
number (range) of adverse events (AEs) in all patients who died up to 30 days after surgical admission with gastric cancer and after gastric resection or palliative surgery in the two periods of the study.
Background The reduction in gastric cancer mortality is due to a reduction in incidence and of surgical mortality. This study was to examine adverse events in patients with gastric cancer dying under surgical care. Methods Adverse events in surgical care were prospectively audited in patients who died of gastric cancer in Scottish hospitals. A cohort retrospective study examining deaths and contributing adverse events was compared for the periods 1996–2000 and 2001–2005. Results Between 1996 and 2005, 1083 patients with gastric cancer died on surgical wards in Scottish hospitals. The annual number of deaths under surgical care fell significantly from an average of 128 deaths per annum in years 1996–2000 to 88 deaths per annum in 2001–2005 (p < 0.001). This occurred in parallel with the decline in gastric cancer incidence over the same period. There was an increase in the proportion of gastric cancer resections carried out in 7 major hospitals in Scotland in the second period of the study (p < 0.001). The mean number of deaths in the group of patients, who had gastric cancer resection and palliative surgery, were significantly lower in the second period of the study In addition, when all patients were considered as a group, the mean number of anaesthetic, critical care, medical management and technical surgery adverse events were significantly lower in the second study period. Conclusion There has been a reduction in deaths and adverse events for patients with gastric cancer under surgical care and this has been associated with surgical subspecialisation in oesophago-gastric cancer surgery.
 
Core Surgical Training (CST) competition ratios in previous years (adapted from www.mmc.nhs.uk) (2).
Reasons guiding decision whether a career in surgery was felt to be appealing. a) Participants that found a career in surgery appealing (n = 19). b) Participants that did not find a career in surgery appealing (n = 48). (Note that participants may have chosen more than one reason).
Flowchart demonstrating career aims of foundation doctors surveyed (CST – Core surgical training).
Suggested surgical career pathway.
Introduction The competition for Core Surgical Training (CST) positions and subsequent Surgical Specialty Training (ST3) posts throughout the UK is fierce. Our aim was to conduct a pilot study to assess whether current foundation year doctors were considering pursuing a career in surgery and the reasons guiding their decisions. Methods A ten-item questionnaire was voluntarily completed by foundation doctors at a large acute teaching trust. Factors evaluated included: experience working within a surgical rotation; previous consideration of a career in surgery; whether they found a career in surgery appealing; reasons guiding their decision and would they be applying to CST. Results All 67 foundation doctors approached agreed to participate: of which 56 (83.6%) had experience working within a surgical rotation. Males were significantly more likely to find a career in surgery appealing (p < 0.001). Although 20 (29.9%) had previously considered a surgical career, only 11 (16.4%) would be applying to CST. Reasons for finding a career in surgery appealing included: job satisfaction (84.2%), diversity of work (79.0%) and working environment/colleagues (47.4%). Of those that did not consider a career in surgery to be appealing, reasons included: working hours (75.0%), work/life balance (62.5%), working environment/colleagues (50%). Discussion and conclusion Although only a small proportion of current foundation doctors were surveyed in our study, only 16.4% were considering applying for CST. These figures are lower than previously suggested and would indicate that there will be fewer applicants for CST in future years, which may potentially reduce the current bottleneck of applicants at ST3.
 
Health care systems are often compared to evaluate and improve the delivery of healthcare to patients. The concept of ‘amenable mortality’ has been introduced as an indicator of quality of care.1 Amenable mortality is defined as deaths from a collection of diseases, such as diabetes and appendicitis, that are potentially preventable given effective and timely health care.1 This serves as a marker that highlights the performance of a health care system, although it has its limitations. A study by Nolte et al. found that the United States was slower to progress in improving amenable mortality when compared to United Kingdom, Germany, and France. 1 Table 1 showed that amenable mortality declined in all countries, although there was significant variation.1 Further, the authors compared those under 65 to those over 65 years old between the countries. Those in the US under 65 had larger amenable mortality compared to other countries. Whilst Those over 65 in all the countries declined in amenable mortality, the US had a slower improvement rate.1 In 2007 the US spent $7,290 US per capita on health care, more than twice the amount of France, Germany, and United Kingdom ($3,601; $3,588; $2,992 respectively) and yet the improvement in amenable mortality is half as good in certain populations compared to other Western countries.2 The commonality amongst the three European countries is that they provided universal health care, while the US did not have this option. This appears to be further evidence for the need for health care reform in the US.1
 
Illustration of SMV and SMPV resection. (SMV: superior mesenteric vein; SMPV: superior mesenteric portal vein confluence; SV: splenic vein; PV: portal vein).
Pre-neoadjuvant therapy triphasic CT scan: 3.2 cm × 2.5 cm head of pancreatic mass caused SMV/portal vein obstruction and superior mesenteric vein collateral circulation development.
Post-neoadjuvant therapy triphasic CT scan: Significant improvement of portal vein flow and diminished SMV collateral circulation.
Illustration of PV and SV anastomosis, SMV ligation. (SMV: superior mesenteric vein; SV: splenic vein; PV: portal vein).
62 year old Caucasian female with pancreatic head mass abutting the superior mesenteric vein (SMV) presented with fine needle aspiration biopsy confirmed diagnosis of ductal adenocarcinoma. CT scan showed near complete obstruction of portal vein and large SMV collateral development. After 3 months of neoadjuvant therapy, her portal vein flow improved significantly, SMV collateral circulation was diminished. Pancreaticoduodenectomy(PD) and superior mesenteric portal vein (SMPV) confluence resection were performed; A saphenous vein interposition graft thrombosed immediately. The splenic vein remnant was distended and adjacent to the stump of the portal vein. Harvesting an internal jugular vein graft required extra time and using a synthetic graft posed a risk of graft thrombosis or infection. As a result, we chose to perform a direct anastomosis of the portal and splenic vein in a desperate situation. The anastomosis decompressed the mesenteric venous system, so we then ligated the SMV. The patient had an uneventful postoperative course, except transient ascites. She redeveloped ascites more than one year later. At that time a PET scan showed bilateral lung and right femur metastatic disease. She expired 15 months after PD. Conclusion The lessons we learned are (1) Before SMPV confluence resection, internal jugular vein graft should be ready for reconstruction. (2) Synthetic graft is an alternative for internal jugular vein graft. (3) Direct portal vein to SMV anastomosis can be achieved by mobilizing liver. (4) It is possible that venous collaterals secondary to SMV tumor obstruction may have allowed this patient’s post-operative survival.
 
Author Helpful Policy (adapted from Marusic and Marusic 15 ) 
At its core, the purpose of healthcare is simple: to maximise quality and quantity of life. To achieve this vision, doctors have assumed an array of roles across a number of domains beyond the one-to-one patient-doctor interaction. Such domains include; teaching, research, leadership, management and clinical governance to name but a few. These roles and the healthcare systems in which they operate, have evolved over time to meet demand from patients, the profession, government and regulators. Further evolution is needed as we move into the 21st century to deal with the “perfect storm” of expensive technological advances, economic challenges and epidemiological changes.1 It is the trainees and students of today who will drive this progress in the future. Journals are a gateway to scientific progress and we believe there is a need for a journal to educate and develop the knowledge, skills and attitudes of trainees and students. Furthermore, over the past few years, the very nature of scientific journal publication has come under scrutiny.2 Hence we seek to establish a modern journal that deals with the challenges and opportunities of the 21st century.
 
Angiogram of the patient revealing right and left pulmonary venous system draining into a venous confluence. The venous confluence drains into the vertical vein which is connected to the superior vena cava through innominate vein. 
Trans-atrial trans-septal incision, opening the left atrium, a corresponding incision in the common pulmonary venous confluence and anastomosis. 
Total anomalous pulmonary venous drainage (TAPVD) accounts for approximately 1.5% of all congenital heart diseases. It is usually diagnosed in the neonatal period and is rarely seen in adults. We report an unusual case of a patient with TAPVD who was successfully treated at the age of 28 years. We believe that this is the oldest person in the South Asian literature to undergo surgical correction of TAPVD.
 
Magnetic Resonance Tomography showing a patent right common iliac pseudoaneurysm with Gadolinium enhancement. 
Angiography depicting an ecstatic distal aorta to 2.5 cm and short common iliac arteries with a right common iliac pseudoaneurysm. 
Digital Subtraction Angiography post procedure showing a corrected right common iliac artery pseudoaneurysm, covered aortic ectasia and preserved Left common iliac artery. 
We present the first case of 45 year-old male with an incidental non-symptomatic right common iliac artery pseudoaneurysm with concomitant aortic ectasia in the setting of severe alcoholic pancreatitis and a horseshoe kidney diagnosed by CT and MRA. Such findings would have posed significant difficulty during an open approach precluding safe surgical repair. Therefore, an exclusion endovascular repair of the pseudoaneurysm was employed using a unibody bifurcated endovascular aortic stent-graft to good results. Although not without their complications, endovascular stent-grafts may be life saving to patients who are not candidates for conventional surgical repair. We describe the diagnosis alongside our technique of endovascular repair.
 
Decisions about the appropriate termination of resuscitation attempts are among the most important that teams must face, yet there have been very few studies looking into the issue. Many national guidelines refer only to advance decisions to prevent the initiation of resuscitation, such as DNAR orders,1, 2 and 3 and yet the decision to continue or abort on-going treatment is a clinical one, which should be evidence based like any other. This observational study4 is one of the largest to examine the relationship between length of resuscitation efforts in hospital and outcome, and provides novel, powerful, and highly relevant results. The authors tested the hypothesis that hospitals with longer attempted duration of resuscitation in patients who don’t survive would correlate with higher hospital survival outcomes, both immediate and to discharge. They assessed whether higher survival rates were associated with poor neurological status; additionally they directly estimated risk ratios for various at-risk groups, including breakdowns by cardiac rhythm. Hospital data was collected from ‘Get With The Guidelines – Resuscitation’; the largest world-wide in-hospital resuscitation registry, managed by the American Heart Association.5 Between 2000–2008, 64,339 cardiac arrests were considered that lasted at least 2 minutes (to exclude ‘partial arrests’) in 435 hospitals in the USA, each with a minimum experience of at least 10 arrests over 8 years. Exclusions were made for Emergency Departments, operating theatres, postoperative areas, procedure areas, rehabilitation areas, and arrests with area unknown, to avoid the ‘distinct circumstances’ of arrests in those settings. The median value for each hospital was calculated, and hospitals were divided into quartiles based on median length of resuscitation in non-survivors, with corresponding lengths of 16, 19, 22, and 25 minutes. Median resuscitation times overall were 17 minutes (IQR 10-26), with a breakdown of 12 minutes (IQR 6-21) for immediate survivors and 20 minutes (IQR 14–30) for non-survivors.4
 
Top-cited authors
Edoardo Raposio
  • Università di Parma
Michele P. Grieco
  • Istituto di Cura e Cura a Carattere Scientifico Basilicata
Francesco Simonacci
  • Università di Parma
Nicolò Bertozzi
  • Università di Parma
Nail Obeidat
  • Jordan University of Science and Technology