1404 NELA Risk Mortality Scores from Admission to Theatre in Emergency Gastrointestinal Perforation – A Retrospective Cohort Study

Abstract Background Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The aim of this study was to assess delay, from symptom onset to theatre in patients with gastrointestinal perforation and its effect on perioperative risk. Method A single-centre retrospective study was performed in the Leeds Trust Hospitals, UK investigating the NELA database for patients requiring emergency laparotomy for perforated gastrointestinal viscus who presented to the acute surgical unit or emergency department between 1st February 2018 and 31st January 2020. Results 101 patients met the inclusion criteria (47% F and 53% M), mean age 59 [21-91]. 37% of patients’ NELA scores worsened from admission to pre-op (median change of + 5.9% IQR 1.3-11.5]), 14% stayed the same and 49% improved (median change of -4.4%[IQR 0.4-9.1]) 3% had their NELA score documented at the time of consent. 18% did not wait for a CT report or went straight to theatre. Mean time from admission to scan report was 9.3 hours (0.9-22.0). Median time from symptom onset to presentation (2 days [IQR 1-13]) was greater in patients with an Index of Multiple Deprivation Decile of 1-5, (n = 64, median 2 days [IQR 1-6]) compared to those in deciles 6-10, (n = 37, median 1 day[IQR 1-3]), p = 0.097. Conclusions NELA mortality risk score changes from presentation to surgery in patients with acute gastrointestinal perforation requiring emergency laparotomy. There is suggestion that delay in symptom onset to presentation may correlate with Index of Multiple Deprivation Decile.

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1020 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology

British Journal of Surgery ◽

10.1093/bjs/znab259.942 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

V Murray ◽

J Burke ◽

M Hughes ◽

C Schofield ◽

A Young

Keyword(s):

Systematic Review ◽

Symptom Onset ◽

Mortality Prediction ◽

Emergency Laparotomy ◽

Management Framework ◽

Gastrointestinal Pathology ◽

National Mortality ◽

Increased Risk ◽

The Impact ◽

Mean Time

Abstract Introduction Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality, and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions. Method A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. Results Eighty-five results were assessed to include 19 papers in the analysis. Fifteen unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway. Conclusions There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

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Are paediatric stabbings in London related to socioeconomic status?

Trauma ◽

10.1177/1460408618789967 ◽

2018 ◽

Vol 21 (4) ◽

pp. 310-316 ◽

Cited By ~ 1

Author(s):

Christine Lam ◽

Christopher Aylwin ◽

Mansoor Khan

Keyword(s):

Socioeconomic Status ◽

Penetrating Trauma ◽

Trauma Centre ◽

Interquartile Range ◽

Negatively Associated ◽

Multiple Deprivation ◽

Deprivation Score ◽

Major Trauma Centre ◽

Increased Risk ◽

Index Of Multiple Deprivation

Introduction Paediatric stabbings are on the increase across the United Kingdom, especially in large urban centres. Many London trauma centres are reporting a significant annual rise in the cases of penetrating trauma. Studies have shown victims with a lower socioeconomic status have an increased risk of paediatric penetrating trauma. This study aims to determine whether high depravity of an area increases the risk of paediatric stabbings in West London. We hypothesise that more deprived areas are likely to have a higher incidence of paediatric stabbings. Methods A retrospective review of data from the emergency department at a major trauma centre in West London was conducted using patient <18 years with a stabbing injury between March 2015 and July 2017. Gender, age, incident postcode and home postcode were collected. Socioeconomic status was measured using the 2015 English index of multiple deprivation. Incident postcode and home postcode were matched to an index of multiple deprivation decile, with 1 being the most deprived. Data were analysed using SPSS© Statistics 24. Results One hundred seventy-four cases were included; 97.7% of the cases were male and the mean age was 16 years. The location of the stabbings had a median index of multiple deprivation score of 3 (interquartile range = 3) with 61% of the cases occurring in areas with an index of multiple deprivation decile of 3 or less. Index of multiple deprivation decile from incident location and frequency of stabbing were strongly negatively associated (r = −0.85, p = 0.002). The victim’s home location had a median index of multiple deprivation score of 3 (interquartile range = 3) and 59.3% of victims living in areas with an index of multiple deprivation decile of less than 3. Again, they were strongly negatively associated (r = −0.85, p = 0.002). Conclusion The location of paediatric stabbings is associated with areas of high depravity and with victims from a more deprived background. To prevent paediatric stabbings, a multifactorial approach is required to increase the socioeconomic status of these areas.

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EP.FRI.752 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology – A Systematic Review

British Journal of Surgery ◽

10.1093/bjs/znab312.114 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Victoria Murray ◽

Joshua Burke ◽

Michael Hughes ◽

Claire Schofield ◽

Alistair Young

Keyword(s):

Systematic Review ◽

Symptom Onset ◽

Final Analysis ◽

Mortality Prediction ◽

Emergency Laparotomy ◽

Management Framework ◽

Gastrointestinal Pathology ◽

National Mortality ◽

Increased Risk ◽

The Impact

Abstract Aims Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions. Methods A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. Results 17 studies were included in the final analysis. 15 unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway. Conclusions There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

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Scottish Index of Multiple Deprivation (SIMD) Indicators as Predictors of Mortality Among Patients Hospitalised with COVID-19 Disease in the Lothian Region, Scotland During the First Wave: A Cohort Study

10.21203/rs.3.rs-1102651/v1 ◽

2021 ◽

Author(s):

Marcello S Scopazzini ◽

Roo Nicola Rose Cave ◽

Callum P Mutch ◽

Daniella A Ross ◽

Anda Bularga ◽

...

Keyword(s):

Cohort Study ◽

Primary Outcome ◽

Multivariable Analysis ◽

Multiple Deprivation ◽

Multiple Risk Factors ◽

Risk Of Mortality ◽

Increased Risk ◽

The Uk ◽

Index Of Multiple Deprivation ◽

Age And Sex

Abstract Background: Sars-CoV-2, the causative agent of COVID-19, has led to more than 100,000 deaths in the UK and multiple risk factors for mortality including age, sex and deprivation have been identified. This study aimed to identify which indicators of Scottish Index of Multiple Deprivation (SIMD), an area-based deprivation index, were predictive of mortality. Methods: This was a prospective cohort study of anonymised electronic health records of 710 consecutive patients hospitalised with Covid-19 disease between March and June 2020 in the Lothian Region of Southeast Scotland. Data sources included automatically extracted data from national electronic platforms and manually extracted data from individual admission records. Exposure variables of interest were SIMD quintiles and more specifically 12 indicators of deprivation deemed clinically relevant selected from the SIMD. Our primary outcome was mortality. Univariable and multivariable logistic regression analyses adjusted for age and sex were used to determine measures of association between exposures of interest and the primary outcome. Results: After adjusting for age and sex, we found an increased risk of mortality in the more deprived SIMD quintiles 1 and 3 (OR 1.75, CI 0.99-3.08, p=0.053 and OR 2.17, CI 1.22-3.86, p=0.009, respectively), but this association was not significant in our multivariable model adjusted for co-morbidities and clinical parameters of severity at admission. Of the 12 pre-selected indicators of deprivation, two were associated with greater mortality in our multivariable analysis: income deprivation rate categorised by quartile (Q4 (most deprived): 2.11 (1.20-3.77) p=0.011)) and greater than expected hospitalisations due to alcohol per SIMD data zone (1.96 (1.28-3.00) p=0.002)). Conclusions: In contrast to other studies, deprivation quintile distribution was not predictive of mortality in our cohort. This possibly reflects the greater affluence and ethnic homogeneity of the Lothian Region compared to the rest of Scotland. We identified an increased risk of mortality in patients residing in areas with greater income-deprivation and/or number of hospitalisations due to alcohol. In areas where aggregate measures fail to capture pockets of deprivation, specific indicators may be helpful in targeting resources to residents at risk of poorer outcomes from Covid-19.

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Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Therapeutic Advances in Neurological Disorders ◽

10.1177/17562864211021182 ◽

2021 ◽

Vol 14 ◽

pp. 175628642110211

Author(s):

Georgios Magoufis ◽

Apostolos Safouris ◽

Guy Raphaeli ◽

Odysseas Kargiotis ◽

Klearchos Psychogios ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Time Windows ◽

Intravenous Thrombolysis ◽

Inclusion Criteria ◽

Stroke Patients ◽

Treatment Algorithms ◽

Late Presenters

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

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Long-Term Physical Health Outcomes of Resettled Refugee Populations in the United States: A Scoping Review

Journal of Immigrant and Minority Health ◽

10.1007/s10903-021-01146-2 ◽

2021 ◽

Author(s):

Gayathri S. Kumar ◽

Jenna A. Beeler ◽

Emma E. Seagle ◽

Emily S. Jentes

Keyword(s):

Health Outcomes ◽

Physical Health ◽

Public Health Practice ◽

The United States ◽

Inclusion Criteria ◽

Physical Health Outcomes ◽

Increased Risk ◽

The Us ◽

Bhutanese Refugee

AbstractSeveral studies describe the health of recently resettled refugee populations in the US beyond the first 8 months after arrival. This review summarizes the results of these studies. Scientific articles from five databases published from January 2008 to March 2019 were reviewed. Articles were included if study subjects included any of the top five US resettlement populations during 2008–2018 and if data described long-term physical health outcomes beyond the first 8 months after arrival in the US. Thirty-three studies met the inclusion criteria (1.5%). Refugee adults had higher odds of having a chronic disease compared with non-refugee immigrant adults, and an increased risk for diabetes compared with US-born controls. The most commonly reported chronic diseases among Iraqi, Somali, and Bhutanese refugee adults included diabetes and hypertension. Clinicians should consider screening and evaluating for chronic conditions in the early resettlement period. Further evaluations can build a more comprehensive, long-term health profile of resettled refugees to inform public health practice.

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354 Differential Attainment in Surgical Training

British Journal of Surgery ◽

10.1093/bjs/znab134.131 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

Z Vinnicombe ◽

M Little ◽

J Super

Keyword(s):

Academic Performance ◽

Surgical Training ◽

General Medical Council ◽

Career Progression ◽

Medical Council ◽

Multiple Deprivation ◽

Surgical Trainees ◽

Economic Background ◽

The Relationship ◽

Index Of Multiple Deprivation

Abstract Introduction Differential attainment (DA), according to the General Medical Council (GMC), is the gap between attainment levels in different groups. Attainment measures should cover aspects that include academic performance and career progression. Two such areas in surgical training are the MRCS examinations and ARCPs, both of which are required for progression in a career in surgery. Our aim was to investigation whether socio-economic background was a significant factor for progression in surgical training. Method Data from the GMC for Core Surgical Trainees (CSTs) taking the MRCS examination between 2016 and 2019 and CST ARCP outcomes between 2017 and 2019 were obtained. Socio-economic background was assessed using the Index of Multiple Deprivation (IMD). ARCP and MRCS outcomes were assessed against IMD. Results Trainees from IMD Q1&2 (most deprived) had a significantly higher (p < 0.01) mean number of attempts (1.86) to pass MRCS examinations than trainees from IMD Q4&5 (least deprived) (1.54). IMD Q1&2 were significantly more likely to obtain unsatisfactory outcomes (24.4%) than trainees from IMD Q4&5 (14.2%) (p < 0.05). Conclusions There is clear evidence that differential attainment exists within Core Surgical Training. The reasons for this are likely to be complex and more work is needed to further investigate the relationship.

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Ruptured intra-abdominal testicular seminoma with hemorrhage shock, after inadequate surgical exploration for undescended testis: a case report

Surgical Case Reports ◽

10.1186/s40792-021-01143-5 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Hirotake Gonda ◽

Takuya Saito ◽

Takaaki Osawa ◽

Shintaro Kurahashi ◽

Tatsuki Matsumura ◽

...

Keyword(s):

Undescended Testis ◽

Pelvic Mass ◽

Major Axis ◽

Retroperitoneal Lymph Node Dissection ◽

Emergency Laparotomy ◽

Testicular Seminoma ◽

Increased Risk ◽

Pathological Evaluation ◽

Risk Of Malignancy ◽

Enhanced Computed Tomography

Abstract Background Undescended testes are associated with an increased risk of malignancy and infertility, and surgical treatment in childhood is recommended. Case presentation A 35-year-old man presented to the emergency department with abdominal pain and vomiting. Despite a history of surgery for a left undescended testis in infancy, his left-sided scrotum appeared underdeveloped. Contrast-enhanced computed tomography showed a pelvic mass, involving a major axis of approximately 15 cm, with high-density ascites suggestive of hemorrhage. A ruptured gastrointestinal stromal tumor was suspected. As he was in hemorrhagic shock, an emergency laparotomy was indicated. The active bleeding mass was controlled through complete resection. A pathological evaluation of the mass revealed a seminoma arising from an undescended testis. His post-operative course was uneventful, and he was discharged on post-operative day 6. Recurrence on the retroperitoneal lymph nodes was detected 1 year postoperatively, and a retroperitoneal lymph node dissection was performed after chemotherapy. He remains well without any apparent signs of recurrence. Conclusions Paying close attention to an empty scrotum is advisable, even postoperatively, for undescended testis because of possible subsequent potential malignancy presenting with hemorrhage, as our patient demonstrated.

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Osteoarthritis, mobility-related comorbidities and mortality: an overview of meta-analyses

Therapeutic Advances in Musculoskeletal Disease ◽

10.1177/1759720x20981219 ◽

2020 ◽

Vol 12 ◽

pp. 1759720X2098121

Author(s):

Gustavo Constantino de Campos ◽

Raman Mundi ◽

Craig Whittington ◽

Marie-Josée Toutounji ◽

Wilson Ngai ◽

...

Keyword(s):

Diabetes Mellitus ◽

Odds Ratio ◽

Meta Analysis ◽

Inclusion Criteria ◽

Increased Risk ◽

All Cause Mortality ◽

Ischemic Attack ◽

Meta Analyses ◽

The Relationship ◽

Related Mortality

Aims: The objective of this review was to examine the relationship between osteoarthritis (OA) and mobility-related comorbidities, specifically diabetes mellitus (DM) and cardiovascular disease (CVD). It also investigated the relationship between OA and mortality. Methods: An overview of meta-analyses was conducted by performing two targeted searches from inception to June 2020. The association between OA and (i) DM or CVD ( via PubMed and Embase); and (ii) mortality ( via PubMed) was investigated. Meta-analyses were selected if they included studies that examined adults with OA at any site and reported associations between OA and DM, CVD, or mortality. Evidence was synthesized qualitatively. Results: Six meta-analyses met inclusion criteria. One meta-analysis of 20 studies demonstrated a statistically significant association between OA and DM, with pooled odds ratio of 1.41 (95% confidence interval: 1.21, 1.65; n = 1,040,175 patients). One meta-analysis of 15 studies demonstrated significantly increased risk of CVD among OA patients, with a pooled risk ratio of 1.24 (1.12, 1.37, n = 358,944 patients). Stratified by type of CVD, OA was shown to be associated with increased heart failure (HF) and ischemic heart disease (IHD) and reduced transient ischemic attack (TIA). There was no association reported for stroke or myocardial infarction (MI). Three meta-analyses did not find a significant association between OA (any site) and all-cause mortality. However, OA was found to be significantly associated with cardiovascular-related death across two meta-analyses. Conclusion: The identified meta-analyses reported significantly increased risk of both DM and CVD (particularly, HF and IHD) among OA patients. It was not possible to confirm consistent directional or causal relationships. OA was found to be associated with increased mortality, but mostly in relation to CVD-related mortality, suggesting that further study is warranted in this area.

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863 Peri-Implant Fluid Collection in Breast Reconstruction and Aesthetic Surgery

British Journal of Surgery ◽

10.1093/bjs/znab134.330 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

G Karagiannidis ◽

E Mallidis

Keyword(s):

Reconstructive Surgery ◽

Cell Lymphoma ◽

Breast Implant ◽

Fluid Collection ◽

Aesthetic Surgery ◽

Large Cell ◽

Inclusion Criteria ◽

Electronic Data Collection ◽

Fluid Collections ◽

Mean Time

Abstract Introduction Peri-implant fluid more than 6 months from surgery is a known complication of breast surgery.Differential diagnosis includes infection, inflammation,implant rupture and haematoma.Other than infection raised no concern until the identification of Breast Implant Associated Anaplastic Large Cell Lymphoma(BIA-ALCL). Method Retrospective electronic data collection for women 18 years or older who met the following inclusion criteria:(a)oncoplastic and/or cosmetic reconstructive surgery with placement of implant(b)peri-implant fluid collection after 6-36 months. Results In total,17 women with implants with a mean age of 56 years were included in the study.The mean time between reconstructive surgery and the peri-implant fluid collection was 23 months.The median peri-implant fluid collection size was 143 ml.14 of the 17 peri-implant fluid collections were benign.12 of 14 had polyurethane-coated textured implants.4 of the 17 were BIA-ALCL. Conclusions The current literature suggests that late peri-implant seromas arise from friction as the implant moves within the cavity and that this friction is increased with textured rather than smooth implants.In our unit 12/14 of the benign collections appeared in reconstructions with polyurethane implants.Furthermore,BIA-ALCL should always be considered in this situation and aspirate should be sent for cytology.Is this change in polyurethane implants a new entity?

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