Can the neural representation of physical pain predict empathy for pain in others?

The question of whether physical pain and vicarious pain have some shared neural substrates is unresolved. Recent research has argued that physical and vicarious pain are represented by dissociable multivariate brain patterns by creating biomarkers for physical pain (Neurologic Pain Signature, NPS) and vicarious pain (Vicarious Pain Signature, VPS), respectively. In the current research, the NPS and two versions of the VPS were applied to three fMRI datasets (one new, two published) relating to vicarious pain which focused on between-subject differences in vicarious pain (Datasets 1 and 3) and within-subject manipulations of perspective taking (Dataset 2). Results show that (i) NPS can distinguish brain responses to images of pain vs no-pain and to a greater extent in vicarious pain responders who report experiencing pain when observing pain and (ii) neither version of the VPS mapped on to individual differences in vicarious pain and the two versions differed in their success in predicting vicarious pain overall. This study suggests that the NPS (created to detect physical pain) is, under some circumstances, sensitive to vicarious pain and there is significant variability in VPS measures (created to detect vicarious pain) to act as generalizable biomarkers of vicarious pain.

Telemedicine and Its Perceptions in a Border Community: A Review of How Health Care Technology Has Helped Increase Access

Introduction: Telemedicine is a practical way of offering medical services to remote and underserved areas. During the COVID-19 pandemic, telemedicine has provided convenient access to health care and has overcome barriers such as distance that prevent patients from receiving care. Border populations are impacted by this change in health care delivery. The goal of this study was to investigate how a border patient population perceives their experiences with telemedicine. Methods: We utilized telephone surveys of patients who had a recent telehealth visit at the Texas Tech University Health Science Center (TTUHSC) Family Medicine Center clinic in El Paso, Texas. Survey measures included patients' demographics, a quality assessment of the patients' most recent telehealth visit and their experience, a comparison of the patients' telehealth visit to past in-person visits, and a rating of their telehealth visit. Result: Over 2,000 individuals (n = 2,040), primarily Hispanic females, older than the age of 44 years were identified for potential inclusion in the study. Of these, 928 had a contact attempt, of which 1,378 could not be contacted, 592 were invited, 70 declined leading to a response rate of 67.6% (number invited/completed the survey). Most patients agreed that during their most recent telehealth visit their clinician listened well (98.7%), spent adequate time with them (98.2%), was prompt (94.5%), explained things well (98.0%), and was someone they would recommend to others (97.2%). When comparing telehealth to in-person visits, patients reported the following: less wait time, easier convenience, and similar quality between virtual and in-person visits. Patients rated both their likelihood of using telehealth again and their likelihood of recommending telehealth to others as an 8.68 out of 10, on average. Patients 65 years old or older had 3.17 times greater likelihood of satisfaction with virtual visits when compared with patients younger than 45 years old (confidence interval [95% CI], 1.24-11.11). Patients also had less satisfaction with virtual visits if they had lower educational attainment (odds ratio = 0.10; 95% CI, 0.01-0.81). Conclusions: We found that individuals in a border community had a positive experience with telehealth primary care visits. This approach may improve access to health care.

Representation of marginalised populations in digital surveillance for notifiable conditions in Australia: a systematic review

AIM

This study aims to establish whether digital surveillance methods for notifiable diseases in Australia collect and report data in relation to marginalised populations.

METHODS

The literature was systematically reviewed to identify primary research studies published between January 2005 and July 2023. Studies were included if they described an Australian digital surveillance system for notifiable conditions. The results were synthesised with a focus on evaluating the collection and reporting of data in relation to marginalised populations.

RESULTS

A total of 13 articles reporting on seven surveillance systems were identified. Influenza and adverse events following immunisation were the two most common notifiable conditions monitored. A total of six surveillance systems encompassing 16 articles reported information on sub-populations. Of these, three surveillance systems (nine articles) included data on marginalised populations.

CONCLUSION

The data collected or reported in relation to sub-groups that characterise diversity in terms of health care needs, access, and marginalised populations are minimal. It is recommended that a set of equity and reporting principles is established for the future creation and use of any digital surveillance system.

Adjunctive technologies in postoperative free-flap monitoring: a systematic review

Patent microvascular anastomoses are essential for successful free tissue transfer. Early accurate detection of microvascular compromise is required for flap salvage. Adjunctive monitoring techniques, in addition to clinical examination, are increasingly used to detect flap compromise. This systematic review synthesized and appraised the literature to determine the efficacy of different postoperative monitoring technologies. Rates of flap takeback, salvage, failure, and mean time to detection of microvascular compromise were extracted, synthesized, and reviewed. Twenty-two studies were included, comprising 6370 flaps. One thousand three hundred and ninety-five flaps were monitored with Cook Swartz Doppler (21.83%), 1417 flaps with tissue oximetry (22.24%), 291 with laser Doppler (4.56%), 175 with duplex echography (2.74%), 210 with indocyanine green (ICG) fluorescence (3.30%), 196 with Synovis flow coupler (3.07%), and 81 (1.27%) with light spectroscopy. The overall true positive rate for microvascular compromise in taken back flaps was 70.18%. Cook Swartz Doppler (n = 1391) had a true positive rate of 80.17% and 83.63% salvage rate and was associated with an overall 2.60% rate of flap failure. Tissue oximetry (n = 1417) had a true positive rate of 74.76% and a salvage rate of 88.62%. Laser Doppler, duplex echography, light spectroscopy, and Synovis flow coupler demonstrated true positive rates between 69.4% and 100% with salvage rates between 64% and 100%. Cook Swartz Doppler and tissue oximetry are associated with prompt identification of microvascular compromise and return to theatre. Alternative modalities, including near-infrared spectroscopy, laser Doppler, and duplex echography, show promise. Further well-designed randomised controlled trials (RCTs) appraising head-to-head efficacy are required to comparatively assess adjunctive technologies.

Trajectories of otitis media and association with health determinants among Indigenous children in Australia: the Longitudinal Study of Indigenous Children

OBJECTIVES

Indigenous children in Australia experience high burden of persistent otitis media (OM) from very early age. The aim was to identify distinct trajectories of OM in children up to age 10-12 years and examine the association with socio-economic determinants.

STUDY DESIGN

A multistage clustered national panel survey.

METHODS

The study analysed the birth cohort of the Longitudinal Study of Indigenous Children from 2008 to 2018, comprising 11 study waves. Group-based trajectory modelling was used to identify different trajectories of OM outcome. Multinomial logistic regression was applied to examine the relationship between trajectories and individual, household and community-level socio-economic determinants.

RESULTS

This analysis included 894 children with at least three responses on OM over the 11 waves, and the baseline mean age was 15.8 months. Three different trajectories of OM were identified: non-severe OM prone, early/persistent severe OM and late-onset severe OM. Overall, 11.4% of the children had early/persistent severe OM from birth to 7.5 to nine years, while late-onset severe OM consisted of 9.8% of the children who had first OM from age 3.5 to five years. Children in communities with middle and the highest socio-economic outcomes have lower relative risk of early/persistent severe OM (adjusted relative risk ratio = 0.39, 95% confidence interval = 0.22-0.70 and adjusted relative risk ratio = 0.22, 95% confidence interval = 0.09-0.52, respectively) compared to children in communities with lowest socio-economic outcomes.

CONCLUSION

Efforts to close the gap in the quality of life of Indigenous children must prioritise strategies that prevent severe ear disease (runny ears and perforation), including improved healthcare access, reduced household crowding, and better education, and more employment opportunities.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Emojis and Emoticons in Health Care and Dermatology Communication: Narrative Review

Background

Emoticons and emojis have become staple additions to modern-day communication. These graphical icons are now embedded in daily society through the various forms of popular social media and through users’ personal electronic conversations. With ever-increasing use and inclusivity, exploration of the possible health care and dermatology applications of these tools is imperative.

Objective

The goal of this narrative review was to provide and evaluate an up-to-date literature survey examining the utility of emoticons and emojis in medicine. Special attention was paid to their existing and potential uses in the field of dermatology, especially during the COVID-19 pandemic.

Methods

A PubMed search of peer-reviewed publications was performed in mid-2021 to collect articles with emoticon or emoji keywords in combination with other health care–relevant or dermatology-relevant keywords. Screening of publications and described studies was performed by the authors with education and research experience in health care, dermatology, social media, and electronic communication trends. Selected articles were grouped based on common subjects for qualitative analysis and presentation for in-depth discussion.

Results

From this extensive search, researchers were able to identify a wide variety of publications detailing the use of emoticons and emojis in general health care, pediatric health care, public health, and dermatology. Key subject areas that emerged from the investigation included the ability of emoticons and emojis to improve communication within pediatric health care, enhance mood and psychological assessment or mental health screening in adults, develop interventions to improve patient medication adherence, complement novel means of public health and COVID-19 surveillance, and bolster dermatology-specific applications.

Conclusions

This review illuminated the repurposing of emojis and emoticons for a myriad of advantageous functions in health care and public health, with applications studied in many populations and situations. Dermatology-specific uses were relatively sparse in the literature, highlighting potential opportunities for growth in future studies and practices. The importance of diversity and inclusivity has extended to emojis, with the recent introduction of skin color customization and new emojis better representing the comprehensive spectrum of users’ experiences. A continuously evolving and technology-driven population creates a unique niche for emoticons and emojis to ease worldwide communication and understanding, transcending the barriers of age, language, and background. We encourage future studies and innovations to better understand and expand their utility.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Learning from alcohol (policy) reforms in the Northern Territory (LEARNT): protocol for a mixed-methods study examining the impacts of the banned drinker register

INTRODUCTION

The Banned Drinker Register (BDR) was reintroduced in the Northern Territory (NT) in September 2017. The BDR is a supply reduction measure and involves placing people who consume alcohol at harmful levels on a register prohibiting the purchase, possession and consumption of alcohol. The current study aims to evaluate the impacts of the reintroduction of the BDR, in the context of other major alcohol policy initiatives introduced across the NT such as Police Auxiliary Liquor Inspectors and a minimum unit price for alcohol of US$1.30 per standard drink.

METHODS AND ANALYSES

The Learning from Alcohol (policy) Reforms in the Northern Territory project will use a mixed-methods approach and contain four major components: epidemiological analysis of trends over time (outcomes include health, justice and social welfare data); individual-level data linkage including those on the BDR (outcomes include health and justice data); qualitative interviews with key stakeholders in the NT (n≥50); and qualitative interviews among people who are, or were previously, on the BDR, as well as the families and communities connected to those on the BDR (n=150). The impacts of the BDR on epidemiological data will be examined using time series analysis. Linked data will use generalised mixed models to analyse the relationship between outcomes and exposures, utilising appropriate distributions. Qualitative data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from NT Department of Health and Menzies School of Health Research Human Research Ethics Committee (HREC), Central Australia HREC and Deakin University HREC. In addition to peer-reviewed publications, we will report our findings to key organisational, policy, government and community stakeholders via conferences, briefings and lay summaries.

Attention, flexibility, and imagery in misophonia: Does attention exacerbate everyday disliking of sound?

INTRODUCTION

Misophonia is an unusually strong aversion to everyday sounds, such as chewing, crunching, or breathing. Here, we ask whether misophonia might be tied to an unusual profile of attention (and related traits), which serves to substantially heighten an otherwise everyday disliking of sounds.

METHODS

In Study 1, we tested 136 misophonics and 203 non-misophonics on self-report measures of attention to detail, cognitive inflexibility, and auditory imagery, as well as collecting details about their misophonia. In Study 2, we administered the Embedded Figures task to 20 misophonics and 36 non-misophonics.

RESULTS

We first showed that the degree to which sounds trigger misophonia reflects the pattern by which they are (more mildly) disliked by everyone. This suggests that misophonia is scaffolded onto existing mechanisms rather than qualitatively different ones. Compared to non-misophonics, we also found that misophonics self-reported greater attention to detail, cognitive inflexibility, and auditory imagery. As their symptoms worsen, they also become more accurate in an attentional task (Embedded Figures).

CONCLUSIONS

Our findings provide a better understanding of misophonia and support the hypothesis that dispositional traits of attention to detail may be key to elevating everyday disliking of sound into the more troubling aversions of misophonia.

Identification of the novel HLA-DRB1*15:184 allele by Next-Generation Sequencing

HLA-DRB1*15:184 differs from HLA-DRB1*15:01:01 by a single base substitution in exon 3 at codon 134. This article is protected by copyright. All rights reserved.

Identification of the novel HLA-B*42:28 allele by Next-Generation Sequencing

HLA-B*42:28 differs from HLA-B*42:01:01 by a single base substitution in exon 4 at codon 267.2. This article is protected by copyright. All rights reserved.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

1134 Incidence of Bile Acid Diarrhoea Post-Cholecystectomy - A Single Centre Cohort

Aim

Bile acid diarrhoea (BAD) can occur as a result of enterohepatic circulation interruption following cholecystectomy. Although up to 57.2% of patients are reported to develop post-cholecystectomy diarrhoea, this is not always because of BAD. The aim of this study was to determine the incidence of post-cholecystectomy BAD diagnosis and evaluate the current practices.

Method

This study was conducted as part of BADCAP study. The electronic records of patients underwent cholecystectomy operation at Oxford University Hospitals between January 2013 and December 2017 were retrospectively analysed. Records were matched with patients who underwent 75SeHCAT testing during the same time period. A positive 75SeHCAT testing was defined as a seven-day retention time of &lt; 15%.

Results

A total of 4327 patients underwent cholecystectomy operation. 2.05% (N = 89) investigated for diarrhoea by 75SeHCAT. Alongside 75SeHCAT, 69.7% (N = 62) had colonoscopy, 37.1% (N = 33) had CT abdomen and pelvis and 3.4% (N = 3) had MRCP/MRE. Gender wise statistics revealed females were 74.5% (N = 73) and males were 19.1% (N = 17). Median time from cholecystectomy to 75SeHCAT test was 780 days (SD +/-510 days). 70.8% (N = 63) had a positive 75SeHCAT test for BAD. IBD was confirmed in 2.2% (N = 2).

Conclusions

A small number of patients were investigated and only 1.5% were diagnosed with post-cholecystectomy diarrhoea. There was a significant time delay from operation to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher and clinicians need to have an increased awareness of this condition. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.

968 Delivering Human Factors and Non-Technical Skills Training Using Interactive Online Platforms in the COVID Era

Aim

To evaluate the impact and effectiveness of an interactive online human factors (HF) and non-technical skills (NTS) course delivered to Core Surgical Trainees during the COVID-19 pandemic

Method

A 1-day HF and NTS course was conducted online, using the Zoom platform, to Core Surgical Trainees in the North West. The course consisted of interactive lectures, small group teaching sessions, and self-directed learning with written reflections. Pre- and post-course surveys were administered, evaluating the participants’ awareness, knowledge and skills using a 5-part Likert scale, along with a multiple-choice assessment of knowledge. Statistical analysis was undertaken with significance considered at p &lt; 0.05

Results

The course was attended by 63 CT1/2 participants, representing all surgical specialties. In the post-course evaluation, participants’ self-rating of awareness and knowledge for both HF and patient safety increased by between 10-20%. There was a significant increase in the mean post-course test score from 7.54 (SD ± 1.7) to 8.65 (SD ± 1.2) out of 10 (p &lt; 0.0001). The course overall was rated relevant and useful (weighted averages 4.4 and 4.5 respectively)

Conclusions

To our knowledge, this is the first time a video conferencing platform has been used to deliver a live HF/NTS course. This study provides evidence supporting the use of such interactive online platforms in postgraduate surgical education. Training and professional development must continue, despite the evolving pressures from COVID-19. Embracing new methods of education delivery is required, with ongoing reporting and evaluation of education practice, sharing lessons learned and informing the evidence base in postgraduate surgical training during this time

What is the Link Between Mental Imagery and Sensory Sensitivity? Insights from Aphantasia

People with aphantasia have impoverished visual imagery so struggle to form mental pictures in the mind's eye. By testing people with and without aphantasia, we investigate the relationship between sensory imagery and sensory sensitivity (i.e., hyper- or hypo-reactivity to incoming signals through the sense organs). In Experiment 1 we first show that people with aphantasia report impaired imagery across multiple domains (e.g., olfactory, gustatory etc.) rather than simply vision. Importantly, we also show that imagery is related to sensory sensitivity: aphantasics reported not only lower imagery, but also lower sensory sensitivity. In Experiment 2, we showed a similar relationship between imagery and sensitivity in the general population. Finally, in Experiment 3 we found behavioural corroboration in a Pattern Glare Task, in which aphantasics experienced less visual discomfort and fewer visual distortions typically associated with sensory sensitivity. Our results suggest for the very first time that sensory imagery and sensory sensitivity are related, and that aphantasics are characterised by both lower imagery, and lower sensitivity. Our results also suggest that aphantasia (absence of visual imagery) may be more accurately defined as a subtype of a broader imagery deficit we name dysikonesia, in which weak or absent imagery occurs across multiple senses.

Perineal reconstruction supplemented by abdominal advancement following recurrent penile cancer: Two cases

Reconstruction after excision of locoregionally recurrent penile cancer can be a surgical challenge. In this short study, we present two cases of perineal reconstruction using bilateral gracilis flaps supplemented by abdominal advancement for salvage of recurrent penile cancer, reviewing relevant literature and outlining our local approach to the perineum.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Different psychophysiological and clinical symptoms are linked to affective versus sensory vicarious pain experiences

For some people, seeing pain in others triggers a pain-like experience in themselves: these experiences can either be described in sensory terms and localized to specific body parts (sensory-localized, or S/L) or in affective terms and nonlocalized or whole-body experiences (affective-general, or A/G). In two studies, it is shown that these are linked to different clinical and psychophysiological profiles relative to controls. Study 1 shows that the A/G profile is linked to symptoms of Blood-Injection-Injury Phobia whereas the S/L profile shows some tendency toward eating disorders. Study 2 shows that the A/G profile is linked to poor interoceptive accuracy (for heartbeat detection) whereas the S/L profile is linked to higher heart-rate variability (HRV) when observing pain, which is typically regarded as an index of good autonomic emotion regulation. Neither group showed significant differences in overall heart rate, systolic blood pressure (SBP), or skin conductance response (SCR) when observing pain, and no overall differences in state or trait anxiety. Overall, the research points to different underlying mechanisms linked to different manifestations of vicarious pain response. Affective-General pain responders have strong subjective bodily experiences (likely of central origin given the absence of major differences in autonomic responsiveness) coupled with a worse ability to read objective interoceptive signals. Sensory-localized pain responders have differences in their ability to construct a multi-sensory body schema (as evidenced by prior research on the Rubber Hand Illusion) coupled with enhanced cardiovagal (parasympathetic) reactivity often indicative of better stress adaptation.

91 Mrs Bad Bones: Impact of COVID-19 on Secondary Prevention of Fragility Fractures

Introduction

Management of osteoporosis is an important consideration for neck of femur fracture patients due to the morbidity and mortality it poses, and the significant financial burden to the NHS. Orthogeriatric teams input is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of healthcare teams and led to the redeployment of the orthogeriatricians to assist with the influx of medically unwell patients. This study explored the impact COVID-19 had on secondary fragility fracture prevention.

Method

A retrospective audit looking at the prescription of vitamin D/calcium supplements, bone-sparing medications, and DEXA scan requests in consecutive neck of femur fracture patients admitted to a trauma and orthopaedic unit pre- and post- UK lockdown in response to the pandemic. A re-audit was conducted following the implementation of our new mnemonic, “MRS BAD BONES”: Medication Review Rheumatology/Renal Advice Smoking Cessation Blood tests Alcohol limits DEXA scan Bone-sparing medications Orthogeriatric review Nutrition Exercise Supplements.

Results

Data for 50 patients was available in each phase. The orthogeriatric team reviewed 88% of patients pre-lockdown falling to 0% due to redeployment, before recovering to 38% in the post-intervention period. Upon lockdown there was a significant drop in the prescription of vitamin D/calcium supplements from 81.6% to 58.0% (p = 0.0156); of bone-sparing medications from 60.7% to 18.2% (p = 0.0037), and DEXA scan requests from 40.1% to 3.6% (p = 0.0027). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (p = 0.0034), bone-sparing medications to 72.4% (p = 0.0002) and DEXA scan requests to 60% (p < 0.0001).

Conclusion

COVID-19 had a major impact on the secondary prevention of fragility fractures in this population. The “MRS BAD BONES” mnemonic significantly improved the management and could be considered for use in a wider setting.

Trait phenomenological control predicts experience of mirror synaesthesia and the rubber hand illusion

In hypnotic responding, expectancies arising from imaginative suggestion drive striking experiential changes (e.g., hallucinations) - which are experienced as involuntary - according to a normally distributed and stable trait ability (hypnotisability). Such experiences can be triggered by implicit suggestion and occur outside the hypnotic context. In large sample studies (of 156, 404 and 353 participants), we report substantial relationships between hypnotisability and experimental measures of experiential change in mirror-sensory synaesthesia and the rubber hand illusion comparable to relationships between hypnotisability and individual hypnosis scale items. The control of phenomenology to meet expectancies arising from perceived task requirements can account for experiential change in psychological experiments.

Clinical presentation, cardiovascular findings, etiology, and outcome of myocarditis in dogs: 64 cases with presumptive antemortem diagnosis (26 confirmed postmortem) and 137 cases with postmortem diagnosis only (2004-2017)

INTRODUCTION

This study describes presentation, cardiovascular abnormalities, etiology, and outcome of canine myocarditis in geographic areas not endemic for Trypanosoma or Leishmania.

ANIMALS

Sixty-four (presumed antemortem diagnosis) and 137 (postmortem diagnosis only) client-owned dogs at two tertiary care facilities were included.

MATERIALS AND METHODS

Medical records of dogs with clinical or histopathological diagnosis of myocarditis were reviewed retrospectively.

RESULTS

Common examination findings in dogs with a presumed antemortem diagnosis included fever (21%) and heart murmur (19%). Median cardiac troponin I was 12.2 ng/mL (range: 0.2-808.0 ng/mL), and troponin exceeded 1.0 ng/mL in 26 of 29 (90%) dogs. Ventricular ectopy was the most common arrhythmia (54%), whereas decreased left ventricular systolic function was the most common echocardiographic abnormality (56%). An infectious etiology was diagnosed in 35 of 64 (55%) dogs. Confirmed infectious etiologies included bacterial sepsis (n = 9) or extension of endocarditis (3), toxoplasmosis or neosporosis (3), parvovirus (2), and one case each of bartonellosis, trypanosomiasis, leptospirosis, and dirofilariasis. Median survival time was 4 days (range: 0-828 days) for all dogs vs. 82 days for dogs who survived at least 2 weeks after diagnosis. Presence of pericardial effusion or azotemia was a significant predictor of non-survival. The most common inflammatory infiltrate on histopathology was neutrophilic (47%), and 20 of 137 (14.5%) dogs had concurrent bacterial endocarditis on postmortem.

CONCLUSIONS

Bacterial infection was the most common confirmed etiology of myocarditis in this study. Prognosis for canine myocarditis is guarded and similar to that reported for infective endocarditis. Criteria for the antemortem diagnosis of canine myocarditis are suggested.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

X-ray diffraction at the National Ignition Facility

We report details of an experimental platform implemented at the National Ignition Facility to obtain in situ powder diffraction data from solids dynamically compressed to extreme pressures. Thin samples are sandwiched between tamper layers and ramp compressed using a gradual increase in the drive-laser irradiance. Pressure history in the sample is determined using high-precision velocimetry measurements. Up to two independently timed pulses of x rays are produced at or near the time of peak pressure by laser illumination of thin metal foils. The quasi-monochromatic x-ray pulses have a mean wavelength selectable between 0.6 Å and 1.9 Å depending on the foil material. The diffracted signal is recorded on image plates with a typical 2θ x-ray scattering angle uncertainty of about 0.2° and resolution of about 1°. Analytic expressions are reported for systematic corrections to 2θ due to finite pinhole size and sample offset. A new variant of a nonlinear background subtraction algorithm is described, which has been used to observe diffraction lines at signal-to-background ratios as low as a few percent. Variations in system response over the detector area are compensated in order to obtain accurate line intensities; this system response calculation includes a new analytic approximation for image-plate sensitivity as a function of photon energy and incident angle. This experimental platform has been used up to 2 TPa (20 Mbar) to determine the crystal structure, measure the density, and evaluate the strain-induced texturing of a variety of compressed samples spanning periods 2-7 on the periodic table.

Prevalence and Epidemiological Pattern of Abdominal Aortic Aneurysms in Africa: A Systematic Review

Introduction

The incidence of abdominal aortic aneurysms (AAAs) in high-income countries has been declining in the last three decades. However, in most low-income and middle-income countries especially in Africa, little is known about its burden. The absence of screening services for AAA in African countries makes it difficult to detect and promptly manage AAA before rupture, which has significant implications for mortality. This study sought to systematically assess the prevalence of AAA amongst patients visiting hospitals in Africa and evaluate its epidemiological pattern.

Materials and Methods

A systematic review was performed on the EMBASE, GLOBAL HEALTH, MEDLINE, and PUBMED databases. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement standards and protocol registered with PROSPERO (CRD42020162214). A data extraction tool was used to get relevant information from these studies. Quality assessment and risk of bias were performed using the Newcastle Ottawa Scale for cross-sectional studies. Results were summarised in tables, figures, and a forest plot. A narrative synthesis approach of the articles was taken.

Results

Two hundred and sixty-one studies were identified and after the exclusion of 246, a final 15 were deemed suitable for analysis. A total of 4012 participants were screened for AAA and of these, 129 cases were identified. The prevalence of AAA in these studies ranged from 0.7 to 6.4%. Male participants accounted for 115 (89.1%) of the cases. There was a wide age range (31-72 years) reflective of both its possible infective and degenerative aetiology. AAA was reported to be associated with hypertension, smoking, advanced age, coronary artery disease, and HIV infection. There was no association between AAA and diabetes. Over 50% of cases were identified incidentally. About one-third (23-54%) of the participants presented aortic rupture with a mortality rate ranging between 65 and 72%.

Conclusions

AAA prevalence in Africa is probably higher than the current thinking as there is no baseline data to compare with. Aetiologically, AAA was shown to be associated with hypertension, smoking, coronary artery disease, and possibly infectious pathologies like HIV. Large epidemiological studies would help better characterise AAA in this setting. Lastly, efforts targeting the reduction of the risk factors for AAA would go a long way in reducing the burden of AAA.

Use of rivaroxaban for treatment of cranial vena cava syndrome secondary to transvenous pacemaker lead thrombosis in a dog

A six-year-old Brussels griffon was presented for cervical swelling three months after implantation of a transvenous pacemaker. Transthoracic echocardiography demonstrated a thrombus associated with the pacemaker lead, partially obstructing right atrial inflow. The laboratory findings were consistent with protein-losing nephropathy. Initial medical therapy consisted of rivaroxaban (0.68 mg/kg orally every 24 hours), clopidogrel (2.5 mg/kg orally every 24 hours), and enalapril (0.5 mg/kg orally every 12 hours). Resolution of cervical and thoracic edema was noted within two weeks of initiating therapy. Recheck echocardiography two months and one year later revealed decreasing thrombus size despite worsening proteinuria. To the authors' knowledge, this is the first documented use of rivaroxaban for successful medical treatment of cranial vena cava syndrome caused by intracardiac pacemaker lead thrombosis in a hypercoagulable patient.

Acute pseudogout – Measure serum magnesium

We report a 49-year-old woman with an acute swollen left knee due to acute pseudogout with chondrocalcinosis as a presenting feature of Gitelman syndrome due a novel homozygous mutation of the SLC12A3 gene. This report highlights the under-recognized importance of excluding metabolic disease, including Gitelman syndrome, in younger patients whose sole presenting feature may be chondrocalcinosis with or without pseudogout, as this may impact on management and risk of further episodes. We also suggest that chondrocalcinosis and hypomagnesaemia with or without hypokalaemia are diagnostic of Gitelman syndrome.

Multisensory enhancement of attention depends on whether you are already paying attention

Multisensory stimuli are argued to capture attention more effectively than unisensory stimuli due to their ability to elicit a super-additive neuronal response. However, behavioural evidence for enhanced multisensory attentional capture is mixed. Furthermore, the notion of multisensory enhancement of attention conflicts with findings suggesting that multisensory integration may itself be dependent upon top-down attention. The present research resolves this discrepancy by examining how both endogenous attentional settings and the availability of attentional capacity modulate capture by multisensory stimuli. Across a series of four studies, two measures of attentional capture were used which vary in their reliance on endogenous attention: facilitation and distraction. Perceptual load was additionally manipulated to determine whether multisensory stimuli are still able to capture attention when attention is occupied by a demanding primary task. Multisensory stimuli presented as search targets were consistently detected faster than unisensory stimuli regardless of perceptual load, although they are nevertheless subject to load modulation. In contrast, task irrelevant multisensory stimuli did not cause greater distraction than unisensory stimuli, suggesting that the enhanced attentional status of multisensory stimuli may be mediated by the availability of endogenous attention. Implications for multisensory alerts in practical settings such as driving and aviation are discussed, namely that these may be advantageous during demanding tasks, but may be less suitable to signaling unexpected events.

Availability of less invasive prenatal, perinatal and paediatric autopsy will improve uptake rates: a mixed-methods study with bereaved parents

Objective

To investigate whether less invasive methods of autopsy would be acceptable to bereaved parents and likely to increase uptake.

Design

Mixed methods study.

Setting

Bereaved parents recruited prospectively across seven hospitals in England and retrospectively through four parent support organisations.

Sample

Eight hundred and fifty‐nine surveys and 20 interviews with bereaved parents.

Methods

Cross‐sectional survey and qualitative semi‐structured telephone interviews.

Main outcome measures

Likely uptake, preferences, factors impacting decision‐making, views on different autopsy methods.

Results

Overall, 90.5% of participants indicated that they would consent to some form of less invasive autopsy [either minimally invasive autopsy (MIA), non‐invasive autopsy (NIA) or both]; 53.8% would consent to standard autopsy, 74.3% to MIA and 77.3% to NIA. Regarding parental preferences, 45.5% preferred MIA, 30.8% preferred NIA and 14.3% preferred standard autopsy. Participants who indicated they would decline standard autopsy but would consent to a less invasive option were significantly more likely to have a lower educational level (odds ratio 0.49; 95% CI 0.35–0.70; P = 0.000062). Qualitative findings suggest that parents value NIA because of the lack of any incision and MIA is considered a good compromise as it enables tissue sampling while easing the parental burden associated with consenting to standard autopsy.

Conclusion

Less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience. Further health economic, validation and implementation studies are now required to assess the viability of offering these in routine widespread clinical care.

Tweetable abstract

Mixed methods UK study finds less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience.

Mixed methods UK study finds less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience.

The association of parental and offspring educational attainment with systolic blood pressure, fasting blood glucose and waist circumference in Latino adults

Objective

The objective of the study is to evaluate the association of intergenerational educational attainment with cardiovascular disease (CVD) risk factors among US Latinos.

Methods

We used cross‐sectional data from the Niños Lifestyle and Diabetes Study, an offspring cohort of middle‐aged Mexican‐Americans whose parents participated in the Sacramento Latino Study on Aging. We collected educational attainment, demographic and health behaviours and measured systolic blood pressure (SBP), fasting glucose and waist circumference. We evaluated the association of parental, offspring and a combined parent–offspring education variable with each CVD risk factor using multivariable regression.

Results

Higher parental education was associated only with smaller offspring waist circumference. In contrast, higher offspring education was associated with lower SBP, fasting glucose and smaller waist circumference. Adjustment for parental health behaviours modestly attenuated these offspring associations, whereas adjustment for offspring health behaviours and income attenuated the associations of offspring education with offspring SBP and fasting glucose but not smaller waist circumference, even among offspring with low parental education.

Conclusions

Higher offspring education is associated with lower levels of CVD risk factors in adulthood, despite intergenerational exposure to low parental education.

Tobacco exposure and sleep disturbance in 498 208 UK Biobank participants

Background

The prevalence of sleep disturbance is high and increasing. The study investigated whether active, former and passive smoking were associated with sleep disturbance.

Methods

This cross-sectional study used data from the UK Biobank: a cohort study of 502 655 participants, of whom 498 208 provided self-reported data on smoking and sleep characteristics. Multivariable multinomial and logistic regression models were used to examine the associations between smoking and sleep disturbance.

Results

Long-sleep duration (>9 h) was more common among current smokers [odds ratio (OR): 1.47; 95% confidence interval (CI): 1.17-1.85; probability value (P) = 0.001] than never smokers, especially heavy (>20/day) smokers (OR: 2.85; 95% CI: 1.66-4.89; P < 0.001). Former heavy (>20/day) smokers were also more likely to report short (<6 h) sleep duration (OR: 1.41; 95% CI: 1.25-1.60; P < 0.001), long-sleep duration (OR: 1.99; 95% CI: 1.47-2.71; P < 0.001) and sleeplessness (OR: 1.47; 95% CI: 1.38-1.57; P < 0.001) than never smokers. Among never smokers, those who lived with more than one smoker had higher odds of long-sleep duration than those not cohabitating with a smoker (OR: 2.71; 95% CI: 1.26-5.82; P = 0.011).

Conclusions

Active and passive exposure to high levels of tobacco smoke are associated with sleep disturbance. Existing global tobacco control interventions need to be enforced.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

PURPOSE

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

METHODS

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

RESULTS

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm³, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019).

CONCLUSION

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

CLINICAL TRIAL NUMBER

NCT02542085.

Cannabis use and risk of schizophrenia: a Mendelian randomization study

Cannabis use is observationally associated with an increased risk of schizophrenia, but whether the relationship is causal is not known. Using a genetic approach, we took 10 independent genetic variants previously identified to associate with cannabis use in 32 330 individuals to determine the nature of the association between cannabis use and risk of schizophrenia. Genetic variants were employed as instruments to recapitulate a randomized controlled trial involving two groups (cannabis users vs nonusers) to estimate the causal effect of cannabis use on risk of schizophrenia in 34 241 cases and 45 604 controls from predominantly European descent. Genetically-derived estimates were compared with a meta-analysis of observational studies reporting ever use of cannabis and risk of schizophrenia or related disorders. Based on the genetic approach, use of cannabis was associated with increased risk of schizophrenia (odds ratio (OR) of schizophrenia for users vs nonusers of cannabis: 1.37; 95% confidence interval (CI), 1.09-1.67; P-value=0.007). The corresponding estimate from observational analysis was 1.43 (95% CI, 1.19-1.67; P-value for heterogeneity =0.76). The genetic markers did not show evidence of pleiotropic effects and accounting for tobacco exposure did not alter the association (OR of schizophrenia for users vs nonusers of cannabis, adjusted for ever vs never smoker: 1.41; 95% CI, 1.09-1.83). This adds to the substantial evidence base that has previously identified cannabis use to associate with increased risk of schizophrenia, by suggesting that the relationship is causal. Such robust evidence may inform public health messages about cannabis use, especially regarding its potential mental health consequences.