IntroductionNational data suggest that surgical site infection (SSI) complicates 2%–10% of general surgery cases, although the patient-reported incidence is much higher. SSIs cause significant ...patient morbidity and represent a significant burden on acute healthcare services, in a cohort predominantly suitable for outpatient management. Over three-quarters of UK adults now own smartphones, which could be harnessed to improve access to care. We aim to investigate if a smartphone-delivered wound assessment tool results in earlier treatment.Methods and analysisThis is a randomised controlled trial aiming to recruit 500 patients across National Health Service (NHS) hospitals. All emergency abdominal surgery patients over the age of 16 who own smartphones will be considered eligible, with the exclusion of those with significant visual impairment. Participants will be randomised in a 1:1 ratio between standard postoperative care and the intervention – use of the smartphone tool in addition to standard postoperative care. The main outcome measure will be time-to-diagnosis of SSI with secondary outcome measures considering use of emergency department and general practitioner services and patient experience. Follow-up will be conducted by clinicians blinded to group allocation. Analysis of time-to-diagnosis will be by comparison of means using an independent two sample t-test.Ethics and disseminationThis is the first randomised controlled trial on the use of a smartphone-delivered wound assessment tool to facilitate the assessment of SSI and the impact on time-to-diagnosis. The intervention is being used in addition to standard postoperative care. The study design and protocol were reviewed and approved by Southeast Scotland Research and Ethics Committee (REC Ref: 16/SS/0072 24/05/2016). Study findings will be presented at academic conferences, published in peer-reviewed journals and are expected in 2020. A written lay summary will be available to study participants on request.Trial registration number NCT02704897; Pre-results.
AbstractObjectiveTo develop and validate a pragmatic risk score to predict mortality in patients admitted to hospital with coronavirus disease 2019 (covid-19).DesignProspective observational cohort ...study.SettingInternational Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study (performed by the ISARIC Coronavirus Clinical Characterisation Consortium—ISARIC-4C) in 260 hospitals across England, Scotland, and Wales. Model training was performed on a cohort of patients recruited between 6 February and 20 May 2020, with validation conducted on a second cohort of patients recruited after model development between 21 May and 29 June 2020.ParticipantsAdults (age ≥18 years) admitted to hospital with covid-19 at least four weeks before final data extraction.Main outcome measureIn-hospital mortality.Results35 463 patients were included in the derivation dataset (mortality rate 32.2%) and 22 361 in the validation dataset (mortality rate 30.1%). The final 4C Mortality Score included eight variables readily available at initial hospital assessment: age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, level of consciousness, urea level, and C reactive protein (score range 0-21 points). The 4C Score showed high discrimination for mortality (derivation cohort: area under the receiver operating characteristic curve 0.79, 95% confidence interval 0.78 to 0.79; validation cohort: 0.77, 0.76 to 0.77) with excellent calibration (validation: calibration-in-the-large=0, slope=1.0). Patients with a score of at least 15 (n=4158, 19%) had a 62% mortality (positive predictive value 62%) compared with 1% mortality for those with a score of 3 or less (n=1650, 7%; negative predictive value 99%). Discriminatory performance was higher than 15 pre-existing risk stratification scores (area under the receiver operating characteristic curve range 0.61-0.76), with scores developed in other covid-19 cohorts often performing poorly (range 0.63-0.73).ConclusionsAn easy-to-use risk stratification score has been developed and validated based on commonly available parameters at hospital presentation. The 4C Mortality Score outperformed existing scores, showed utility to directly inform clinical decision making, and can be used to stratify patients admitted to hospital with covid-19 into different management groups. The score should be further validated to determine its applicability in other populations.Study registrationISRCTN66726260
"I was thinking that I was already dead... now I can talk with you people, I’m so happy! ” These words, spoken quietly but with great warmth by a young woman devastated by a vesicovaginal fistula and ...restored to dignity through compassionate operative treatment, cut cleanly through divides of geography, culture, and class. More eloquently than any statistic she speaks of the life–changing and life–saving importance of surgical services in all health care systems. The woman’s testimony features in Jaymie Ang Henry’s film, ‘The Right to Heal’, a deeply moving piece of advocacy that makes a clear case for focusing far greater global attention on the huge need to achieve more equitable access to essential surgery. This is the case we take up here, with a particular focus on the needs of sub–Saharan Africa.
Objective
The aim of this study was to investigate the association of obesity with in‐hospital coronavirus disease 2019 (COVID‐19) outcomes in different ethnic groups.
Methods
Patients admitted to ...hospital with COVID‐19 in the United Kingdom through the Clinical Characterisation Protocol UK (CCP‐UK) developed by the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) were included from February 6 to October 12, 2020. Ethnicity was classified as White, South Asian, Black, and other minority ethnic groups. Outcomes were admission to critical care, mechanical ventilation, and in‐hospital mortality, adjusted for age, sex, and chronic diseases.
Results
Of the participants included, 54,254 (age = 76 years; 45.0% women) were White, 3,728 (57 years; 41.1% women) were South Asian, 2,523 (58 years; 44.9% women) were Black, and 5,427 (61 years; 40.8% women) were other ethnicities. Obesity was associated with all outcomes in all ethnic groups, with associations strongest for black ethnicities. When stratified by ethnicity and obesity status, the odds ratios for admission to critical care, mechanical ventilation, and mortality in black ethnicities with obesity were 3.91 (3.13‐4.88), 5.03 (3.94‐6.63), and 1.93 (1.49‐2.51), respectively, compared with White ethnicities without obesity.
Conclusions
Obesity was associated with an elevated risk of in‐hospital COVID‐19 outcomes in all ethnic groups, with associations strongest in Black ethnicities.
Malnutrition represents a key priority for global health policy, yet the impact of nutritional state on cancer surgery worldwide remains poorly described. We aimed to analyse the effect of ...malnutrition on early postoperative outcomes following elective surgery for colorectal or gastric cancer.
We did an international, multicentre, prospective cohort study of patients undergoing elective surgery for colorectal or gastric cancer between April 1, 2018, and Jan 31, 2019. Patients were excluded if the primary pathology was benign, they presented with cancer recurrence, or if they underwent emergency surgery (within 72 h of hospital admission). Malnutrition was defined with the Global Leadership Initiative on Malnutrition criteria. The primary outcome was death or a major complication within 30 days of surgery. Multilevel logistic regression and a three-way mediation analysis were done to establish the relationship between country income group, nutritional status, and 30-day postoperative outcomes.
This study included 5709 patients (4593 with colorectal cancer and 1116 with gastric cancer) from 381 hospitals in 75 countries. The mean age was 64·8 years (SD 13·5) and 2432 (42·6%) patients were female . Severe malnutrition was present in 1899 (33·3%) of 5709 patients, with a disproportionate burden in upper-middle-income countries (504 44·4% of 1135) and low-income and lower-middle-income countries (601 62·5% of 962). After adjustment for patient and hospital risk factors, severe malnutrition was associated with an increased risk of 30-day mortality across all country income groups (high income: adjusted odds ratio aOR 1·96 95% CI 1·14–3·37, p=0·015; upper-middle income: 3·05 1·45–6·42, p=0·003; low income and lower-middle income: 11·57 5·87–22·80, p<0·0001). Severe malnutrition mediated an estimated 32% of early deaths in low-income and lower-middle-income countries (aOR 1·41 95% CI 1·22–1·64) and an estimated 40% of early deaths in upper-middle-income countries (1·18 1·08–1·30).
Severe malnutrition is common in patients undergoing surgery for gastrointestinal cancers and is a risk factor for 30-day mortality following elective surgery for colorectal or gastric cancer. There is an urgent need to examine whether perioperative nutritional interventions can improve early outcomes following gastrointestinal cancer surgery worldwide.
National Institute for Health Research Global Health Research Unit.
The ongoing SARS-CoV-2 pandemic was initially managed by non-pharmaceutical interventions such as diagnostic testing, isolation of positive cases, physical distancing and lockdowns. The advent of ...vaccines has provided crucial protection against SARS-CoV-2. Neutralising antibody (nAb) responses are a key correlate of protection, and therefore measuring nAb responses is essential for monitoring vaccine efficacy. Fingerstick dried blood spots (DBS) are ideal for use in large-scale sero-surveillance because they are inexpensive, offer the option of self-collection and can be transported and stored at ambient temperatures. Such advantages also make DBS appealing to use in resource-limited settings and in potential future pandemics. In this study, nAb responses in sera, venous blood and fingerstick blood stored on filter paper were measured. Samples were collected from SARS-CoV-2 acutely infected individuals, SARS-CoV-2 convalescent individuals and SARS-CoV-2 vaccinated individuals. Good agreement was observed between the nAb responses measured in eluted DBS and paired sera. Stability of nAb responses was also observed in sera stored on filter paper at room temperature for 28 days. Overall, this study provides support for the use of filter paper as a viable sample collection method to study nAb responses.
Medical students have an essential role in medical research, yet often lack opportunities for involvement within randomised trials. This study aimed to understand the educational impact of clinical ...trial recruitment for medical students. Tracking wound infection with smartphone technology (TWIST) was a randomised controlled trial that included adult patients undergoing emergency abdominal surgery across two university teaching hospitals. All recruiters underwent prerecruitment training based on 'Generating Student Recruiters for Randomised Trials' principles, and completed prerecruitment and postrecruitment surveys. Respondent agreement with statements were assessed using 5-point Likert scales (from 1 ('strongly disagree') to 5 ('strongly agree')). Quantitative data were analysed using paired t-tests to compare differences pre-involvement and post-involvement. Thematic content analysis was performed on free-text data to generate recommendations for future student research involvement. Of 492 patients recruited to TWIST between 26 July 2016 and 4 March 2020, 86.0% (n=423) were recruited by medical students. Following introduction of student co-investigators (n=31), the overall monthly recruitment rate tripled (4.8-15.7 patients). 96.8% of recruiters (n=30/31) completed both surveys, and all respondents reported significant improvement in clinical and academic competencies. Three higher-level thematic domains emerged from the qualitative analysis: (1) engagement, (2) preparation and (3) ongoing support. Student recruitment in clinical trials is feasible and accelerates recruitment to clinical trials. Students demonstrated novel clinical research competencies and increased their likelihood of future involvement. Adequate training, support and selection of suitable trials are essential for future student involvement in randomised trials.
Abstract
Admission procalcitonin measurements and microbiology results were available for 1040 hospitalized adults with coronavirus disease 2019 (from 48 902 included in the International Severe ...Acute Respiratory and Emerging Infections Consortium World Health Organization Clinical Characterisation Protocol UK study). Although procalcitonin was higher in bacterial coinfection, this was neither clinically significant (median IQR, 0.33 0.11–1.70 ng/mL vs 0.24 0.10–0.90 ng/mL) nor diagnostically useful (area under the receiver operating characteristic curve, 0.56 95% confidence interval, .51–.60).
OBJECTIVE:To systematically review studies reporting survival data following neoadjuvant chemoradiation and orthotopic liver transplantation (NCR-OLT) for unresectable perihilar cholangiocarcinoma ...(pCC).
BACKGROUND:Despite survival improvements for other cancers, the prognosis of pCC remains dismal. Since publication of the Mayo protocol in 2000, increasing numbers of series globally are reporting outcomes after NCR-OLT.
METHODS:MEDLINE, EMBASE, Scopus, and Web of Science databases were searched from January 2000 to February 2019. A meta-analysis of proportions was conducted, pooling 1, 3-, and 5-year overall survival and recurrence rates following NCR-OLT across centers. Per protocol and intention to treat data were interrogated. Meta-regression was used to evaluate PSC as a confounder affecting survival.
RESULTS:Twenty studies comprising 428 patients were eligible for analysis. No RCTs were retrieved; the majority of studies were noncomparative cohort studies. The pooled 1, 3-, and 5-year overall survival rates following OLT without neoadjuvant therapy were 71.2% (95% CI 62.2%–79.4%), 48.0% (95% CI 35.0%–60.9%), and 31.6% (95% CI 23.1%–40.7%). These improved to 82.8% (95% CI 73.0%–90.8%), 65.5% (95% CI 48.7%–80.5%), and 65.1% (95% CI 55.1%–74.5%) if neoadjuvant chemoradiation was completed. Pooled recurrence after 3 years was 24.1% (95% CI 17.9%–30.9%) with neoadjuvant chemoradiation, 51.7% (95% CI 33.8%–69.4%) without.
CONCLUSIONS:In unresectable pCC, NCR-OLT confers long-term survival in highly selected patients able to complete neoadjuvant chemoradiation followed by transplantation. PSC patients appear to have the most favorable outcomes. A high recurrence rate is of concern when considering extending national graft selection policy to pCC.
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