Publications by authors named "Susan Moug"

46 Publications

Healthcare professional preferences in the health and fitness assessment and optimization of older patients facing colorectal cancer surgery.

Colorectal Dis 2021 Sep 1;23(9):2331-2340. Epub 2021 Jul 1.

Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.

Aim: There are few age- and fitness-specific, evidence-based guidelines for colorectal cancer surgery. The uptake of different assessment and optimization strategies is variable. The aim of this study was to explore healthcare professional opinion about these issues using a mixed methods design.

Methods: Semi-structured qualitative interviews were undertaken with healthcare professionals from a single UK region involved in the treatment, assessment and optimization of colorectal surgery patients. Interviews were analysed using the framework approach. An online questionnaire survey was subsequently designed and disseminated to UK surgeons to quantitatively assess the importance of interview themes. Descriptive statistics were used to analyse questionnaire data.

Results: Thirty-seven healthcare professionals out of 42 approached (response rate 88%) were interviewed across five hospitals in the south Yorkshire region. Three broad themes were developed: attitudes towards treatment of the older patient, methods of assessment of suitability and optimization strategies. The questionnaire was completed by 103 out of an estimated 256 surgeons (estimated response rate 40.2%). There was a difference in opinion regarding the role of major surgery in older patients, particularly when there is coexisting dementia. Assessment was not standardized. Access to optimization strategies was limited, particularly in the emergency setting.

Conclusion: There is wide variation in the process of assessment and provision of optimization strategies in UK practice. Lack of evidence-based guidelines, cost and time constraints restrict the development of services and pathways. Differences in opinion between surgeons towards patients with frailty or dementia may account for some of the variation in colorectal cancer outcomes.
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http://dx.doi.org/10.1111/codi.15758DOI Listing
September 2021

Multiple House Occupancy is Associated with Mortality in Hospitalised Patients with Covid-19.

Eur J Public Health 2021 May 17. Epub 2021 May 17.

Institute of Applied Health Science, University of Aberdeen, Aberdeen Scotland.

Background: In response to the COVID-19 pandemic, many countries mandated staying at home to reduce transmission. This study examined the association between living arrangements (house occupancy numbers) and outcomes in COVID-19.

Methods: Study population was drawn from the COPE Study, a multicentre cohort study. House occupancy was defined as: living alone; living with one other person; living with multiple other people; or living in a nursing/residential home. Outcomes were time from admission to mortality and discharge (Cox regression), and Day-28 mortality (logistic regression), analyses were adjusted for key comorbidities and covariates including admission: age; sex, smoking; heart failure; admission CRP; COPD; eGFR, frailty and others.

Results: 1584 patients were included from 13 hospitals across UK and Italy: 676 (42.7%) were female, 907 (57.3%) were male, median age was 74 years (range: 19-101). At 28 days, 502 (31.7%) had died. Median admission CRP was 67, 82, 79.5 and 83mg/L for those living alone, with someone else, in a house of multiple occupancy and in a nursing/residential home, respectively. Compared to living alone, living with anyone was associated with increased mortality: within a couple (aHR 1.39, 95%CI 1.09-1.77, p = 0.007); living in a house of multiple occupancy (aHR=1.67, 95%CI 1.17-2.38, p = 0.005); and living in a residential home (aHR=1.36, 95%CI 1.03-1.80, p = 0.031).

Conclusion: For patients hospitalised with COVID-19, those living with one or more people had an increased association with mortality, they also exhibited higher CRP indicating increased disease severity suggesting they delayed seeking care.
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http://dx.doi.org/10.1093/eurpub/ckab085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247274PMC
May 2021

Defining standards in colorectal optimisation: a Delphi study protocol to achieve international consensus on key standards for colorectal surgery prehabilitation.

BMJ Open 2021 03 24;11(3):e047235. Epub 2021 Mar 24.

Department of Surgery, Royal Alexandra Hospital, Paisley, Renfrewshire, UK

Introduction: Prehabilitation in colorectal surgery is evolving and may minimise postoperative morbidity and mortality. With many different healthcare professionals contributing to the prehabilitation literature, there is significant variation in reported primary endpoints that restricts comparison. In addition, there has been limited work on patient-related outcome measures suggesting that patients with colorectal cancer needs and issues are being overlooked. The Defining Standards in Colorectal Optimisation Study aims to achieve international consensus from all stakeholders on key standards to provide a framework for reporting future prehabilitation research.

Methods And Analysis: A systematic review will identify key standards reported in trials of prehabilitation in colorectal surgery. Standards that are important to patients will be identified by a patient and public involvement (PPI) event. The longlist of standards generated from the systematic review and PPI event will be used to develop a three-round online Delphi process. This will engage all stakeholders (healthcare professionals and patients) both nationally and internationally. The results of the Delphi will be followed by a face-to-face interactive consensus meeting that will define the final standards for prehabilitation for elective colorectal surgery.

Ethics And Dissemination: The University of Glasgow College of Medical, Veterinary and Life Sciences Ethics Committee has approved this protocol, which is registered as a study (200190120) with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of the standards developed by all stakeholders will increase the potential for comparative research that advances understanding of the clinical application of prehabilitation.

Prospero Registration Number: CRD42019120381.
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http://dx.doi.org/10.1136/bmjopen-2020-047235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993327PMC
March 2021

The role of C-reactive protein as a prognostic marker in COVID-19.

Int J Epidemiol 2021 05;50(2):420-429

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Background: C-reactive protein (CRP) is a non-specific acute phase reactant elevated in infection or inflammation. Higher levels indicate more severe infection and have been used as an indicator of COVID-19 disease severity. However, the evidence for CRP as a prognostic marker is yet to be determined. The aim of this study is to examine the CRP response in patients hospitalized with COVID-19 and to determine the utility of CRP on admission for predicting inpatient mortality.

Methods: Data were collected between 27 February and 10 June 2020, incorporating two cohorts: the COPE (COVID-19 in Older People) study of 1564 adult patients with a diagnosis of COVID-19 admitted to 11 hospital sites (test cohort) and a later validation cohort of 271 patients. Admission CRP was investigated, and finite mixture models were fit to assess the likely underlying distribution. Further, different prognostic thresholds of CRP were analysed in a time-to-mortality Cox regression to determine a cut-off. Bootstrapping was used to compare model performance [Harrell's C statistic and Akaike information criterion (AIC)].

Results: The test and validation cohort distribution of CRP was not affected by age, and mixture models indicated a bimodal distribution. A threshold cut-off of CRP ≥40 mg/L performed well to predict mortality (and performed similarly to treating CRP as a linear variable).

Conclusions: The distributional characteristics of CRP indicated an optimal cut-off of ≥40 mg/L was associated with mortality. This threshold may assist clinicians in using CRP as an early trigger for enhanced observation, treatment decisions and advanced care planning.
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http://dx.doi.org/10.1093/ije/dyab012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989395PMC
May 2021

Routine use of immunosuppressants is associated with mortality in hospitalised patients with COVID-19.

Ther Adv Drug Saf 2021 18;12:2042098620985690. Epub 2021 Feb 18.

Department of Geriatric Medicine, 3rd Floor Academic Centre, Llandough Hospital, Penlan Road, Penarth, CF64 2XX.

Background: Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations.

Methods: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group.

Results: In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62-83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01-2.88 (14-day mortality). There also appeared to be a dose-response relationship.

Conclusion: Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results.

Plain Language Summary: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.
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http://dx.doi.org/10.1177/2042098620985690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897811PMC
February 2021

Protocol for a multi-centre observational and mixed methods pilot study to identify factors predictive of poor functional recovery after major gastrointestinal surgery and strategies to enhance uptake of perioperative optimization: Optimizing the care and treatment pathways for older patients facing major gastrointestinal surgery (OCTAGON).

Colorectal Dis 2021 06 22;23(6):1552-1561. Epub 2021 Mar 22.

University of Sheffield, Sheffield, UK.

Introduction: National datasets report large variations in outcomes from older people (≥65 years) between different UK surgical units. This implies that not all patients receive the same level of care or access to resources, such as rehabilitation or allied health professional input. This might impact functional decline.

Aims: Our aim is to evaluate the baseline status of older patients facing major gastrointestinal surgery and the impact of variation in perioperative assessment and provision of perioperative support on functional outcomes. Patients' experiences and views of assessment and optimization will be explored via integrated qualitative semi-structured interviews.

Methods And Analysis: This multi-centre, pilot cohort study will include patients ≥65 years presenting via both elective and emergency pathways at three to five South Yorkshire NHS hospitals (Clinical Trials registration NCT04545125). The primary outcome is functional recovery measured using the World Health Organization Disability Assessment Schedule 2.0 at 6 weeks post-operation. Secondary outcomes include feasibility, quality of life, length of stay and complication rate. An opportunistic sample size of 120 has been estimated and will inform the design of a future, adequately powered study. For the qualitative study, 20-30 semi-structured patient interviews will be undertaken with patients from the cohort study to explore experiences of assessment and optimization. Interviews will be digitally recorded, transcribed verbatim and analysed according to the framework approach.

Ethics And Dissemination: This study has been approved by the National Health Service Research Ethics Committee and is registered centrally with Health Research Authority. It has been adopted by the National Institute for Health Research Portfolio scheme. Dissemination will be via international and national surgical and geriatric conferences.
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http://dx.doi.org/10.1111/codi.15603DOI Listing
June 2021

A Systematic Review of the Abdominal Surgeon's Personality: Exploring Common Traits in Western Populations.

Behav Sci (Basel) 2020 Dec 26;11(1). Epub 2020 Dec 26.

Department of General Surgery, Royal Alexandra Hospital, Paisley PA2 9PN, UK.

The personality traits commonly seen in abdominal surgeons remains undefined, and its potential influence on decision-making and patient outcomes underexplored. This systematic review identified studies on abdominal surgeons who had undergone validated personality testing, with assessment of decision-making and post-operative patient outcomes. The study protocol was registered on PROSPERO (University of York, UK (CRD42019151375)). MEDLINE, Embase, PsycInfo and Cochrane Library databases were searched using the keywords: surgeon; surgeon personality; outcomes. All study designs were accepted including adult visceral surgeons published in English. Five articles from 3056 abstracts met our inclusion criteria and one article was identified from hand searches with two reviewers screening studies. Bias was assessed using the Newcastle-Ottawa scale. Six studies included 386 surgeons. Studies assessing personality using the Five Factor Model (four studies, 329 surgeons) demonstrated higher levels of conscientiousness (self-discipline, thoughtfulness), extraversion (sociability, emotional expression) and openness (creative, conventional) in surgeons versus population norms. Surgeon characterisation of agreeableness and emotional stability was less clear, with studies reporting mixed results. Post-operative outcomes were reported by only one study. Further exploration of the influence of surgeon personality and its influence on decision-making is necessary to deliver patient-centred care and targeted non-technical skills training for surgeons.
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http://dx.doi.org/10.3390/bs11010002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7823302PMC
December 2020

The influence of ACE inhibitors and ARBs on hospital length of stay and survival in people with COVID-19.

Int J Cardiol Heart Vasc 2020 Dec 15;31:100660. Epub 2020 Oct 15.

Cardiff University and Honorary Consultant Physician, Aneurin Bevan University Health Board, UK.

Objective: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay.

Methods: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox's proportional baseline hazards model and logistic equivalent were used.

Results: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02-1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09-1.77, p = 0.007).

Conclusions: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.
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http://dx.doi.org/10.1016/j.ijcha.2020.100660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561344PMC
December 2020

Study protocol for the COPE study: COVID-19 in Older PEople: the influence of frailty and multimorbidity on survival. A multicentre, European observational study.

BMJ Open 2020 09 29;10(9):e040569. Epub 2020 Sep 29.

Geriatric Medicine, Cardiff University, Cardiff, UK.

Introduction: This protocol describes an observational study which set out to assess whether frailty and/or multimorbidity correlates with short-term and medium-term outcomes in patients diagnosed with COVID-19 in a European, multicentre setting.

Methods And Analysis: Over a 3-month period we aim to recruit a minimum of 500 patients across 10 hospital sites, collecting baseline data including: patient demographics; presence of comorbidities; relevant blood tests on admission; prescription of ACE inhibitors/angiotensin receptor blockers/non-steroidal anti-inflammatory drugs/immunosuppressants; smoking status; Clinical Frailty Score (CFS); length of hospital stay; mortality and readmission. All patients receiving inpatient hospital care >18 years who receive a diagnosis of COVID-19 are eligible for inclusion. Long-term follow-up at 6 and 12 months is planned. This will assess frailty, quality of life and medical complications.Our primary analysis will be short-term and long-term mortality by CFS, adjusted for age (18-64, 65-80 and >80) and gender. We will carry out a secondary analysis of the primary outcome by including additional clinical mediators which are determined statistically important using a likelihood ratio test. All analyses will be presented as crude and adjusted HR and OR with associated 95% CIs and p values.

Ethics And Dissemination: This study has been registered, reviewed and approved by the following: Health Research Authority (20/HRA1898); Ethics Committee of Hospital Policlinico Modena, Italy (369/2020/OSS/AOUMO); Health and Care Research Permissions Service, Wales; and NHS Research Scotland Permissions Co-ordinating Centre, Scotland. All participating units obtained approval from their local Research and Development department consistent with the guidance from their relevant national organisation.Data will be reported as a whole cohort. This project will be submitted for presentation at a national or international surgical and geriatric conference. Manuscript(s) will be prepared following the close of the project.
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http://dx.doi.org/10.1136/bmjopen-2020-040569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526029PMC
September 2020

The Clinical Frailty Scale: Estimating the Prevalence of Frailty in Older Patients Hospitalised with COVID-19. The COPE Study.

Geriatrics (Basel) 2020 Sep 21;5(3). Epub 2020 Sep 21.

Division of Population Medicine, Aneurin Bevan UHB, Cardiff University, Cardiff CF14 4XN, UK.

Frailty assessed using Clinical Frailty Scale (CFS) is a good predictor of adverse clinical events including mortality in older people. CFS is also an essential criterion for determining ceilings of care in people with COVID-19. Our aims were to assess the prevalence of frailty in older patients hospitalised with COVID-19, their sex and age distribution, and the completion rate of the CFS tool in evaluating frailty. Data were collected from thirteen sites. CFS was assessed routinely at the time of admission to hospital and ranged from 1 (very fit) to 9 (terminally ill). The completion rate of the CFS was assessed. The presence of major comorbidities such as diabetes and cardiovascular disease was noted. A total of 1277 older patients with COVID-19, aged ≥ 65 (79.9 ± 8.1) years were included in the study, with 98.5% having fully completed CFS. The total prevalence of frailty (CFS ≥ 5) was 66.9%, being higher in women than men (75.2% vs. 59.4%, < 0.001). Frailty was found in 161 (44%) patients aged 65-74 years, 352 (69%) in 75-84 years, and 341 (85%) in ≥85 years groups, and increased across the age groups (<0.0001, test for trend). Conclusion: Frailty was prevalent in our cohort of older people admitted to hospital with COVID-19. This indicates that older people who are also frail, who go on to contract COVID-19 may have disease severity significant enough to warrant hospitalization. These data may help inform health care planners and targeted interventions and appropriate management for the frail older person.
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http://dx.doi.org/10.3390/geriatrics5030058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554723PMC
September 2020

Prior Routine Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19.

J Clin Med 2020 Aug 10;9(8). Epub 2020 Aug 10.

Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland, UK.

Coronavirus disease 2019 (COVID-19) infection causes acute lung injury, resulting from aggressive inflammation initiated by viral replication. There has been much speculation about the potential role of non-steroidal inflammatory drugs (NSAIDs), which increase the expression of angiotensin-converting enzyme 2 (ACE2), a binding target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter the host cell, which could lead to poorer outcomes in COVID-19 disease. The aim of this study was to examine the association between routine use of NSAIDs and outcomes in hospitalised patients with COVID-19. This was a multicentre, observational study, with data collected from adult patients with COVID-19 admitted to eight UK hospitals. Of 1222 patients eligible to be included, 54 (4.4%) were routinely prescribed NSAIDs prior to admission. Univariate results suggested a modest protective effect from the use of NSAIDs, but in the multivariable analysis, there was no association between prior NSAID use and time to mortality (adjusted HR (aHR) = 0.89, 95% CI 0.52-1.53, = 0.67) or length of stay (aHR 0.89, 95% CI 0.59-1.35, = 0.58). This study found no evidence that routine NSAID use was associated with higher COVID-19 mortality in hospitalised patients; therefore, patients should be advised to continue taking these medications until further evidence emerges. Our findings suggest that NSAID use might confer a modest benefit with regard to survival. However, as this finding was underpowered, further research is required.
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http://dx.doi.org/10.3390/jcm9082586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465199PMC
August 2020

The influence of social media on recruitment to surgical trials.

BMC Med Res Methodol 2020 07 28;20(1):201. Epub 2020 Jul 28.

Department of General Surgery, Royal Alexandra Hospital, Paisley, PA2 9PN, UK.

Background: Social media has changed the way surgeons communicate worldwide, particularly in dissemination of trial results. However, it is unclear if social media could be used in recruitment to surgical trials. This study aimed to investigate the influence of Twitter in promoting surgical recruitment in The Emergency Laparotomy and Frailty (ELF) Study.

Methods: The ELF Study was a UK-based, prospective, observational cohort that aimed to assess the influence of frailty on 90-day mortality in older adults undergoing emergency surgery. A power calculation required 500 patients to be recruited to detect a 10% change in mortality associated with frailty. A 12-week recruitment period was selected, calculated from information submitted by participating hospitals and the numbers of emergency surgeries performed in adults aged > 65 years. A Twitter handle was designed (@ELFStudy) with eye-catching logos to encourage enrolment and inform the public and clinicians involved in the study. Twitter Analytics and Twitonomy (Digonomy Pty Ltd) were used to analyse user engagement in relation to patient recruitment.

Results: After 90 days of data collection, 49 sites from Scotland, England and Wales recruited 952 consecutive patients undergoing emergency laparotomy, with data logged into a database created on REDCap. Target recruitment (n = 500) was achieved by week 11. A total of 591 tweets were published by @ELFStudy since its conception, making 218,136 impressions at time of writing. The number of impressions (number of times users see a particular tweet) prior to March 20th 2017 (study commencement date) was 23,335 (343.2 per tweet), compared to the recruitment period with 114,314 impressions (256.3 per tweet), ending June 20th 2017. Each additional tweet was associated with an increase in recruitment of 1.66 (95%CI 1.36 to 1.97; p < 0.001).

Conclusion: The ELF Study over-recruited by nearly 100%, reaching over 200,000 people across the U.K. Branding enhanced tweet aesthetics and helped increase tweet engagement to stimulate discussion and healthy competition amongst clinicians to aid trial recruitment. Other studies may draw from the social media experiences of the ELF Study to optimise collaboration amongst researchers.

Trial Registration: This study is registered online at www.clinicaltrials.gov (registration number NCT02952430 ) and has been approved by the National Health Service Research Ethics Committee.
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http://dx.doi.org/10.1186/s12874-020-01072-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388470PMC
July 2020

The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.

Lancet Public Health 2020 08 30;5(8):e444-e451. Epub 2020 Jun 30.

Department of Surgery and Care of the Elderly, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Electronic address:

Background: The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay.

Methods: This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1-2=fit; 3-4=vulnerable, but not frail; 5-6=initial signs of frailty but with some degree of independence; and 7-9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality).

Findings: Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61-83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5-8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1-2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00-2·41) for CFS 3-4, 1·83 (1·15-2·91) for CFS 5-6, and 2·39 (1·50-3·81) for CFS 7-9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63-2·38) for CFS 3-4, 1·62 (0·81-3·26) for CFS 5-6, and 3·12 (1·56-6·24) for CFS 7-9.

Interpretation: In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19.

Funding: None.
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http://dx.doi.org/10.1016/S2468-2667(20)30146-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326416PMC
August 2020

Prehabilitation vs Postoperative Rehabilitation for Frail Patients.

JAMA Surg 2020 09;155(9):896

Department of Surgery, Royal Alexandra Hospital, University of Glasgow, Paisley, Scotland.

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http://dx.doi.org/10.1001/jamasurg.2020.1798DOI Listing
September 2020

Decision-Making in COVID-19 and Frailty.

Geriatrics (Basel) 2020 May 6;5(2). Epub 2020 May 6.

Department of Surgery, Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK.

We write in response to the COVID-19 pandemic and the important recognition of co-existing frailty [COVID-19 rapid guideline: critical care in adults; NICE NG159] [...].
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http://dx.doi.org/10.3390/geriatrics5020030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344473PMC
May 2020

Measuring sarcopenia on pre-operative CT in older adults undergoing emergency laparotomy: a comparison of three different calculations.

Int J Colorectal Dis 2020 Jun 25;35(6):1095-1102. Epub 2020 Mar 25.

Countess of Chester Hospital, Chester, UK.

Introduction: Sarcopenia is associated with outcomes in older-adults undergoing emergency surgery. Psoas major measurement is a surrogate marker of sarcopenia with multiple calculations existing normalising to body size and no consensus as to which is optimal. We compared three different psoas-major calculations to predict outcomes in older adults undergoing emergency laparotomy.

Methods: Consecutive over 65s were identified from the National Emergency Laparotomy Audit(NELA) database at a single centre between 2014 and 2018. Psoas major was measured at the L3 level and normalised to height (psoas muscle index, PMI), L3 vertebral body (psoas muscle:L3 ratio, PML3) or body surface area (psoas:body surface area, PBSA) and each correlated to outcomes. Outcome measures included inpatient, 30-day and 90-day mortality. A comparison of the three calculations was performed using the Mann-Whitney U, chi-squared, receiver operating characteristic curves (ROC) and binary logistic regression.

Results: Two hundred and sixty-four older adults underwent emergency laparotomy (median age, 75 years ((IQR, 70-81 years), 50% female)). Inpatient mortality was 19.6%, 30-day mortality was 15.1% and 90-day mortality was 18.5%. A total of 31.1% of males and 30% of females were sarcopenic (30.6% overall). A multivariate analysis confirmed each method of psoas major calculation (p < 0.0001) to be associated with mortality, as was ASA-grade (p < 0.0001). Area under the curve (AUC) was greatest for PML3 in predicting mortality (inpatient: PML3, 0.76; PMI, 0.71; PBSA, 0.70; 30-day: PML3, 0.74; PMI, 0.68; PBSA, 0.68; and 90-day: PML3, 0.78; PMI, 0.71; PBSA, 0.70). ASA-grade, P-POSSUM and PML3 were independently associated with mortality on multivariate analysis. ROC analysis of predictions from logistic regression models demonstrated PML3 to be more closely aligned to mortality than ASA or P-POSSUM (inpatient: AUC:PML3, 0.807; ASA, 0.783; P-POSSUM, 0.762; 30-day:AUC: PML3, 0.799; ASA, 0.784; P-POSSUM, 0.787; and 90-day: AUC:PML3, 0.805; ASA, 0.781; P-POSSUM, 0.756).

Conclusions: Sarcopenia was present in 30.6% of older adults undergoing emergency surgery and is associated with a significantly increased mortality. PML3 is superior to PMI or PBSA and should be considered the method of calculation of choice. Additionally, PML3 compares favourably to ASA and P-POSSUM.
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http://dx.doi.org/10.1007/s00384-020-03570-6DOI Listing
June 2020

Systematic review protocol examining the influence of surgeon personality on perioperative decision making in abdominal surgery.

BMJ Open 2020 02 3;10(2):e035361. Epub 2020 Feb 3.

Department of General Surgery, Royal Alexandra Hospital, Paisley, UK.

Introduction: There is limited published literature exploring how the personality traits of surgeons may influence preoperative decision making, particularly in the context of visceral/abdominal surgery. Multiple validated personality scoring systems exist and have been used to describe surgeon personalities previously. The degree to which each trait is expressed by abdominal surgeons is neither currently known, nor the impact of these traits on postoperative outcomes. The protocol has been written in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.

Methods And Analysis: The search strategy has been developed by a Health Scientist Librarian in collaboration with the review team. The search was conducted on 1st October 2019.Database subject headings and text words relating to 'abdominal/general surgeons', 'personality', 'postoperative outcomes' and 'decision making' formed the basis of our literature search strategy; the MEDLINE, EMBASE, PsycInfo and Cochrane databases will be searched. Three reviewers will independently screen and appraise articles, with a fourth reviewer utilised if disagreements arise.A systematic narrative synthesis will be performed, with information presented in text and table format. These will summarise the findings and characteristics of any included studies. Using guidance from the Centre for Reviews and Dissemination, the reviewers will describe the potential relationship and findings between studies using the narrative synthesis. Studies will only be reported if they are felt to have low or mid-levels of bias. Studies felt to display high levels of bias will be excluded.

Ethics And Dissemination: This study does not require ethical approval. The formal systematic review will be submitted for peer reviewed publication and presented at relevant conferences. The methods may inform future reviews in other surgical specialties regarding surgeon personality.

Prospero Registration Number: CRD42019151375.
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http://dx.doi.org/10.1136/bmjopen-2019-035361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045243PMC
February 2020

The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome.

Geriatrics (Basel) 2019 Oct 16;4(4). Epub 2019 Oct 16.

Department of Surgery, Royal Alexandra hospital Paisley, G12 9PF, UK.

Background: With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment).

Objectives: To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay.

Method: This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models.

Results: The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2-11.9%) and cognitive impairment was 70.3% (95% CI 65.6-74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, = 0.67; OR 1.4, 95% CI 0.4 to 4.1. = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, = 0.009).

Conclusion: Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.
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http://dx.doi.org/10.3390/geriatrics4040057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960557PMC
October 2019

Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study.

Ann Surg 2021 04;273(4):709-718

Department of Surgery, Royal Alexandra Hospital, Paisley, Scotland, UK.

Objective: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality.

Summary Background Data: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions.

Methods: An observational multicenter (n=49) UK study was performed (March-June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5-7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay.

Results: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24-8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26-16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay.

Conclusions: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.
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http://dx.doi.org/10.1097/SLA.0000000000003402DOI Listing
April 2021

Barriers and facilitators to deliberate practice using take-home laparoscopic simulators.

Surg Endosc 2019 09 19;33(9):2951-2959. Epub 2018 Nov 19.

Scottish Surgical Simulation Collaborative, Royal College of Surgeons of Edinburgh and Royal College of Physicians and Surgeons of Glasgow, Edinburgh, UK.

Background: Several regions in the UK and Ireland have delivered home-based laparoscopic simulation programmes in an attempt to progress surgical trainees' skills through deliberate practice. However, engagement with these programmes has been poor. This study aims to uncover the barriers to engagement with home-based simulation, with a view to developing an improved programme.

Methods: This was a qualitative study using focus groups with key stakeholders including junior surgical trainees, consultants/attendings and simulation faculty. Data were collected across four regions in three countries. Data were audio-recorded, transcribed and a thematic analysis was performed using NVivo software.

Results: Sixty-three individuals were interviewed in 12 focus groups (43 trainees, 20 trainers). Trainees cited competing commitments as a barrier to engaging with home-based simulation. They tended to focus on scoring 'points' towards career progression rather than viewing tasks as interesting, or associated with personal development. Their view was that this approach is perpetuated by the training system, which rewards trainees for publications and exams, but not for operative skill. Trainees were unsatisfied with metric feedback and wanted individual feedback from consultants (attendings). Trainees perceived consultants as lacking interest in the programmes and training in general. However, some consultants were unaware of the programmes being delivered and others felt lacking in confidence to deliver the necessary training.

Conclusions: Scheduled simulation sessions which provide trainees with the opportunity for consultant feedback may improve engagement. Tackling the 'point-scoring' culture is more challenging. This could be addressed by modified assessment structures, greater recognition and accountability for trainers, and recognition and funding of simulation strategies including in-house skills sessions.
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http://dx.doi.org/10.1007/s00464-018-6599-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684499PMC
September 2019

Cognitive impairment is associated with mortality in older adults in the emergency surgical setting: Findings from the Older Persons Surgical Outcomes Collaboration (OPSOC): A prospective cohort study.

Surgery 2019 05 19;165(5):978-984. Epub 2018 Nov 19.

Institute of Applied Health Sciences, University of Aberdeen, UK.

Background: Cognitive impairment is prevalent in older surgical patients; however, the condition is greatly under-recognized, and outcomes associated with it are poorly understood.

Methods: This is a prospective multicenter cohort study of unselected consecutive older adults admitted to 5 emergency general surgical units across the United Kingdom participating in the Older Persons Surgical Outcomes Collaboration from 2013-2014. The effect of moderate cognitive impairment defined as ≤17, bottom quartile of Montreal Cognitive Assessment was examined using multivariate logistic regression models. Primary outcome measure was the relationship between a low Montreal Cognitive Assessment score (≤17) and mortality at 30 and 90 days. Secondary outcome measures included the association between having a low Montreal Cognitive Assessment and hospital length of stay.

Results: A total of 539 older patients admitted consecutively to 5 surgical units during the 2013 and 2014 study periods were included. The median age (interquartile range) was 76 years (70-82 years), the emergency operation rate was 13% (n = 72). The prevalence of cognitive impairment, using the traditional Montreal Cognitive Assessment cutoff score of ≤26, was 84.4% and, using the recently suggested cutoff score of ≤23, the prevalence was 61.0%. Multivariable analyses showed patients with a low Montreal Cognitive Assessment score (≤17) had a three-fold increase in 30-day mortality (adjusted odds ratio = 3.10; 95% confidence interval:1.19-8.11; P = .021) and an increased length of hospital stay (10 or more days; 1.80 [1.10-2.94; P = .02] and 14 or more days; 2.06 [1.17-3.61; P = .012]).

Conclusion: We recommend a routine cognitive assessment in an emergency surgical setting whenever feasible to help identify patients at risk of poor outcomes.
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http://dx.doi.org/10.1016/j.surg.2018.10.013DOI Listing
May 2019

Is anemia associated with cognitive impairment and delirium among older acute surgical patients?

Geriatr Gerontol Int 2018 Jul 1;18(7):1025-1030. Epub 2018 Mar 1.

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Aim: The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients.

Methods: Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only.

Results: A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group.

Conclusions: There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; 18: 1025-1030.
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http://dx.doi.org/10.1111/ggi.13293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6099313PMC
July 2018

Influence of frailty in older patients undergoing emergency laparotomy: a UK-based observational study.

BMJ Open 2017 Oct 6;7(10):e017928. Epub 2017 Oct 6.

Department of General Surgery, Royal Alexandra Hospital, Paisley, UK.

Introduction: The National Emergency Laparotomy Audit (NELA) has reported that older patients (≥65 years) form a large percentage of emergency high-risk cases with increased postoperative morbidity and mortality. With the population continuing to age rapidly, it is clear that a greater understanding of the factors affecting surgical outcomes in older patients is required. Frailty is a relatively new concept taking into account a variety of factors that increase an individual's vulnerability to increased dependency and death. Research has suggested that high frailty scores increase postoperative complications, length of stay and mortality but the majority of these studies have been carried out on elective patients. Knowledge of how frailty affects patients in an emergency setting would aid clinicians' and patients' decision-making process.

Methods And Analysis: This multicentre study will include consecutive adult patients aged 65 years and over undergoing emergency laparotomies over a 3-month period at 52 National Health Service hospitals across the UK. The primary outcome will be 90-day mortality. Secondary outcomes will include length of hospital stay, 30-day complications, change in level of independence and 30-day readmission. This study has been powered to detect a 10% change in mortality associated with frailty (n=500 patients).

Ethics And Dissemination: This study has been approved by the National Health Service Research Ethics Committee. It has been registered centrally with HRA for English sites, NRSPCC for Scottish sites and Health and Care Research Permissions Service for sites in Wales.Dissemination will be via international and national surgical and geriatric conferences. In addition, manuscripts will be prepared following the close of the project.

Trial Registration Number: This study is also registered online at www.clinicaltrials.gov (registration number NCT02952430).
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http://dx.doi.org/10.1136/bmjopen-2017-017928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640048PMC
October 2017

Electrospun collagen-based nanofibres: A sustainable material for improved antibiotic utilisation in tissue engineering applications.

Int J Pharm 2017 Oct 12;531(1):67-79. Epub 2017 Aug 12.

Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, United Kingdom; Medway School of Pharmacy, University of Kent, Medway Campus, Anson Building, Central Avenue, Chatham Maritime, Chatham, Kent, ME4 4TB, United Kingdom. Electronic address:

For the creation of scaffolds in tissue engineering applications, it is essential to control the physical morphology of fibres and to choose compositions which do not disturb normal physiological function. Collagen, the most abundant protein in the human body, is a well-established biopolymer used in electrospinning compositions. It shows high in-vivo stability and is able to maintain a high biomechanical strength over time. In this study, the effects of collagen type I in polylactic acid-drug electrospun scaffolds for tissue engineering applications are examined. The samples produced were subsequently characterised using a range of techniques. Scanning electron microscopy analysis shows that the fibre morphologies varied across PLA-drug and PLA-collagen-drug samples - the addition of collagen caused a decrease in average fibre diameter by nearly half, and produced nanofibres. Atomic force microscopy imaging revealed collagen-banding patterns which show the successful integration of collagen with PLA. Solid-state characterisation suggested a chemical interaction between PLA and drug compounds, irgasan and levofloxacin, and the collagen increased the amorphous regions within the samples. Surface energy analysis of drug powders showed a higher dispersive surface energy of levofloxacin compared with irgasan, and contact angle goniometry showed an increase in hydrophobicity in PLA-collagen-drug samples. The antibacterial studies showed a high efficacy of resistance against the growth of both E. coli and S. Aureus, except with PLA-collagen-LEVO which showed a regrowth of bacteria after 48h. This can be attributed to the low drug release percentage incorporated into the nanofibre during the in vitro release study. However, the studies did show that collagen helped shift both drugs into sustained release behaviour. These ideal modifications to electrospun scaffolds may prove useful in further research regarding the acceptance of human tissue by inhibiting the potential for bacterial infection.
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http://dx.doi.org/10.1016/j.ijpharm.2017.08.071DOI Listing
October 2017

Heuristics and bias in rectal surgery.

Int J Colorectal Dis 2017 Aug 25;32(8):1109-1115. Epub 2017 Apr 25.

University of Sydney, Sydney, NSW, Australia.

Purpose: Deciding to defunction after anterior resection can be difficult, requiring cognitive tools or heuristics. From our previous work, increasing age and risk-taking propensity were identified as heuristic biases for surgeons in Australia and New Zealand (CSSANZ), and inversely proportional to the likelihood of creating defunctioning stomas. We aimed to assess these factors for colorectal surgeons in the British Isles, and identify other potential biases.

Methods: The Association of Coloproctology of Great Britain and Ireland (ACPGBI) was invited to complete an online survey. Questions included demographics, risk-taking propensity, sensitivity to professional criticism, self-perception of anastomotic leak rate and propensity for creating defunctioning stomas. Chi-squared testing was used to assess differences between ACPGBI and CSSANZ respondents. Multiple regression analysis identified independent surgeon predictors of stoma formation.

Results: One hundred fifty (19.2%) eligible members of the ACPGBI replied. Demographics between ACPGBI and CSSANZ groups were well-matched. Significantly more ACPGBI surgeons admitted to anastomotic leak in the last year (p < 0.001). ACPGBI surgeon age over 50 (p = 0.02), higher risk-taking propensity across several domains (p = 0.044), self-belief in a lower-than-average anastomotic leak rate (p = 0.02) and belief that the average risk of leak after anterior resection is 8% or lower (p = 0.007) were all independent predictors of less frequent stoma formation. Sensitivity to criticism from colleagues was not a predictor of stoma formation.

Conclusions: Unrecognised surgeon factors including age, everyday risk-taking, self-belief in surgical ability and lower probability bias of anastomotic leak appear to exert an effect on decision-making in rectal surgery.
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http://dx.doi.org/10.1007/s00384-017-2823-7DOI Listing
August 2017

Peritoneal fluid biomarkers in the detection of colorectal anastomotic leaks: a systematic review.

Int J Colorectal Dis 2017 Jul 12;32(7):935-945. Epub 2017 Apr 12.

Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK.

Purpose: Anastomotic leak (AL) in colorectal surgery leads to significant morbidity, mortality and poorer oncological outcomes. Diagnosis of AL is frequently delayed as current methods of detection are not 100% sensitive or specific. 'Biomarkers', such as cytokines and markers of ischaemia, from the milieu of the anastomosis may aid early detection. This paper aims to review the evidence for their role in AL detection, allowing identification of targets for future research.

Methods: A systematic review was performed using PubMed, MEDLINE and Cochrane Library databases. Papers concerning detection or prediction of AL with biomarkers were identified. References within the papers were used to identify further relevant articles.

Results: Research has taken place in small cohorts with varying definitions of AL. Lactate has consistently been shown to be elevated in patients with intra-abdominal complications and ALs. pH on post-operative day 3 showed excellent specificity. Despite mixed results, a meta-analysis found that the cytokines tumour necrosis factor-α and interleukin-6 were elevated early in AL. Detection of bacteria in drain fluid by RT-PCR has good specificity but a high rate of false positives.

Conclusions: Peritoneal cytokines, lactate and pH have the potential to identify AL early. The consistency of the results for lactate and pH, alongside the fact that they are easy, quick and inexpensive to test, makes them the most attractive targets. Studies in larger cohorts with standardized definitions of AL are required to clarify their usefulness. Emerging biosensor technology may facilitate the development of small, low-cost and degradable intra-abdominal devices to measure peritoneal fluid biomarkers.
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http://dx.doi.org/10.1007/s00384-017-2799-3DOI Listing
July 2017

Lifestyle interventions are feasible in patients with colorectal cancer with potential short-term health benefits: a systematic review.

Int J Colorectal Dis 2017 Jun 3;32(6):765-775. Epub 2017 Apr 3.

Centre for Public Health Nutrition Research, Division of Cancer Research, Ninewells Medical School, Level 7, Mailbox 7, Dundee, DD1 9SY, UK.

Purpose: Lifestyle interventions have been proposed to improve cancer survivorship in patients with colorectal cancer (CRC), but with treatment pathways becoming increasingly multi-modal and prolonged, opportunities for interventions may be limited. This systematic review assessed the evidence for the feasibility of performing lifestyle interventions in CRC patients and evaluated any short- and long-term health benefits.

Methods: Using PRISMA Guidelines, selected keywords identified randomised controlled studies (RCTs) of lifestyle interventions [smoking, alcohol, physical activity (PA) and diet/excess body weight] in CRC patients. These electronic databases were searched in June 2015: Dynamed, Cochrane Database, OVID MEDLINE, OVID EMBASE, and PEDro.

Results: Fourteen RCTs were identified: PA RCTs (n = 10) consisted mainly of telephone-prompted walking or cycling interventions of varied durations, predominately in adjuvant setting; dietary/excess weight interventions RCTs (n = 4) focused on low-fat and/or high-fibre diets within a multi-modal lifestyle intervention. There were no reported RCTs in smoking or alcohol cessation/reduction. PA and/or dietary/excess weight interventions reported variable recruitment rates, but good adherence and retention/follow-up rates, leading to short-term improvements in dietary quality, physical, psychological and quality-of-life parameters. Only one study assessed long-term follow-up, finding significantly improved cancer-specific survival after dietary intervention.

Conclusions: This is the first systematic review on lifestyle interventions in patients with CRC finding these interventions to be feasible with improvements in short-term health. Future work should focus on defining the optimal type of intervention (type, duration, timing and intensity) that not only leads to improved short-term outcomes but also assesses long-term survival.
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http://dx.doi.org/10.1007/s00384-017-2797-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5432596PMC
June 2017

Fabrication and characterisation of drug-loaded electrospun polymeric nanofibers for controlled release in hernia repair.

Int J Pharm 2017 Jan 14;517(1-2):329-337. Epub 2016 Dec 14.

Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, United Kingdom; Medway School of Pharmacy, University of Kent, Medway Campus, Anson Building, Central Avenue, Chatham Maritime, Chatham, Kent, ME4 4TB, United Kingdom. Electronic address:

The chemical distribution and mechanical effects of drug compounds in loaded electrospun scaffolds, a potential material for hernia repair mesh, were characterised and the efficacy of the material was evaluated. Polycaprolactone electrospun fibres were loaded with either the antibacterial agent, irgasan, or the broad-spectrum antibiotic, levofloxacin. The samples were subsequently characterised by rheological studies, scanning electron microscopy (SEM), atomic force microscopy (AFM), contact angle goniometry (CAG), in vitro drug release studies, antibacterial studies and time-of-flight secondary ion mass spectrometry (ToF-SIMS). Increased linear viscoelastic regions observed in the rheometry studies suggest that both irgasan and levofloxacin alter the internal structure of the native polymeric matrix. In vitro drug release studies from the loaded polymeric matrix showed significant differences in release rates for the two drug compounds under investigation. Irgasan showed sustained release, most likely driven by molecular diffusion through the scaffold. Conversely, levofloxacin exhibited a burst release profile indicative of phase separation at the edge of the fibres. Two scaffold types successfully inhibited bacterial growth when tested with strains of E. coli and S. aureus. Electrospinning drug-loaded polyester fibres is an alternative, feasible and effective method for fabricating non-woven fibrous meshes for controlled release in hernia repair.
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http://dx.doi.org/10.1016/j.ijpharm.2016.12.022DOI Listing
January 2017

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study.

Surg Endosc 2017 07 8;31(7):2959-2967. Epub 2016 Nov 8.

Department of Surgery, Royal Alexandra Hospital, Corsebar Road, Paisley, PA2 9PN, Scotland, UK.

Background: Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors.

Methods: Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012-2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded.

Results: 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20-0.60 95% CI and 0.47; 0.25-0.88, respectively).

Conclusion: Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.
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http://dx.doi.org/10.1007/s00464-016-5313-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487844PMC
July 2017
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