Omental necrosis masquerading as urinary retention following laparoscopic Roux en Y gastric bypass for super obesity

Omental torsion is a rare cause of abdominal pain requiring a high degree of clinical suspicion and often laparoscopy

Management evaluation of metastasis in the brain (MEMBRAIN)—a United Kingdom and Ireland prospective, multicenter observational study

Background:In recent years an increasing number of patients with cerebral metastasis (CM) have been referred to the neuro-oncology multidisciplinary team (NMDT). Our aim was to obtain a national picture of CM referrals to assess referral volume and quality and factors affecting NMDT decision making. Methods:A prospective multicenter cohort study including all adult patients referred to NMDT with 1 or more CM was conducted. Data were collected in neurosurgical units from November 2017 to February 2018. Demographics, primary disease, KPS, imaging, and treatment recommendation were entered into an online database. Results:A total of 1048 patients were analyzed from 24 neurosurgical units. Median age was 65 years (range, 21-93 years) with a median number of 3 referrals (range, 1-17 referrals) per NMDT. The most common primary malignancies were lung (36.5%, n = 383), breast (18.4%, n = 193), and melanoma (12.0%, n = 126). A total of 51.6% (n = 541) of the referrals were for a solitary metastasis and resulted in specialist intervention being offered in 67.5% (n = 365) of cases. A total of 38.2% (n = 186) of patients being referred with multiple CMs were offered specialist treatment. NMDT decision making was associated with number of CMs, age, KPS, primary disease status, and extent of extracranial disease (univariate logistic regression, P < .001) as well as sentinel location and tumor histology (P < .05). A delay in reaching an NMDT decision was identified in 18.6% (n = 195) of cases. Conclusions:This study demonstrates a changing landscape of metastasis management in the United Kingdom and Ireland, including a trend away from adjuvant whole-brain radiotherapy and specialist intervention being offered to a significant proportion of patients with multiple CMs. Poor quality or incomplete referrals cause delay in NMDT decision making

More questions than answers to the diagnosis and management of cauda equina syndrome-Authors' reply

No abstract available

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

The ‘Great Decarceration’: Historical Trends and Future Possibilities

During the 19th Century, hundreds of thousands of people were caught up in what Foucault famously referred to as the ‘great confinement’, or ‘great incarceration’, spanning reformatories, prisons, asylums, and more. Levels of institutional incarceration increased dramatically across many parts of Europe and the wider world through the expansion of provision for those defined as socially marginal, deviant, or destitute. While this trend has been the focus of many historical studies, much less attention has been paid to the dynamics of ‘the great decarceration’ that followed for much of the early‐ to mid‐20th Century. This article opens with an overview of these early decarceration trends in the English adult and youth justice systems and suggests why these came to an end from the 1940s onwards. It then explores parallels with marked decarceration trends today, notably in youth justice, and suggests how these might be expedited, extended, and protected

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Depenalization, diversion and decriminalization: A realist review and programme theory of alternatives to criminalization for simple drug possession

Alternatives to criminalization for the simple possession of illicit drugs are increasingly of interest to policy makers. But there is no existing theoretically based, empirically tested framework that can inform development and evaluation. This article presents a realist programme theory of such alternatives. It bases this on a realist review, which followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES). It describes the systematic process of searching the literature in English on nine relevant countries (Australia, Czech Republic, Denmark, Germany, Jamaica, Netherland, Portugal, the UK, the USA) for information on alternative measures in three categories: depenalization; diversion; and decriminalization. It shows how these measures – in theory and in practice – combine with pre-existing social conditions and institutional contexts to trigger mechanisms across three causal pathways (normative; criminal justice; and health and social services). It shows how some posited causal processes are more empirically supported than others. Alternative measures can reduce harms imposed by criminal justice processes without increasing drug use or related health and crime harms, but this depends on specific combinations of contexts, mechanisms and outcomes