Three decades (1978–2008) of Advanced Trauma Life Support (ATLS™) practice revised and evidence revisited

The Advanced Trauma Life Support (ATLS) Program was developed to teach doctors one safe, reliable method to assess and initially manage the trauma patient. The ATLS principles represents an organized approach for evaluation and management of seriously injured patients and offers a foundation of common knowledge for all members of the trauma team. After 3 decades of teaching (1978–2008) of ATLS worldwide one should intuitively perceive that the evidence for the effect of ATLS teaching on the improved management of the injured patient be well established. This editorial addresses aspects of trauma education with needs for further development of better evidence of best practice

The role of high-mobility group box-1 (HMGB-1) in the management of suspected acute appendicitis: useful diagnostic biomarker or just another blind alley?

Acute abdominal pain is one of the most frequent reasons for admitting patients to the emergency department for surgical evaluation. A wide number of differential diagnoses are available and their pre-test likelihood ratio varies according to the patients' age, gender, duration of symptoms and overall clinical context. While many patients with abdominal pain do not need to be admitted to the hospital wards and even fewer need eventual surgical intervention, the diagnosis of acute appendicitis remains one of the most frequently entertained differential in patients with abdominal pain. In fact, surgery for appendicitis is one of the most frequently performed operations in the Western world. As the authors of the current study point out, the high mobility group box-1 protein (HMGB1) has been known for many years. The study demonstrates in a small pilot that there is a difference in expression of HMGB1 between those with and those without appendicitis. However, is this difference clinically important? Clinically relevant results can only be documented through larger studies comparing its use and expression levels in both healthy subjects, subjects with abdominal pain for other reasons, patients with 'clear-cut' (histopathologically confirmed) appendicitis and in the difficult subgroup of patients with suspected appendicitis and equivocal symptoms

Cellular metabolism in colorectal carcinogenesis: Influence of lifestyle, gut microbiome and metabolic pathways

The interconnectivity between diet, gut microbiota and cell molecular responses is well known; however, only recently has technology allowed the identification of strains of microorganisms harbored in the gastrointestinal tract that may increase susceptibility to cancer. The colonic environment appears to play a role in the development of colon cancer, which is influenced by the human metabolic lifestyle and changes in the gut microbiome. Studying metabolic changes at the cellular level in cancer be useful for developing novel improved preventative measures, such as screening through metabolic breath-tests or treatment options that directly affect the metabolic pathways responsible for the carcinogenicity

Clinical Management of Pancreatic Premalignant Lesions

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Genetic and Epigenetic Traits as Biomarkers in Colorectal Cancer

Colorectal cancer is a major health burden, and a leading cause of cancer-related deaths in industrialized countries. The steady improvements in surgery and chemotherapy have improved survival, but the ability to identify high- and low-risk patients is still somewhat poor. Molecular biology has, over the years, given insight into basic principles of colorectal cancer initiation and development. These findings include aberrations increasing risk of tumor development, genetic changes associated with the stepwise progression of the disease, and errors predicting response to a specific treatment. Potential biomarkers in colorectal cancer are extensively studied, and how the molecular aberrations relate to clinical features. Yet, little of this knowledge has been possible to transfer into clinical practice. In this review, an overview of colorectal cancer genetics will be given, as well as how aberrations found in this tumor type are proposed as biomarkers for risk prediction, as diagnostic tools, for prognosis or prediction of treatment outcome.publishedVersio

A year of contemplation: looking back and moving forward

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"Getting your message through": an editorial guide for meeting publication standards

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Cancer epigenetics in solid organ tumours: A primer for surgical oncologists

Cancer is initiated through both genetic and epigenetic alterations. The end-effect of such changes to the DNA machinery is a set of uncontrolled mechanisms of cell division, invasion and, eventually, metastasis. Epigenetic changes are now increasingly appreciated as an essential driver to the cancer phenotype. The epigenetic regulation of cancer is complex and not yet fully understood, but application of epigenetics to clinical practice and in cancer research has the potential to improve cancer care. Epigenetics changes do not cause changes in the DNA base-pairs (and, hence, does not alter the genetic code per se) but rather occur through methylation of DNA, by histone modifications, and, through changes to chromatin structure to alter genetic expression. Epigenetic regulators are characterized as writers, readers or erasers by their mechanisms of action. The human epigenome is influenced from cradle to grave, with internal and external life-time exposure influencing the epigenetic marks that may act as modifiers or drivers of carcinogenesis. Preventive and public health strategies may follow from better understanding of the life-time influence of the epigenome. Epigenetics may be used to define risk, to investigate mechanisms of carcinogenesis, to identify biomarkers, and to identify novel therapeutic options. Epigenetic alterations are found across many solid cancers and are increasingly making clinical impact to cancer management. Novel epigenetic drugs may be used for a more tailored and specific response to treatment of cancers. We present a primer on epigenetics for surgical oncologists with examples from colorectal cancer, breast cancer, pancreatic cancer and hepatocellular carcinoma.publishedVersio

A multilevel, step-based model to evaluate progress in procedure efficiency for laparoscopic appendicectomy in surgical training: structured evaluation using 'ebb-and-flow' and 'string-of-pearls' concepts

Background Surgical training is aimed towards entrusted professional activity to obtain operative independence. Laparoscopic appendicectomy is performed early in training but except for simulators, real-life evaluation towards proficiency is scarce. The aim of this study was to model how each consecutive step may impact on the overall proficiency score for surgical trainees performing laparoscopic appendicectomy. Methods This was an observational cohort study of laparoscopic appendicectomy performed by junior trainees (PGY1–4) under supervision and evaluated for each of eight steps. Each step was scored on a validated six-point performance scale and classified as ‘fail’, ‘pass’, or ‘proficient’. Modelling was conducted with a multivariable regression model and artificial neural network model with a multilayer perceptron for the relationship between steps and overall performance. Results Of 157 procedures, 97 (61.8 per cent) procedures were evaluated as ‘proficient’, 46 (29.3 per cent) were ‘pass’, and 14 (8.9 per cent) were ‘fail’. In regression analyses, handling the mesoappendix was significantly associated with procedure proficiency, as were division of appendix, access to abdomen, and ability to handle the small bowel. The widest variation in operative flow was shown for steps involving mesoappendix and division of appendix, conceptualized in ‘ebb-and-flow’ and ‘string-of-pearls’ models. Sensitivity analyses for experience using 20 or fewer, 30 or fewer, or more than 30 procedures as cut-offs reproduced comparable results. Conclusions Consistent stumbling blocks for junior trainees performing laparoscopic appendectomies can be conceptualized through novel models that identify steps deemed to be the most difficult to trainees with variable experience.publishedVersio

Open access publishing: a girder in the success of the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

The Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (SJTREM) has entered its third year as an independent, open access international scientific on-line journal. SJTREM converted into open access (OA) online publishing in July 2008. The decision was based on the importance of making research accessible for all, regardless of financial status or capabilities. This conversion resulted in a substantial rise in submissions, and not least citations. Scandinavian research founders have for the last two years been steadily moving from a supportive attitude for the OA principles, to making policy decisions that have a direct guidance to authors to publish OA. The Scandinavian move is part of the wider global picture where mandates and funding mechanisms, constituting the equivalent of library budgets at many universities, are springing into life. With the support of European Commission, OA are evolving all over Europe. As a result of such initiatives, the list of universities with central funds for OA publications is growing rapidly. The OA conversion of SJTREM was timely, and the number papers cited in other journals are increasing. All published papers reach a significant number of readers, far above what was achievable for the earlier paper version of SJTREM