Quick and simple: psoas density measurement is an independent predictor of anastomotic leak and other complications after colorectal resection

Purpose: Radiologically-defined sarcopenia has been shown to predict negative outcomes after cancer surgery, however radiological assessment of sarcopenia often requires additional software and standardisation against anthropomorphic data. Measuring psoas density using hospital Picture Archiving and Communication Systems, universally available in the UK, may have advantages over methods requiring the use of additional specialist and often costly software. This study aimed to assess the association between radiologically-defined sarcopenia measured by psoas density and postoperative outcome in patients having a colorectal cancer resectionMethods: All patients having a resection for colorectal cancer, discussed at the colorectal multi-disciplinary team in one institution between 1/1/15 and 31/12/15, were retrospectively identified. Mean psoas density at the level of the L3 vertebra were analysed from preoperative CT scans to define sarcopenia. Postoperative complications and mortality were recorded.Results: One hundred and sixty-nine patients had a colorectal resection for cancer and 140 of these had a primary anastomosis. Ninety-day mortality and 1-year mortality was 1.1% and 7.1% respectively. Eighteen(10.7%) patients suffered a Clavien-Dindo(CD) grade 3 or 4 complication of which 6(33%) were anastomotic leaks. In the whole cohort, sarcopenia was associated with an increased risk of CD3/4 complication(adjusted OR 6.33(1.65-24.23) p= 0.007). In those who had an anastomosis, sarcopenia was associated with an increased risk of anastomotic leak (adjusted OR 14.37(1.37-150.04) p=0.026).Conclusions: A quick and easy radiological assessment of sarcopenia using psoas density on standard hospital PACS is associated with a 6-fold increased risk of major post-operative complication and a 14-fold increase in anastomotic leak

Short-term (<8 weeks) high-intensity interval training in diseased cohorts

Background & Aim: Exercise training regimes can lead to improvements in measures of cardiorespiratory fitness (CRF), improved general health, and reduced morbidity and overall mortality risk. High intensity interval training (HIIT) offers a time-efficient approach to improve CRF in healthy individuals, but the relative benefits of HIIT compared to traditional training methods are unknown in across different disease cohorts. Methods: This systematic review and meta-analysis compares CRF gains in randomised controlled trials of short-term (<8 weeks) HIIT vs. either no exercise control (CON) or moderate continuous exercise training (MCT) within diseased cohorts. Literature searches of the following databases were performed: MEDLINE, EMBASE, CINAHL, AMED, and PubMed (all from inception to 1st December 2017), with further searches of Clinicaltrials.gov and citations via Google Scholar. Primary outcomes were effect upon CRF variables; VO2peak and Anaerobic Threshold (AT). Results: Thirty-nine studies met the inclusion criteria. HIIT resulted in a clinically significant increase in VO2peak compared with CON (mean difference (MD) 3.32 ml∙kg-1∙min-1; 95% CI 2.56 to 2.08). Overall HIIT provided added benefit to VO2peak over MCT (MD 0.79 ml∙kg-1∙min-1; 95% CI 0.20 to 1.39). The benefit of HIIT was most marked in patients with cardiovascular disease when compared to MCT (VO2peak (MD 1.66 ml∙kg-1∙min-1; 95% CI 0.60 to 2.73); AT (MD 1.61 ml∙kg-1∙min-1; 95% CI 0.33 to 2.90)). Conclusions: HIIT elicits improvements in objective measures of CRF within 8 weeks in diseased cohorts compared to no intervention. When compared to MCT, HIIT imparts statistically significant additional improvements in measures of CRF, with clinically important additional improvements in VO2peak in cardiovascular patients. Comparative efficacy of HIIT vs MCT combined with an often reduced time commitment may warrant HIIT’s promotion as a viable clinical exercise intervention

Short-term (less 8 wk) high-intensity interval training in diseased cohorts

Background and Aim: Exercise training regimes can lead to improvements in measures of cardiorespiratory fitness (CRF), improved general health, and reduced morbidity and overall mortality risk. High-intensity interval training (HIIT) offers a time-efficient approach to improve CRF in healthy individuals, but the relative benefits of HIIT compared with traditional training methods are unknown in across different disease cohorts. Methods: This systematic review and meta-analysis compares CRF gains in randomized controlled trials of short-term (G8 wk) HIIT versus either no exercise control (CON) or moderate continuous training (MCT) within diseased cohorts. Literature searches of the following databases were performed: MEDLINE, EMBASE, CINAHL, AMED, and PubMed (all from inception to December 1, 2017), with further searches of Clinicaltrials.gov and citations via Google Scholar.Primary outcomes were effect on CRF variables: V˙ O2peak and anaerobic threshold. Results: Thirty-nine studies met the inclusion criteria. HIIT resulted in a clinically significant increase in V˙ O2peak compared with CON (mean difference [MD] = 3.32 mLIkgj1 Iminj1, 95% confidence interval [CI] = 2.56–2.08). Overall HIIT provided added benefit to V˙ O2peak over MCT (MD = 0.79 mLIkgj1 Iminj1, 95% CI =0.20–1.39). The benefit of HIIT was most marked in patients with cardiovascular disease when compared with MCT (V˙ O2peak: MD =1.66 mLIkgj1 Iminj1, 95% CI = 0.60–2.73; anaerobic threshold: MD = 1.61 mLIkgj1 Iminj1, 95% CI = 0.33–2.90). Conclusions: HIIT elicits improvements in objective measures of CRF within 8 wk in diseased cohorts compared with no intervention. When compared with MCT, HIIT imparts statistically significant additional improvements in measures of CRF, with clinically important additional improvements in V˙ O2peak in cardiovascular patients. Comparative efficacy of HIIT versus MCT combined with an often reduced time commitment may warrant HIIT_s promotion as a viable clinical exercise intervention

Six weeks high-intensity interval training enhances contractile-activity induced vascular reactivity and skeletal muscle perfusion in older adults

Background:Impairments in muscle microvascular function are associated with the pathogenesis of sarcopenia and cardiovascular disease. High-intensity interval training (HIIT) is an intervention by which a myriad of beneficial skeletal muscle/ cardiovascular adaptations have been reported across age, including capillarisation and improved endothelial function. Herein, we hypothesised HIIT would enhance muscle microvascular blood flow and vascular reactivity to acute contractile activity in older adults, reflecting HIIT-induced vascular remodelling.Methods:In a randomised controlled-trial, twenty-five healthy older adults aged 65-85 y (mean BMI 27.0) were randomised to 6 weeks HIIT or a no-intervention control period of an equal duration. Measures of microvascular responses to a single bout of muscle contractions (i.e. knee extensions) were made in the m. vastus lateralis using contrast-enhanced ultrasound during a continuous intravenous infusion of Sonovue™ contrast agent, before and after the intervention period, with concomitant assessments of cardiorespiratory fitness and resting blood pressure. Results: HIIT led to improvements in anaerobic threshold (13.2±3.4 vs. 15.3±3.8 ml/kg/min,

Fibrin glue is a quick and effective treatment for primary and recurrent pilonidal sinus disease

BackgroundPilonidal sinus disease (PSD) is a common, chronic inflammatory condition involving hair follicles within the natal cleft. It mainly affects young males and creates a significant health, social and economic burden. Traditional surgery is often radical resulting in pain, wound complications, long recovery times and poor cosmesis. The aim of our study was to evaluate fibrin glue as a primary treatment for PSD.MethodsFibrin glue procedures for a single surgeon at our institution were identified from operative coding databases and the logbook from January 2011 to January 2016. Patients had curettage of the sinus with fibrin glue obliteration. Recurrence data was collected retrospectively.ResultsOne hundred and forty-six patients were identified; (115 (79%) males, mean age 30 (range 16–78 years). One hundred and forty-four (99%) were discharged the same day. Four (2.7%) were treated conservatively for wound discharge. Median operating time was 9 (range 4–28) min. There were 40 (27%) recurrences after one glue application. Median time to recurrence was 4 (range 0.25–36) months. Twenty-four (60%) of the recurrences had repeat glue treatment with 4 (16.6%) recurrences. After 2 rounds of treatment with glue alone, 126 out of 130 (96.9%) patients had healed.ConclusionsFibrin glue application following curettage of the sinus is a quick and effective procedure for first and second line treatment of PSD

Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis

The incidence of hypertension increases with advancing age and represents a significant burden of disease. Lifestyle modification represents the first-line intervention in treatment algorithms; however, the majority of evidence for this comes from studies involving young participants using interventions that may not always be feasible in the elderly. This manuscript presents a systematic review of all randomized controlled trials involving participants with a mean age of 65 or over investigating nonpharmacological strategies to reduce blood pressure (BP). Fifty-three randomized controlled trials were included. The majority of interventions described aerobic exercise training, dynamic resistance exercise training, or combined aerobic and dynamic resistance exercise training (COM), with limited studies reporting isometric exercise training or alternative lifestyle strategies. Aerobic exercise training, dynamic resistance exercise training, COM, and isometric exercise training all elicited significant reductions in both systolic and diastolic BP, with no additional benefit of COM compared with single modality exercise training. Three months of traditional exercise-based lifestyle intervention may produce a reduction in BP of approximately 5 mmHg systolic and 3 mmHg diastolic in older individuals, similar to that expected in younger individuals

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

BackgroundCurrent evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER.MethodsA retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).ResultsOne hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.ConclusionsThis study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging

Short-term (<8 weeks) high-intensity interval training in diseased cohorts

Background & Aim: Exercise training regimes can lead to improvements in measures of cardiorespiratory fitness (CRF), improved general health, and reduced morbidity and overall mortality risk. High intensity interval training (HIIT) offers a time-efficient approach to improve CRF in healthy individuals, but the relative benefits of HIIT compared to traditional training methods are unknown in across different disease cohorts. Methods: This systematic review and meta-analysis compares CRF gains in randomised controlled trials of short-term (<8 weeks) HIIT vs. either no exercise control (CON) or moderate continuous exercise training (MCT) within diseased cohorts. Literature searches of the following databases were performed: MEDLINE, EMBASE, CINAHL, AMED, and PubMed (all from inception to 1st December 2017), with further searches of Clinicaltrials.gov and citations via Google Scholar. Primary outcomes were effect upon CRF variables; VO2peak and Anaerobic Threshold (AT). Results: Thirty-nine studies met the inclusion criteria. HIIT resulted in a clinically significant increase in VO2peak compared with CON (mean difference (MD) 3.32 ml∙kg-1∙min-1; 95% CI 2.56 to 2.08). Overall HIIT provided added benefit to VO2peak over MCT (MD 0.79 ml∙kg-1∙min-1; 95% CI 0.20 to 1.39). The benefit of HIIT was most marked in patients with cardiovascular disease when compared to MCT (VO2peak (MD 1.66 ml∙kg-1∙min-1; 95% CI 0.60 to 2.73); AT (MD 1.61 ml∙kg-1∙min-1; 95% CI 0.33 to 2.90)). Conclusions: HIIT elicits improvements in objective measures of CRF within 8 weeks in diseased cohorts compared to no intervention. When compared to MCT, HIIT imparts statistically significant additional improvements in measures of CRF, with clinically important additional improvements in VO2peak in cardiovascular patients. Comparative efficacy of HIIT vs MCT combined with an often reduced time commitment may warrant HIIT’s promotion as a viable clinical exercise intervention

Association between surgeon special interest and mortality after emergency laparotomy

© 2019 BJS Society Ltd Published by John Wiley & Sons Ltd Background: Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy. Methods: Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes. Results: A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12). Conclusion: Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London