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Background: Analyse admissions to Royal Perth Hospital (RPH) with acute small bowel obstruction (SBO), and identify trends between outcomes and management. Methods: Retrospective, single‐centre review of patients admitted to RPH with acute SBO, between May 2017 and May 2018. Results: A total of 251 admissions met inclusion criteria. Increasing age correlated with increasing total length of stay (LOS) (r = 0.134, P = 0.033) and post‐operative LOS (r = 0.349, P < 0.0001). Increasing age led to poorer outcomes (P < 0.0001). Diagnoses were most commonly adhesions (167/251 = 66.5%), hernias (47/251 = 18.7%) and inflammatory bowel diseases (11/251 = 4.4%). Operation rate for adhesional SBO was 24.6% (41/167) and non‐adhesional SBO 54.8% (46/84). Median total LOS for operative versus conservative management was 9 days (interquartile range (IQR) 8) versus 3 days (IQR 3) (P < 0.0001). Median time to surgery was 1 day (IQR 2). Increased time from admission to theatre led to increasing post‐operative LOS (r = 0.398, P = 0.0013). Median post‐operative LOS for bowel resection versus no resection was 9 days (IQR 4.5) versus 6 days (IQR 4) (P = 0.0128). Of 101, 81 (80.2%) adhesional SBO resolved non‐operatively after receiving Gastrografin, compared to 45 of 66 (68.2%) of those who did not (P = 0.07). It did not significantly alter total or post‐operative LOS (P = 0.65 and P = 0.96), patient outcome (P = 0.26), or need for bowel resection (P = 0.63). Conclusions: Operative management, bowel resection, older age and increasing time from admission to surgery increase LOS. Trial of Gastrografin in non‐operative management of adhesion type small bowel obstructions does not significantly affect outcomes but tends to reduce operative rates. [ABSTRACT FROM AUTHOR]

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world. [ABSTRACT FROM AUTHOR]

Seat belt-related female breast trauma (SFBT) is an uncommon cause of haemorrhage following motor vehicle collision. Classification systems have been used to grade the severity of SFBT, ranging from mild class I to severe class IV injuries with evidence of active haemorrhage. In the case of class IV injuries, contrast extravasation represents active haemorrhage, prompting angiographic embolisation or surgery to arrest the bleed. Contrary to the majority of reports published in the literature, our institution has been successful with conservative management of class IV SFBT. None of the patients required specific intervention to control haemorrhage from SFBT. [ABSTRACT FROM AUTHOR]

To our knowledge, there have been only four reported cases of life-threatening splenic haemorrhage in patients who have already had a splenectomy for trauma, although three of these were for spontaneous haemorrhage, rather than attributed to a second traumatic injury. In trauma, these splenunculi may undergo hypertrophy in patients who have had a trauma splenectomy. Leon I et al i . and Celii and Raves describe cases of patients who experienced spontaneous atraumatic splenic haemorrhage which required emergency splenectomy in patients who had already had a splenectomy for trauma in the past.4,5 Tartaglia I et al i . described a situation similar to our patient, where a splenectomy was performed on an accessory spleen of a patient who had fallen 2 m sustaining a laceration of an accessory spleen.6 The patient had also undergone splenectomy for trauma a number of years prior. [Extracted from the article]

Background Multiple scoring systems are used in the assessment of post-injury outcomes in pelvic fracture patients. Although commonly used, there is scarce evidence as to their validity. Methods We performed a systematic review of the current literature to compare a well validated generic outcome tool (Short Form-36 (SF-36)) and three commonly used pelvic-specific outcome tools, the Iowa Pelvic Score, Majeed Pelvic Score and Orlando Pelvic Score. Results Eleven papers were found that used both the SF-36 and one or more of the pelvic-specific outcome tools. The data demonstrate great variability in both the method of application and form of reporting. Conclusion The pelvic-specific tools produce similar results to the SF-36 and are potentially more sensitive in examining specific areas related to pelvic injuries and easier to perform and calculate than the SF-36. [ABSTRACT FROM AUTHOR]

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs. [ABSTRACT FROM AUTHOR]

Background: Classical medical teaching has made a clear distinction between signs and symptoms, and diagnosis. However, at the time of ward admission, a diagnosis may remain unclear. We propose administrative pressures during the admission process may have reduced the ability for pathological diagnosis. This may result in increased hospitalisation for investigation of signs and symptoms, rather than for treatment of clear diagnoses. We sought to further clarify this hypothesis and investigate changes in the nature of admissions during the last two decades in an adult emergency general surgery service. Methods: A retrospective analysis of emergency general surgical admissions during four six-month time periods, between 2000 and 2018, was conducted. The six-month periods were spaced evenly during the 18-year study. Demographic information, emergency department length of stay, incidence of a pathological diagnosis on ward admission and accuracy of admission diagnosis were analysed. Results: 2763 patients were admitted in the four six-month time periods. A significant reduction in number of patients admitted with a pathological diagnosis was noted between the 2012 and 2018 study periods (p < 0.05), with 21.2% of patients admitted in 2018 for investigation of signs and symptoms. The incidence of an accurate admission diagnosis (as assessed by the discharge diagnosis) ranged from 62.3 to 63.6% and did not differ significantly by year. Conclusion: Between 2012 and 2018, there was a significant increase in the number of emergency general surgical patients admitted for investigation of signs and symptoms. However, accuracy of admission diagnosis was unchanged during the study period. [ABSTRACT FROM AUTHOR]

Background: Electric scooters (e‐Scooters) are a form of motorized vehicle that offers cheap, efficient and environmentally friendly transportation. Increased e‐Scooter utilization has been accompanied by increases in e‐Scooter related injuries in multiple countries. This project describes the incidence, injury pattern, injury severity and patient factors associated with e‐Scooter use from the Western Australian State Trauma Registry. Methods: Retrospective cohort of all trauma patients captured by the Western Australian State Trauma Registry between 01 July 2017 and 30 June 2022 were analysed. Patient demographics, helmet use, reported drug use, and injury details (including principal and additional diagnoses, ISS) were collected. Results: Eighty‐one patients sustained e‐Scooter related injuries between 2017 and 2022. Fifty‐four (66%) of hospital admissions were recorded in 2021–2022, an annual percent change of 385.7% from the previous year. Most patients were male (80%). Median age was 40 years (IQR: 32–50). Helmet use was reported in 43% of patients. Helmet use was associated with a significantly lower odds of head injury (OR = 4.42, CI: 1.38–14.21; P = 0.01). Thirty‐five percent of patients were intoxicated with either alcohol or drugs. Forty‐four (54%) patients required surgery. Conclusion: E‐Scooter crashes are a new mechanism of injury affecting patients captured by the Western Australian State Trauma Registry. Helmet use correlated with a reduced risk of head injury. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic led to a global shortage of iodinated contrast media (ICM) in early 2022. ICM is used in more than half of the computed tomography of the abdomen and pelvis (CTAP) performed to diagnose an acute abdomen (AA). In response to the shortage, the RANZCR published contrast‐conserving recommendations. This study aimed to compare AA diagnostic outcomes of non‐contrast CTs performed before and during the shortage. Methods: A single‐centre retrospective observational cohort study of all adult patients presenting with an AA who underwent a CTAP was conducted during the contrast shortage period from May to July 2022. The pre‐shortage control comparison group was from January to March 2022; key demographics, imaging modality indication and diagnostic outcomes were collected and analysed using SPSS v27. Results: Nine hundred and sixty‐two cases met the inclusion criteria, of which n = 502, 52.2% were in the shortage period group. There was a significant increase of 464% in the number of non‐contrast CTAPs performed during the shortage period (P < 0.001). For the six AA pathologies, only n = 3, 1.8% of non‐contrast CTAPs had equivocal findings requiring further imaging with a contrast CTAP. Of the total CTs performed, n = 464, 48.2% were negative. Conclusion: This study showed that when non‐contrast CTs are selected appropriately, they appear to be non‐inferior to contrast‐enhanced CTAPs in diagnosing acute appendicitis, colitis, diverticulitis, hernia, collection, and obstruction. This study highlights the need for further research into utilizing non‐contrast scans for assessing the AA to minimize contrast‐associated complications. [ABSTRACT FROM AUTHOR]

Background: The incidence of Blunt Carotid Artery and Vertebral Artery Injury (BCVI) is relatively low in modern trauma practice. However, these injuries may be associated with severe neurological consequences. Following the introduction of a Diagnostic Imaging Pathway in Department of Health of Western Australia, we hypothesized that this injury would be less likely to be missed, and accordingly diagnosed more frequently.Method: A review of all major trauma (Injury Severity Scale>15) admissions at the State Major Trauma Centre in Royal Perth Hospital was undertaken from 1995 until 2013. BCVI was identified from the hospital's trauma registry. The medical records of these patients were then reviewed.Result: 58 of 7451 (0.78%) major trauma patients were diagnosed of BCVI during the study period. An increased incidence, from 0.52% (20/3880) to 1.06% (38/3571), was seen after the introduction of the Diagnostic Imaging Pathway in 2007 (p=0.010). The majority of the cases were caused by motor vehicle crashes, with 66% (n=38) of the cases sustaining concomitant head or cervical spine injury. Other commonly associated injuries included chest, extremity and thoracic spine injury.Conclusion: Our study reports a significant increase in the diagnosis of BCVI among major traumas after the introduction of a Diagnostic Imaging Pathway for the screening of this injury in 2007. The previously low incidence of BCVI compared with other centres' reports indicated possible previous under-screening and diagnosis of this injury. [ABSTRACT FROM AUTHOR]

Background: Despite the negative effect of sarcopenia on postoperative outcomes being well recognized in the elective setting, there remains a paucity of studies describing this phenomenon in the emergency laparotomy (EL) setting. This systematic review and meta‐analysis aimed to compare short‐ and long‐term postoperative outcomes following EL in patients with and without sarcopenia. Methods: A systematic review using PRISMA guidelines was used to identify studies comparing perioperative outcomes following EL for patients with and without sarcopenia. A subsequent meta‐analysis was conducted. The following data were extracted from the included studies: patient demographics, pathology or type of operation performed for EL, post‐operative mortality at inpatient, 30‐day, 90‐day and 1‐year, and functional outcomes. A quality assessment of included studies was undertaken. Results: Twelve studies reporting the outcomes of sarcopenia following EL were identified. Sarcopenia was significantly associated with higher 30‐day and 1‐year mortality rates following EL (OR 3.50, P < 0.01; OR 3.49, P < 0.01, respectively). Additionally, sarcopenia was significantly associated with unfavourable functional outcomes at discharge following emergency laparotomy (OR 2.44, p < 0.01). Conclusion: Opportunistically identified on cross‐sectional imaging, sarcopenia is a valuable predictor of short‐ and long‐term morbidity and mortality following EL. Further studies are required to identify the most appropriate diagnostic criteria of sarcopenia and better define this physiological phenomenon. [ABSTRACT FROM AUTHOR]

Background: Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Method: A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Conclusions: The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting. [ABSTRACT FROM AUTHOR]

Background and aims: Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. Methods: This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. Conclusions: The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy. [ABSTRACT FROM AUTHOR]

Background: Peptic ulcer disease is common with a lifetime prevalence in the general population of 5–10% and an incidence of 0.1–0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10–20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods: The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions: The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To assess the rate of undertriage of major trauma patients and to assess factors contributing to undertriage in a modern Australian Level 1 trauma centre. Methods: A retrospective case series of 600 consecutive major trauma (injury severity score [ISS] >15) patients admitted to Royal Perth Hospital (RPH) during 2015 was performed. Data were compiled via the prospectively maintained hospital trauma registry for all patients admitted with a major trauma during the study period. Results were analysed for patient demographics, mechanism and outcomes. The primary outcome of the study was to determine the rate of undertriage of major trauma at RPH by establishing whether or not the trauma team activation page was correctly sent at the time of patient arrival based on hospital criteria. Results: The average age of patients in the study population was 46.5 (±21.5) years and the mean ISS was 24.7 (±9.3). The most common mechanism of injury was falls, motor vehicle accidents and motorbike accidents. One hundred and sixty‐nine patients (28%) did not have trauma team activation on arrival to the ED. Among these patients, 132 did not fulfil the RPH trauma activation criteria. The remaining 37 patients (6.1%) did meet the criteria and were considered undertriaged. Subgroup analysis showed a statistically significant difference in age between the patients who had trauma team activation (42.7 ± 19.5 years) and those who did not (55.9 ± 23.3 years). Conclusion: In this cohort of major trauma, a 6.1% undertriage performance of the triage tool was observed. Sub‐analysis of the data showed that elderly patients were more likely to be undertriaged. [ABSTRACT FROM AUTHOR]

Background: Lipase is both a sensitive and specific marker for diagnosing pancreatitis. However, the benefit of serial lipase in both monitoring and defining prognosis remains undetermined. This systematic review was conducted to further evaluate this potential application. In addition, this review also looked into the benefits of serial lipase in the subgroup of traumatic pancreatitis. Methods: PubMed, Cochrane Library and Google Scholar were systematically searched for related articles, between January 1995 and December 2015, according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses standards. Data was extracted and analysed by two authors. Results: Seven studies were included in the final analysis: six retrospective and one prospective studies were identified. Five studies (all retrospective) concluded no benefits in serial lipase for prognostication, while two studies identified serial lipase as a beneficial prognostic factor for acute pancreatitis. Of the included studies, only two involved traumatic pancreatitis (both dedicated to the paediatric population). Conclusion: The evidence supporting or opposing serial lipase as a prognostic factor for pancreatitis is weak and consists mainly of retrospective analyses. The only prospective data identified suggested benefits to serial lipase in prognosis. Further prospective studies evaluating the prognostic value of serial lipase in the adult population with both traumatic and non‐traumatic pancreatitis are required given the paucity of available evidence. [ABSTRACT FROM AUTHOR]

Background: In patients with primary hyperparathyroidism (PHPT) and preoperative imaging suggesting a solitary parathyroid adenoma (SPA), focused parathyroidectomy is most often curative. Even so, large studies show up to 3% of patients experience persistent or recurrent PHPT. Unilateral neck exploration (UNE) aiming to identify the SPA and the other ipsilateral parathyroid may reduce this failure rate. We hypothesized that: (i) minimally invasive video‐assisted (MIVA) approach would facilitate UNE and (ii) this would be a clinically relevant strategy. Methods: Prospective case series of a consecutive cohort of PHPT patients (with preoperative diagnosis of SPA), who underwent MIVA‐UNE. A 15 mm collar incision and endoscopic magnification were utilized to both excise the SPA and seek the ipsilateral parathyroid gland. Results: From 2009 to 2014, 132 patients were offered MIVA‐UNE (age: 63.0 (interquartile range: 11.2); females: 94 (71.2%); symptomatic: 89 (67.4%); mean serum corrected calcium: 2.7 (standard deviation: 0.9) mmol/L; mean serum parathyroid hormone: 16.8 (standard deviation: 11.8) pmol/L). Conversion from MIVA‐UNE to open UNE was required in 14 (10.6%) patients (excluded from subsequent analysis). MIVA‐UNE was concluded in 118 patients. The second ipsilateral parathyroid was identified in 62 (52.5%) patients and in 13 (11.0%) it appeared enlarged and was excised. Histopathology confirmed five (4.2%) of these glands to be hyperplastic. Conclusion: MIVA‐UNE allows identification of the second ipsilateral parathyroid in about half the patients. This approach helped to diagnose and treat unexpected multigland disease in almost 5% of patients. [ABSTRACT FROM AUTHOR]

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45-60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or postcolonoscopy), the type of ICP, the characteristics and general status of the patient, the operator's level of experience, and surgical device availability. Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers' clinical judgment for individual patients, and they may need to be modified based on the medical team's level of experience and the availability of local resources. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Operative management of acute abdomen after bariatric surgery in the emergency setting."

A description of the Generic Surgical Sciences Examination (GSSE) short course developed by University of Western Australia (UWA) is presented.

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics. [ABSTRACT FROM AUTHOR]

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR). [ABSTRACT FROM AUTHOR]