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Objectives: Persistent obstructive sleep apnea (OSA) after adenotonsillectomy (AT) has been reported in 20%–30% of children. The aim of this study was to determine the predictive value of drug‐induced sleep endoscopy (DISE) at the time of AT on subjective AT outcomes. Methods: This was a prospective cohort study of children aged 2–18 years being treated with AT for sleep disordered breathing (SDB) with one or more risk factors for AT failure: age >7 years, obesity, severe baseline OSA, Black race. All underwent DISE at the time of AT. Potential predictors of subjective AT outcome included age, sex, obesity, and DISE patterns. Multivariable linear regression was used to model predictors of post‐AT Pediatric Sleep Questionnaire (PSQ) and OSA‐18 outcomes. Results: Pre‐ and post‐AT PSQ/OSA‐18 responses were available from 194 children. Mean age was 9.3 ± 3.5 years, with 59% obese, 50% female, and 67% White. After AT, mean PSQ score decreased from 0.60 ± 0.19 to 0.28 ± 0.22, p < 0.001 and mean OSA‐18 score decreased from 66 ± 21 to 37 ± 18, p < 0.001. The most frequent sites of obstruction were the tonsils (92%), nasal airway (77%), adenoids (64%), and velopharynx (65%). Multivariable regression modeling demonstrated worse outcomes with obesity, male gender, and multilevel obstruction that included the nasal airway and tongue base in addition to adenotonsillar obstruction. Conclusions: Persistent OSA and symptom burden after AT was common in this population. Obesity, male gender, and multilevel obstruction during DISE were all associated with worse subjective outcomes. Level of Evidence: 3 Laryngoscope, 135:377–384, 2025 [ABSTRACT FROM AUTHOR]

Background/Aims: Youth with prenatal alcohol exposure (PAE) are under‐recognised in the justice system, warranting improved identification. This study aimed to compare neuropsychological profiles of adolescents, with and without PAE and identify neuropsychological tasks predictive of PAE‐group membership. It was hypothesised that participants with PAE would score significantly lower on neuropsychological tests. Methods: Participants included 85 young people sentenced to detention (mean 15.7 years, 78 males), 46 with PAE. A one‐way‐multivariate analysis of variance tested differences in neuropsychological functioning between PAE/No‐PAE groups, while logistic regression determined tests predictive of PAE. Results: No statistically significant difference in test scores emerged between groups, and regression was not indicative of any models predictive of PAE‐group membership. Neuropsychological profiles were characterised by both strengths and weaknesses, with lower verbal and mathematical skills. Conclusion(s): While no statistically significant differences were found between the groups, the results provided a unique insight into the neurocognitive profile of Australian youth in detention. Routine screening assessments were recommended for young people sentenced to detention. [ABSTRACT FROM AUTHOR]

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0–12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross‐promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest. Key message: Mothers' and health professionals' exposure to commercial milk formula (CMF) promotion was still widespread in Singapore even after the new CMF restriction was implemented in 2019.Digital marketing, distribution of free samples of milk for toddlers and mothers, dubious premium health and nutrition claims, and sponsorship from CMF industries were common tactics found in this study.Updating CMF restrictions to align with the Code, including restricting CMF marketed for toddler milk, prohibiting cross‐promotion, and disallowing sponsorship from CMF industries, together with an effective enforcement system, may facilitate better control of unethical CMF promotions in Singapore. [ABSTRACT FROM AUTHOR]

Genital Chlamydia trachomatis infection remains a major health issue as it causes severe complications including pelvic inflammatory disease, ectopic pregnancy and infertility in females as a result of infection‐associated chronic inflammation. Podoplanin, a transmembrane receptor, has been previously reported on inflammatory macrophages. Thus, strategies that specifically target podoplanin might be able to reduce local inflammation. This study investigated the expression level and function of podoplanin in a C. trachomatis infection model. C57BL/6 mice infected with the mouse pathogen Chlamydia muridarum were examined intermittently from days 1 to 60 using flow cytometry analysis. Percentages of conventional macrophages (CD11b+CD11c−F4/80+) versus inflammatory macrophages (CD11b+CD11c+F4/80+), and the expression of podoplanin in these cells were investigated. Subsequently, a podoplanin‐knockout RAW264.7 cell was used to evaluate the function of podoplanin in C. trachomatis infection. Our findings demonstrated an increased CD11b+ cell volume in the spleen at day 9 after the infection, with augmented podoplanin expression, especially among the inflammatory macrophages. A large number of podoplanin‐expressing macrophages were detected in the genital tract of C. muridarum–infected mice. Furthermore, analysis of the C. trachomatis–infected patients demonstrated a higher percentage of podoplanin‐expressing monocytes than that in the noninfected controls. Using an in vitro infection in a transwell migration assay, we identified that macrophages deficient in podoplanin displayed defective migratory function toward C. trachomatis–infected HeLa 229 cells. Lastly, using immunoprecipitation–mass spectrometry method, we identified two potential podoplanin interacting proteins, namely, Cofilin 1 and Talin 1 actin‐binding proteins. The present study reports a role of podoplanin in directing macrophage migration to the chlamydial infection site. Our results suggest a potential for reducing inflammation in individuals with chronic chlamydial infections by targeting podoplanin. [ABSTRACT FROM AUTHOR]

Small‐fiber neuropathy (SFN) is a disorder that exclusively affects the small nerve fibers, sparing the large nerve fibers. Thinly myelinated Aδ‐fibers and unmyelinated C‐fibers are damaged, leading to development of neuropathic pain, thermal dysfunction, sensory symptoms, and autonomic disturbances. Although many SFNs are secondary and due to immunological causes or metabolic disturbances, the etiology is unknown in up to half of the patients. Over the years, this proportion of "idiopathic SFN" has decreased, as familial and genetic causes have been discovered, thus shifting a proportion of once "idiopathic" cases to the genetic category. After the discovery of SCN9A‐gene variants in 2012, SCN10A and SCN11A variants have been found to be pathogenic in SFN. With improved accessibility of SFN diagnostic tools and genetic tests, many non‐SCN variants and genetically inherited systemic diseases involving the small nerve fibers have also been described, but only scattered throughout the literature. There are 80 SCN variants described as causing SFN, 8 genes causing hereditary sensory autonomic neuropathies (HSAN) described with pure SFN, and at least 7 genes involved in genetically inherited systemic diseases associated with SFN. This systematic review aims to consolidate and provide an updated overview on the genetic variants of SFN to date‐‐‐SCN genes and beyond. Awareness of these genetic causes of SFN is imperative for providing treatment directions, prognostication, and management of expectations for patients and their health‐care providers. [ABSTRACT FROM AUTHOR]

Helicobacter pylori colonization and persistence could precede gastric adenocarcinoma. Elucidating immune recognition strategies of H. pylori is therefore imperative to curb chronic persistence in the human host. Toll-like receptor 7 (TLR7) and TLR8 are widely known as viral single-stranded RNA (ssRNA) sensors yet less studied in the bacteria context. Here, we investigated the involvement of these receptors in the immunity to H. pylori. Human THP-1 monocytic cells were infected with H. pylori, and the expression levels of human Toll-like receptors (TLRs) were examined. The roles of TLR7 and TLR8 in response to H. pylori infection were further investigated using receptor antagonists. Among all TLR transcripts examined, TLR8 exhibited the most prominent upregulation, followed by TLR7 in the THP-1 cells infected with H. pylori J99 or SS1 strains. H. pylori infection-mediated IFN-α and IFN-β transactivation was significantly abrogated by the TLR7/8 (but not TLR7) antagonist. Additionally, TLR7/8 antagonist treatment reduced H. pylori infection-mediated phosphorylation of interferon regulatory factor 7 (IRF7). Our study suggests a novel role of TLR8 signaling in host immunity against H. pylori through sensing live bacteria to elicit the production of type I interferon. [ABSTRACT FROM AUTHOR]

Objective(s): Tympanostomy tube (TT) placement is the most common surgical procedure in children. Less than 10% of TT do not self‐extrude. This study is a systematic review (SR) on elective TT removal in the pediatric population: timing, perforation rates, and role of simultaneous repair. A PICOTS (population, intervention, comparison, outcome, timing, setting) question was formulated: In pediatric patients who have retained TT, what is the preferred time to elective removal of such tubes, and what are the outcomes in terms of perforation rates? Does an intervention at the time of TT removal improve perforation rates? Study Design: Systematic review and meta‐analysis. Methods: We searched four major electronic databases: EMBASE, MEDLINE, CDSR, CCRCT for articles published prior to 02/19/20. EndNote® was used to gather references, review abstracts, and obtain full text articles. Inclusion criteria were studies reporting patients aged 0 to 18 years undergoing elective TT removal with follow‐up greater than 3 months. Exclusion criteria included patients >18 years, duplicate patient series, or case series with fewer than five patients. Articles that were not available in English, not available in full text, and those that only addressed long‐acting TT were excluded. Data were pooled and meta‐analysis was conducted to examine how timing of TT removal, patching of the tympanic membrane, or any TM intervention at TT removal affected outcomes. Results: A total of 1,064 references were found. We identified 63 unique studies for full text review. Of these, 17 were selected for SR. MINORS (Methodological Index for Nonrandomized Studies) scores were low‐revealing high bias among the studies. Reported perforation rates after elective TT removal ranged from 0% to 57%. Four studies had data suitable for comparative meta‐analysis, which showed a significant increase in perforation rates after elective removal of TT after 3 years compared to removal prior to 3 years (OR 2.89; CI 1.78–4.69). No difference in perforation rates were identified when TM intervention vs. no intervention at time of TT removal was performed (six studies: OR 1.21; CI 0.71–2.07). No difference in perforation rates was identified when the type of TM intervention was compared, including freshening of TM edges, to patching with various materials (paper, fat, gelfoam®/gelfilm®, Trichloroacetic acid) (three studies: OR 1.07; CI 0.52–2.19). Conclusion: From the data reviewed in this SR and meta‐analysis, elective TT removal at or prior to 3 years' retention showed decreased perforation rates. However, TM intervention at the time of TT removal was not shown to lower perforation rates. In the absence of tube complications such as granuloma formation, nonfunctional tube, or chronic tube otorrhea, it may be reasonable to wait up to 3 years to electively remove a retained TT. Laryngoscope, 132:2063–2070, 2022 [ABSTRACT FROM AUTHOR]

Background: Autosomal dominant polycystic kidney disease (ADPKD) is an inherited cystic kidney disease associated with a spectrum of various renal and extrarenal manifestations, including increased risk of kidney cancers. Here, we present the initial molecular description of sarcomatoid renal cell carcinoma (sRCC) arising in the setting of ADPKD. Methods: Multiregion whole‐exome sequencing and whole transcriptomic sequencing were used to examine intratumoral molecular heterogeneity among histologically‐distinct spindle (sarcomatoid), epithelioid, or biphasic compartments within the tumor and compared with the non‐malignant ADPKD component. Results: Spindle and biphasic components harbored several overlapping driver gene mutations, but do not share any with the epithelioid component. Mutations in ATM, CTNNB1, and NF2 were present only in the biphasic and spindle components, while mutations in BID, FLT3, ARID1B, and SMARCA2 were present only in the epithelioid component. We observed dichotomous evolutionary pathways in the development of epithelioid and spindle compartments, involving early mutations in TP53 and ATM/CTNNB1/NF2 respectively. Wnt, PI3K‐mTOR, and MAPK signaling pathways, known key mechanisms involved in ADPKD development, featured prominently in the sarcomatoid component. Conclusion: This highlights that common pro‐oncogenic signals are present between ADPKD and sRCC providing insights into their shared pathobiology. [ABSTRACT FROM AUTHOR]

Giant cells (GC) are a poorly understood subset of tumor cells that have been increasingly recognized as a potential contributor to tumor heterogeneity and treatment resistance. We aimed to characterize the biological and clinical significance of GC in angiosarcoma, an aggressive rare cancer of endothelial origin. Archival angiosarcoma samples were examined for the presence of GC and compared with clinicopathological as well as NanoString gene expression data. GC were examined in angiosarcoma cell lines MOLAS and ISOHAS using conventional and electron microscopy, single cell whole genome profiling, and other assays. In the cell lines, GC represented a rare population of mitotically active, non–senescent CD31+ cells, and shared similar genomic profiles with regular‐sized cells, consistent with a malignant endothelial phenotype. GC remained viable and persisted in culture following exposure to paclitaxel and doxorubicin. In patient samples, GC were present in 24 of 58 (41.4%) cases. GC was correlated with poorer responses to chemotherapy (25.0% vs 73.3%, P = 0.0213) and independently contributed to worse overall survival outcomes (hazard ratio 2.20, 95% confidence interval 1.17‐4.15, P = 0.0142). NanoString profiling revealed overexpression of genes, including COL11A1, STC1, and ERO1A, accompanied by upregulation of immune‐related metabolic stress and metastasis/matrix remodeling pathways in GC‐containing tumors. In conclusion, GC may contribute to chemoresistance and poor prognosis in angiosarcoma. [ABSTRACT FROM AUTHOR]

Background: This study aimed to determine pre‐ and peri‐operative parameters with significant predictive value for post‐operative outcomes in patients with recurrent colorectal cancer presenting as peritoneal carcinomatosis undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS‐HIPEC), and to develop a novel prognostic scoring system for prediction of survival outcomes. Methods: A single‐institution review of prospectively collected data from all patients who underwent CRS‐HIPEC between October 2005 and October 2017 was conducted. Univariate and multivariate analyses were used to identify significant parameters for prediction of post‐CRS‐HIPEC disease‐free survival and overall survival (OS). Results: A total of 278 patients underwent CRS‐HIPEC, of whom 72 were for peritoneal carcinomatosis from recurrent colorectal cancer. Disease‐free interval (DFI; P = 0.006), peritoneal cancer index (PCI; P = 0.001) and left upper quadrant disease (P = 0.023) were significant independent predictors of 3‐year OS. DFI (0.007), PCI (P < 0.001) and intraoperative blood loss (BL; P = 0.001) were significant independent predictors of 5‐year OS. PCI and BL were significant independent predictors of both 3‐year (P = 0.026, PCI; P = 0.009, BL) and 5‐year (P = 0.002, PCI; P = 0.011, BL) disease‐free survival. Predictive models were developed for risk stratification of OS. Conclusion: PCI, DFI, left upper quadrant disease and BL have significant predictive value for post‐CRS‐HIPEC outcomes. Risk stratification models allow for more prudent patient selection and ultimately more accurate prognostication of post‐operative outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been found to prolong survival in selected patients with peritoneal disease, but the extent of cytoreduction and chemoperfusion can result in systemic toxicities. We evaluate the incidence of perioperative hematological complications and its associated risk factors. Methods: Retrospective analysis of a prospectively collected database of CRS‐HIPEC cases between April 2001 and October 2016 was performed. Patients were stratified based on the clinicopathological characteristics, perioperative incidence, grade, and duration of leukopenia (white blood cells < 4000/mm3), neutropenia (absolute neutrophils < 2000/mm3), and thrombocytopenia (platelets < 140 000/mm3). Results: Two hundred and thirty‐five CRS‐HIPEC were performed in 220 patients with peritoneal metastasis of colorectal, ovarian, primary peritoneal, appendiceal, or mesothelioma origins. The incidences of leukopenia, neutropenia, and thrombocytopenia were 15.3%, 3.8%, and 37.9%, respectively. Median time to onset was 1 day (0‐16 days), 0 day (0‐2 days), and 1 day (1‐2 days), respectively, after operation. Median duration of leukopenia, neutropenia, and thrombocytopenia was 1 day (1‐3 days), 1 day (1‐2days), and 3 days (range 0‐16 days), respectively. Age > 60 (odds ratio [OR] 0.229 [95% CI: 0.105‐0.502], P <.001) and the use of prior chemotherapy (OR 2.46 [95% CI: 1.24, 4.83], P =.010) were independent risk factors for thrombocytopenia on multivariable logistic regression. Conclusion: Hematological toxicities are common after hyperthermic intraperitoneal chemotherapy with thrombocytopenia being most common. Patients with age > 60, and who have undergone chemotherapy, are at risk of these toxicities and should be closely monitored post CRS‐HIPEC. [ABSTRACT FROM AUTHOR]

Angiosarcomas of the breast (ASB) are rare, making up to less than 8% of all angiosarcomas. The surgical management for this disease continues to vary throughout centres worldwide due to the current limited evidence. We aim to examine the necessity of axillary lymph node dissection in this pathology through a retrospective study of axillary metastasis and recurrence patterns in patients treated at our institution. A retrospective review of a prospectively-maintained database was performed. All adult patients with a histologically confirmed diagnosis of ASB seen at the National Cancer Centre Singapore between 2006 and 2019 were identified. Axillary lymph node status, treatment, survival, and recurrence data were collated. Thirteen patients were identified with a confirmed diagnosis of ASB, of which there were 11 primary and 2 secondary angiosarcoma cases. Eight patients had some form of axillary lymph node dissection and 5 did not. No positive nodes were found in any examined axillary nodes despite high median number of nodes harvested (13, range 8–24). 5/13 patients had disease progression, of whom none had locoregional recurrence to the axilla. ASB continues to be rare and recurrent and presents as a challenge to treat. Axillary lymph node involvement is most likely not present in a majority of patients. Prophylactic removal is unwarranted in patients presenting without lymph node involvement due to the lack of axillary metastasis. [ABSTRACT FROM AUTHOR]

Background: Patients may present with a resectable pancreatic tumour in the context of a concurrent primary extra‐pancreatic malignancy. These patients pose a dilemma regarding their suitability for surgery. We evaluated our experience with such patients who underwent pancreatic resection with curative intent and detailed their outcomes and rationale for surgical decision‐making. Methods: A retrospective review of patients with pancreatic concurrent extra‐pancreatic primary malignancy who underwent pancreatic resection at our institution over a 12‐year period (2005–2016) was performed. Clinical, histopathological and perioperative outcomes were reviewed. Results: Ten patients with a median age of 74 years (40–85 years) were identified. Secondary primary tumours included thyroid (n = 2), gastrointestinal (n = 4), small bowel neuroendocrine (n = 1), renal (n = 1) and haematological malignancies (n = 2). Pancreatic tumours included pancreatic ductal adenocarcinomas (n = 6), solid pseudopapillary neoplasms (n = 2) and ampullary carcinomas (n = 2). After a median follow up of 41.3 months (31.3–164 months), 8 of 10 patients were still alive. Two patients died due to metastatic disease from the secondary malignancy (small bowel neuroendocrine tumour and sigmoid colon adenocarcinoma). The post‐operative complication rate was 30% with no perioperative 90‐day mortality. Conclusion: Selected patients with a pancreatic and concurrent primary extra‐pancreatic malignancy may undergo curative pancreatic resection with favourable outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: District wellness policies provide an avenue to advance the Whole School, Whole Community, Whole Child (WSCC) model. The extent to which wellness policies currently align with WSCC is unclear; to‐date, tools have been unavailable to examine this issue. METHODS: We reviewed written health‐focused policies among 37 school districts in Los Angeles County in 2017 utilizing a 54‐item tool designed to examine the quality of policies in the 10 WSCC domains. Descriptive analyses explored overall and domain‐specific comprehensiveness and strength; simple negative binomial regression models examined differences in the policy quality and structure by legislated status. RESULTS: Approximately half of expected policies were present in wellness policies (mean comprehensiveness score = 52.65, ±18.09), < 20% were strong (mean strength score = 16.97, ±8.05). Content in WSCC domains addressed by legislative mandates was significantly more comprehensive and stronger, and more frequently located within the wellness policies, relative to content in non‐legislated domains. CONCLUSIONS: Opportunities exist for better alignment of wellness policies with WSCC. Education and health practitioners can utilize the tool developed for this study to identify priority areas where policy support is needed in their jurisdictions. Additional efforts are needed to help schools facilitate and document practice gains around WSCC‐aligned policies. [ABSTRACT FROM AUTHOR]

Objectives: (1) Describe outcomes of bronchoscopy with foreign body removal among children on the basis of a large standardized multi-institutional data set. (2) Identify factors associated with 30-day adverse events.Study Design: Cross-sectional analysis of a US national database.Setting: Public data set from the ACS NSQIP-P (American College of Surgeons National Surgical Quality Improvement Program-Pediatric) from 2012 to 2015.Subjects and Methods: Children <18 years old who underwent bronchoscopy with removal of foreign body were identified. Patient demographics, comorbidities, hospitalization factors, surgical characteristics, and 30-day postoperative adverse events, including complication and readmission, were analyzed. Multivariate logistic regression identified predictive factors for postoperative complications and prolonged length of stay.Results: A total of 275 children underwent bronchoscopic foreign body removal (n = 165 male, 60%; n = 75 nonwhite and/or Hispanic, 27%; mean age, 3.5 years [range, 0.63-17.9; median, 2.0]). Adverse events occurred among 10 children (4%). Seven had pulmonary-related complications, and 1 patient died. Three patients were readmitted; there were no reoperations. On multivariate analysis, preoperative pulmonary disease or need for pulmonary support (odds ratio [OR], 6.42; P = .04) predicted postoperative complications. Preoperative pulmonary compromise (OR, 8.10; P < .01), American Society of Anesthesiologists class 3 or 4 (OR, 4.13; P < .01), and prolonged operative time (OR, 3.05; P = .01) were associated with prolonged hospital stay.Conclusion: Bronchoscopy for retrieval of foreign body among children has an overall low incidence of 30-day adverse events. Children with preoperative pulmonary compromise have a significantly higher risk of postoperative complications. These findings may be applied to optimize perioperative care and counsel parents and families. [ABSTRACT FROM AUTHOR]

Background: Metastatic gastric cancer has a poor prognosis. We aim to study how clinical features and prognosis differs between different metastatic sites, and to identify prognostic factors for overall survival. Methods: We retrospectively reviewed patients with metastatic gastric adenocarcinoma managed at a tertiary referral cancer center over a 5‐year period. We divided our cohort into three groups based on the site(s) of metastasis at presentation—peritoneal metastasis only (P), distant metastasis only (D), and peritoneal and distant metastases (PD). Results: We studied 470 patients with 175 (37.2%), 193 (41.1%) and 102 (21.7%) patients in the P, D and PD groups, respectively. Patients with peritoneal disease (both P and PD) had higher proportions of patients experiencing chemotherapy disruption due to unplanned hospitalizations, which were also of a longer average duration. The P group had the longest overall median survival of 8.9 months compared to the PD and D groups with 7.4 and 5.5 months, respectively (P < 0.001). On multivariate Cox regression analysis, the presence of ≥1 metastatic site (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.23–2.28; P  =  0.001) was significantly associated with increased overall mortality, whereas palliative systemic chemotherapy (HR 0.29; 95% CI, 0.22–0.37; P < 0.001) and palliative gastrectomy (HR 0.24; 95% CI, 0.15–0.39; P < 0.001) were significantly associated with decreased overall mortality. Conclusion: Metastatic gastric cancer represents a heterogeneous disease, with specific disease complications and treatment outcomes unique to different metastatic sites. We can consider novel multimodality therapies for patient subgroups with isolated metastatic disease and good prognostic factors in a bid to improve long‐term survival. [ABSTRACT FROM AUTHOR]

Background: Primary mucosal melanomas (MM) are rare neoplasms arising from melanocytes in mucosal membranes. Delayed diagnosis and aggressive disease biology contribute to a poorer prognosis. The clinical patterns of MMs treated in a large tertiary centre, and the differences between MMs in the head and neck versus other anatomical sites are described. Methods: A retrospective review of 43 patients diagnosed with MM in the head and neck, urogenital, esophageal and anorectal sites from 1993 to 2015 was conducted. Results: Distribution of head and neck, urogenital and gastrointestinal MM were 42, 30 and 28% respectively. Disease extent was local in 44%, regional in 40% and distal in 12% at diagnosis. Head and neck MMs were more likely to be diagnosed at an earlier stage as compared to other sites (P = 0.04). Surgery was performed with curative intent in 72%, while 2% had palliative surgery for symptom control. Of the remaining patients who did not undergo surgery, four had palliative chemotherapy and/or radiotherapy. Median disease‐free survival was 13 months (1–179 months). There was a significantly longer time to locoregional recurrence in head and neck MM (16 months) compared to other sites (11 months) (P = 0.03). The 2‐year overall survival was also significantly higher in head and neck MM (P = 0.003). Conclusion: MM of the head and neck is diagnosed at an earlier stage and associated with a longer time to locoregional recurrence. Surgical resection is the mainstay of treatment and may offer long‐term survival benefit in selected patients. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is known to improve survival in selected patients with peritoneal metastasis. However, there is limited data supporting the role of CRS and HIPEC in elderly patients (≥65 years old). Methods: A retrospective review of a prospectively maintained database of patients who underwent CRS‐HIPEC between April 2001 and July 2015 from a single institution was performed. Patients were divided into two groups non‐elderly (<65 years old), and elderly (≥65 years old). Clinico‐ pathological parameters, morbidity and overall (OS) and disease‐free survival (DFS) of the patients were compared. Results: A total of 177 patients (median age 52, range 9–74) underwent CRS‐HIPEC with curative intent. There were 159 non‐elderly patients and 18 elderly patients. Median PCI scores were 12 (0–39) for the non‐ elderly patients and 11 (1–29) for the elderly patients (p=0.77). High‐grade complications occurred in 39 non‐elderly patients (24.5%) and 8 elderly patients (44.4%) (p=0.79), while 58 non‐elderly patients (38.7%) and 7 elderly patients (41.2%) stayed in ICU for more than 1 day (p=0.69). There was no difference in the 30‐day mortality between the two groups (0% vs. 0%, p=1). After a median follow‐up of 16 months for all patients, there was no difference in 5‐years OS (51.0% vs. 59.6%, p=0.88) and 5‐years DFS (23.3% vs. 53.3%, p=0.60) between non‐elderly and elderly patients. Conclusions: Surgical outcomes after CRS‐HIPEC do not differ significantly between non‐elderly and elderly patients. Hence, age should not be a contraindication in selecting patients for CRS and HIPEC. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acral melanoma (AM) and mucosal melanoma (MM) make up more than half of melanomas in Asia but comprise only 5% of cases in Caucasians, where cutaneous melanoma (CM) predominates. AM and MM are thought to be genetically and biologically distinct from CM. We report the characteristics and outcomes of melanoma patients from the National Cancer Centre Singapore. Methods: Case records of 210 patients treated between 2002 and 2014 were reviewed. Results: Median follow‐up was 2.5 years. CM, AM and MM made up of 37.6%, 33.8% and 16.2% of cases, respectively, with 6.2% each having ocular melanoma and unknown primary. Caucasians made up 16.2% of patients, accounting for 36.7% of CM but only 2.8 of AM and 2.9% of MM. Patients with MM (2.9% stage I, 14.7% stage IV) presented with higher American Joint Committee on Cancer (AJCC) stage than those with AM (16.9% stage I, 5.6% stage IV) or CM (24.1% stage I, 8.9% stage IV) (P = 0.01). Median overall survival (OS) was 5.7 years for all patients, and 1.0 year for metastatic disease. Considering stage I–III disease, multivariable Cox regression analysis demonstrated age ≥60 years and higher stage to be independent adverse prognostic factors for RFS and OS. Sentinel lymph node biopsy, undertaken for 56 stage I–III patients (25 AM, 31 CM) did not influence outcome. Conclusion: Our study reinforces the known unique clinicopathologic features of melanomas in Asians where AM and MM predominate. Age and stage remain the most critical prognostic factors across all subtypes. [ABSTRACT FROM AUTHOR]

Aim To review our experience in the management of retroperitoneal sarcomas (RPSs) in a single institution, with a predominantly Asian population, and identify associated prognostic factors for overall survival (OS), disease-free survival (DFS) and local recurrence. Materials and methods All RPSs diagnosed and managed at our center between January 2000 and March 2014 were included. Exclusion criteria included patients whose medical records were untraceable and patients who underwent biopsy but did not undergo resection. The variables studied were age, gender, histological subtype, tumor size, tumor grade, surgical margins, type of presentation of tumor (primary or recurrent) and presence of contiguous organ resection. The primary outcome measured was OS. Results Eighty-five patients underwent resection of RPS with curative intent. Eight patients underwent adjuvant chemotherapy and 15 patients underwent radiotherapy. The median DFS was 21 months (range: 0-146) and median OS was 45 months (range: 1-233). On univariate analysis, resection margin ( P = 0.04), tumor grade ( P = 0.011) and type of presentation of tumor ( P = 0.007) were found to significantly affect OS. Patients with tumor adherent to contiguous organs had a greater OS as compared to patients with tumor invasive into the contiguous organs ( P = 0.02). Conclusion An aggressive surgical approach in primary and recurrent RPS is associated with good OS. Complete resection, with contiguous organ resection if necessary should be performed to achieve microscopically negative surgical margins to allow for long-term survival. However, tumor biology remains the main determinant for OS. [ABSTRACT FROM AUTHOR]

Aim A nomogram for prediction of 12-year sarcoma-specific survival has been developed based on patients with soft tissue sarcomas treated in Memorial Sloan Kettering Cancer Centre (MSKCC). We aim to evaluate the predictive accuracy of the MSKCC sarcoma nomogram in a cohort of patients treated at an Asian institution. This has not been validated in an Asian population and thus its universal applicability remains unproven. Materials and methods Between 1990 and 2013, 840 adult patients underwent treatment for primary soft tissue sarcoma (STS) at the National Cancer Centre Singapore. Patients who presented with locally recurrent or metastatic disease were excluded from the analysis. The variables included in the MSKCC nomogram included age at diagnosis, tumor size, histologic grade, histologic subtype, depth and site. A total of 399 patients were left for analysis. The nomogram was validated by assessing its extent of discrimination and level of calibration. Results All patients had deep tumors. Disease occurred most commonly in the lower extremity ( n = 149 [37.3%]), the most common histologic subtype was 'Others' (angiosarcoma, ewing's sarcoma, endometrial stromal sarcoma, sarcoma NOS [not otherwise specified] and rhabdomyosarcoma). Sixty-four percent of all patients had high-grade tumors while 36% had low-grade tumors. The median patient age at diagnosis was 54 years (range: 17-88 years). The median follow up time for all patients and surviving patients were 29 (range: 1-174) and 33 (range: 1-157) months, respectively. The observed 5- and 10-year sarcoma-specific survival were 55% and 33%, respectively. The concordance index was 0.71. For level of calibration, the observed correspondence between predicted and actual outcomes suggest that the MSKCC nomogram generally predicts well for patients with higher survival probability, but consistently overpredicts survival for the other groups, in our cohort of patients. Conclusion The MSKCC sarcoma nomogram was found to be accurate in terms of extent of discrimination. In terms of level of calibration, it generally predicts well for patients with higher survival probability, but consistently overpredicts survival for the other groups in our population. [ABSTRACT FROM AUTHOR]

Background Gastrointestinal stromal tumours ( GISTs) represent the most common mesenchymal tumour of the gastrointestinal tract. Although the efficacy of targeted therapy cannot be over-emphasized, surgery remains the only curative primary treatment for patients with localized disease. The median size of GIST at diagnosis is approximately 5-7 cm; however, it is not uncommon for tumours to be as large as 30-40 cm and involving multiple viscera. Methods Data were retrospectively collected from patients with GISTs treated at the Singapore General Hospital and the National Cancer Centre Singapore over a 15-year period. Standard resection of GIST without any additional organ removal was termed as a single organ resection ( SOR). If the tumour was adjacent to another organ, necessitating the removal of more than one organ, the procedure was defined as a multivisceral resection ( MVR). We aim to evaluate the role of MVR in the management of large GISTs. Results A total of 187 patients underwent curative surgery for GIST between January 2000 and January 2014. Of the 187 patients, 40 (21%) underwent MVR whereas 147 (79%) had SOR. Patients in the MVR group had significantly larger tumour sizes ( P < 0.001) yet R0 and R1 resection was achieved in all patients, and no intra-peritoneal rupture was reported. On comparison of MVR versus SOR groups, there was no significant difference in in-hospital morbidity and mortality. Conclusion MVR may be required to achieve negative margins in patients with large GISTs, and can be performed with acceptable morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background Gastrointestinal stromal tumours ( GISTs), despite complete surgical cytoreduction, are associated with recurrence rates of up to 50% at 2 years. At recurrence, tyrosine kinase inhibitor ( TKI) therapy is recommended, conferring a survival of up to 55 months. Several studies have shown that patients with TKI-responsive recurrent GIST benefit from surgery. However, no studies have compared upfront surgery versus TKI alone. Methods Data were retrospectively collected from patients with recurrent GIST treated at Singapore General Hospital and National Cancer Centre Singapore over a 12-year period. Our primary end points were disease-free and overall survival ( OS). Results A total of 186 patients underwent curative surgery for GIST between January 2000 and June 2012. Fifty-six (30%) patients experienced recurrence, of which 30 (54%) had resectable recurrent disease. Twenty-four patients underwent upfront surgery for their recurrence while the remaining six patients opted for non-surgical management. The median OS for all patients with recurrent GIST was 5.3 years (95% confidence interval ( CI) 3.2-8.4). It was not reached for patients who underwent curative surgery for their recurrence, and was 3.9 years (95% CI 2.4-7.0) for patients who had palliative TKI and conservative management. There were significant differences in OS and disease-specific survival between patients who underwent curative surgery for recurrence compared with those who had not. Conclusion Our study shows that upfront surgery is a reasonable treatment strategy for selected patients with recurrent GIST. [ABSTRACT FROM AUTHOR]

This study investigated the kinetics of drying and polyphenol degradation during hot air and sun drying of cocoa beans. Hot air drying was carried out using a constant humidity-controlled (50% relative humidity) oven at temperature range of 60-80C, and sun drying was carried out by exposing the beans under direct sunlight. Several semi-theoretical models were used to model the kinetics of moisture diffusion and it was found that the Page and Logarithmic models were able to provide good prediction. A first-order reaction kinetics was used to predict the polyphenol degradation process with rate constants ranging from 0.011/h to 0.052/h. Activation energy for polyphenol degradation was determined at 8.97 kJ/mol using the Arrhenius equation. Effective diffusivity during drying was found within the order of magnitude (10−12-10−10 m2/s) reported in most drying literatures. Practical Applications The understanding of moisture diffusion is important in dryer design especially in the determination of effective diffusivities during drying. Polyphenols are important antioxidants that are beneficial to human health. By investigating the polyphenol degradation kinetics, this helps to link the reactions with moisture diffusion kinetics. [ABSTRACT FROM AUTHOR]

Background: The selection of patients for cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy infusion (HIPEC) is important, and relies heavily on imaging. However, it has been reported that Computer Tomographic (CT) scans may only achieve a low sensitivity of 33% for peritoneal disease. We propose a set of radiological criteria for pre-operative determination of resectability of peritoneal disease in peritoneal-based malignancies and validate this in our cohort of patients.Methods: A retrospective review of all patients who underwent laparotomy with a view for CRS and HIPEC, at the National Cancer Centre Singapore from January 2000 to April 2010, was performed. Intra-operative Peritoneal Cancer Index (PCI) scores were recorded. The pre-operative imaging was reviewed with a senior radiologist who was blinded, and recorded the radiological PCI scores (CT-PCI) and eight additional CT prognostic factors (CT-PF). The CT-PCI and CT-PF scores were then compared with the intra-operative findings to determine the radiological accuracy. The scores and the individual prognostic factors were then evaluated for their predictive ability for unresectability.Results: Comparison of the CT-PCI and PCI scores showed a concordance correlation coefficient at 0.52 (95% CI 0.34-0.7). Accuracy was increased with the addition CT-PF. The presence of omental caking and ascites were predictors of unresectability. We propose a scoring system which is able to predict for unresectable disease with a specificity of 80% and a sensitivity of 62%.Conclusion: With our proposed criteria, and scoring system, the selection of patients for CRS and HIPEC can be improved, and unnecessary exploratory operations avoided. [ABSTRACT FROM AUTHOR]

Background. Peritoneal Carcinomatosis Index (PCI) is a widely established scoring system that describes disease burden in isolated colorectal peritoneal carcinomatosis (CPC). Its significance may be diminished with complete cytoreduction. We explore the utility of the recently described Peritoneal Surface Disease Severity Score (PSDSS) and compare its prognostic value against PCI. Methods. The endpoints were overall survival (OS), progression-free survival (PFS), and survival less than 18 months (18 MS). Results. Fifty patients underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for CPC from 2003 to 2014, with 98% achieving complete cytoreduction. Median OS was 28.8 months (95% CI, 18.0–39.1); median PFS was 9.4 months (95% CI, 7.7–13.9). Univariate analysis showed that higher PCI was significantly associated with poorer OS (HR 1.11; 95% CI, 1.03–1.20) and PFS (HR 1.09; 95% CI, 1.03–1.14). Conversely, PSDSS was not associated with either endpoint. Multivariate analysis showed that PCI, but not PSDSS, was predictive of OS and PFS. PCI was also able to discriminate survival outcomes better than PSDSS for both OS and PFS. There was no association between 18 MS and either score. Conclusion. PCI is superior to PSDSS in predicting OS and PFS and remains the prognostic score of choice in CPC patients undergoing CRS/HIPEC. [ABSTRACT FROM AUTHOR]

Background: Peritoneal-based malignancy (PBM), especially peritoneal carcinomatosis from gastrointestinal malignancies traditionally carries a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) have been shown to attain long median survival of 34-92 months and 5 year survival of 29-59 % in patients with favorable histopathological subtypes. Recurrence after CRS and HIPEC poses a management dilemma. This paper evaluates our institution's experience with repeat CRS and HIPEC, its associated morbidity and outcomes. Methods: One-hundred and thirty underwent CRS and HIPEC for PBM from April 2001 to June 2013. 49 had peritoneal recurrences, of which 24 had peritoneal only recurrence. 7 out of the 24 underwent a second CRS and HIPEC. Results: Five females and two males with median age of 51 (37-63), underwent a second CRS and HIPEC. The primary malignancies were: 1 peritoneal mesothelioma, 3 appendiceal, 2 ovarian, and 1 colorectal cancers. Median peritoneal cancer indices for the initial and second CRS were 19 and 12, respectively. Completeness of cytoreduction score of 0 was achieved for all patients. Median hospitalization after second CRS and HIPEC was 12 days (7-60). 1 out of 7 (14 %) experienced grade 3 or 4 post-operative complications. There was no 30-day or inpatient mortality. Median follow-up was 13 months (1-97). Median disease-free interval between the first CRS and HIPEC to peritoneal recurrence was 20 months (14-87). Median disease-free survival of 6 months (1-97) was achieved after the second CRS and HIPEC. Six patients remained alive without disease and one passed away with disease. Two had recurrences at 12 and 71 months after second CRS and HIPEC, 1 died and the other, still alive, went on to have a third CRS. Conclusion: Repeat CRS and HIPEC can achieve prolonged survival in selected patients with peritoneal-based malignancies, and can be performed with acceptable morbidity and mortality. [ABSTRACT FROM AUTHOR]

We investigated global and regional effects of myocardial transplantation of human induced pluripotent stem cell (i PSC)-derived mesenchymal stem cells (i MSCs) in infarcted myocardium. Acute myocardial infarction ( MI) was induced by ligation of left coronary artery of severe combined immunodeficient mice before 2 × 105 i MSCs or cell-free saline were injected into peri-infarcted anterior free wall. Sham-operated animals received no injection. Global and regional myocardial function was assessed serially at 1-week and 8-week by segmental strain analysis by using two dimensional (2D) speckle tracking echocardiography. Early myocardial remodelling was observed at 1-week and persisted to 8-week with global contractility of ejection fraction and fractional area change in saline- (32.96 ± 14.23%; 21.50 ± 10.07%) and i MSC-injected (32.95 ± 10.31%; 21.00 ± 7.11%) groups significantly depressed as compared to sham control (51.17 ± 11.69%, P < 0.05; 34.86 ± 9.82%, P < 0.05). However, myocardial dilatation was observed in saline-injected animals (4.40 ± 0.62 mm, P < 0.05), but not i MSCs (4.29 ± 0.57 mm), when compared to sham control (3.74 ± 0.32 mm). Furthermore, strain analysis showed significant improved basal anterior wall strain (28.86 ± 8.16%, P < 0.05) in the i MSC group, but not saline-injected (15.81 ± 13.92%), when compared to sham control (22.18 ± 4.13%). This was corroborated by multi-segments deterioration of radial strain only in saline-injected (21.50 ± 5.31%, P < 0.05), but not i MSC (25.67 ± 12.53%), when compared to sham control (34.88 ± 5.77%). Improvements of the myocardial strain coincided with the presence of interconnecting telocytes in interstitial space of the infarcted anterior segment of the heart. Our results show that localized injection of i MSCs alleviates ventricular remodelling, sustains global and regional myocardial strain by paracrine-driven effect on neoangiogenesis and myocardial deformation/compliance via parenchymal and interstitial cell interactions in the infarcted myocardium. [ABSTRACT FROM AUTHOR]

Epidermolytic acanthoma is an uncommon benign tumor with a predilection for the anogenital region, that is characterized histologically by epidermolytic hyperkeratosis. Most reported cases are asymptomatic while some are pruritic. Treatment of this condition is challenging and not well studied. We report a 55-year-old man with pruritic anogenital epidermolytic acanthomas that persisted despite various topical and ablative therapies, and whose pruritus was not relieved with emollients and antihistamines. He was given 0.1% tacrolimus ointment twice daily and experienced a marked improvement in his pruritus within 2 weeks. At 1 month, there was marked improvement in itch score from 8 to 3.5 (maximum of 10), itch frequency from 20 times a day to once every 4 days, sleep score from 5 to 1 (maximum of 5), and Dermatology Life Quality Index score from 15 to 5 (maximum of 30). Apart from a transient burning sensation, no other adverse effects were noted. To our knowledge, this is the first report of the effective use of a topical calcineurin inhibitor in relieving the intractable itch associated with epidermolytic acanthoma. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the performance of two enzyme immunoassays (EIA), Murex and ICE, and the Determine TP point-of-care test (POCT) in diagnosing treponemal infection (syphilis or yaws) in patients attending a large HIV clinic in Ghana; to determine the prevalence of treponemal co-infections; and to characterise demographic and clinical features of patients with infection. Methods Samples were tested with EIAs and rapid plasma reagin (RPR), then POCT and reference assays for Treponema pallidum to determine prevalence of active and past infection. Sensitivity and specificity of each assay were calculated and demographic and clinical characteristics of patients compared. Data were collected from case notes of patients retrospectively. Results Overall, 45/284 patient samples (14.8%, 95% CI, 11.1-19.4%) were Treponema pallidum particle agglutination (TPPA) positive, and of these, 27 (64.3%) were RPR positive and 4 (8.9%) were treponemal IgM positive. Both EIAs and Determine TP POCT showed high sensitivities and specificities for identifying infection although RPR was less reliable. Clinical features of syphilis or yaws were rarely identified in TPPA-positive patients suggesting most had previous or late latent infection. Treatment of various intercurrent infections using short courses of antibiotics active against T. pallidum was common in the clinic. Conclusions A high proportion of this HIV-infected cohort showed evidence of treponemal infection. Both EIAs as well as the POCT were practical and effective at diagnosing treponemal co-infection in this setting. RPR alone was unreliable at identifying active treponemal co-infection, however might be useful in some settings where treponemal-specific assays are unaffordable. [ABSTRACT FROM AUTHOR]

Objective: To determine if screening for undiagnosed type 2 diabetes mellitus (T2DM) and pre-diabetes is feasible in an Australian ED; to estimate the prevalence of T2DM and pre-diabetes in the Australian ED population. Methods: Prospective cross-sectional prevalence survey in the ED of St Vincent's Hospital, Melbourne, an adult, tertiary referral centre seeing approximately 40 000 patients annually. A convenience sample of adult patients was screened with finger-prick random blood glucose and glycosylated haemoglobin (HbA1c); those over 6.0 mmol/L and 6.0% were referred for oral glucose tolerance test (OGTT). Diagnoses of T2DM and pre-diabetes were made according to World Health Organization definitions. Those not attending for OGTT were contacted by phone, and interviewed about their reasons. Results: Seven hundred and twenty-five patients were recruited; 135 (18.6%; 95% confidence intervals [CI] 15.9-21.6%) had known T2DM, leaving 590 screened, of whom 210 screened positive. Of the 192 referred for OGTT, 147 (77%) did not attend despite several telephone reminders. Of the 45 (23%) completing OGTT, pre-diabetes was present in eight (17.8%; 95% CI 9.0-31.6%) and T2DM in six (13.3%; 95% CI 5.9-26.6%). Many people interviewed (18/86, 21%) did not attend for OGTT on the advice of their doctors. Conclusions: This inner city tertiary ED has a high prevalence of T2DM, diagnosed and undiagnosed, with as much as half our population possibly affected. Although ED screening might have a high yield, opportunistic screening is not feasible, with difficulties in staff engagement and patient follow up for diagnostic testing. Future studies might consider finger-prick fasting blood glucose through a patient's general practitioner for diagnosis. [ABSTRACT FROM AUTHOR]

SUMMARY Achondrogenesis is a rare form of short-limbed dwarfism which is invariably lethal. This is the first reported case of achondrogenesis in Singapore. As most newborns with a large head and short limbs were assumed to have achondroplasia, the importance of radiological studies of short-limbed dwarfism is stressed. Recognition of achondrogenesis has also an important implication in genetic counselling as present evidence suggests that it is an autosomal recessive disorder. [ABSTRACT FROM AUTHOR]

Although respiratory tract infections can be a common complication in people with Parkinson’s disease (PD), there is little published data on the nature of such infections in this patient group. We wished to investigate whether sputum samples were being taken from PD patients in order to establish whether an infection was present and if so which bacteria were responsible for the infection. We recorded the number of positive sputum samples taken from admission to North Tyneside General Hospital in North-East England across a ten-year period from June 2001 to June 2011. Of 643 in-patient episodes involving people with PD, positive sputum samples were recorded for only 12 episodes (1.9%) in eight patients. All patients were in early stage disease. In all admissions to the NHS Trust running the hospital, there were 23,069 sputum cultures from 1,056,693 in-patient episodes (2.2%). Our findings may reflect the difficultly of expectorating in many people with PD, particularly in late-stage disease. Since people with PD are especially vulnerable to respiratory tract infections, clinicians need to ensure that, where possible, a sputum sample is obtained from people with PD when clinically indicated. [ABSTRACT FROM AUTHOR]

The ward round, central to inpatient care, has not been well studied. One recent trend is for hospitals to run at capacity by placing 'overflow' patients into 'outlying' beds. Bed occupancy rates are increased and ward rounds may require visits to many wards. The present study aims to identify the time spent in different activities on general surgical ward rounds, with particular reference to the impact of outlying patients. For 4 days, the morning ward round was observed. Activity was timed to the second. The resulting data were analysed to compare outlying wards, acute wards and home ward patients. Seven hours and 7 min of ward rounds were documented. One hundred ten consultations were observed. Four hours and 4 min were spent at the bedside (58%). Sixty-six minutes were spent in transit between wards. The average times spent at the bedside and in patient discussion were similar for the different ward types. The mean average time per patient was nearly doubled for outlying patients compared with home wards (5:40 min versus 2:57 min, respectively). Although patient discussion and consultation were longer for outlying patients, most of the increased time was related to time travelling between wards (2:16 min average per patient consultation). Most of the time spent on surgical ward rounds is in patient contact. Travel time to outlying patients for morning ward rounds is more than an hour per week. [ABSTRACT FROM AUTHOR]