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Purpose: To assess whether preoperative radiologically defined lean muscle measures are associated with adverse clinical outcomes in patients undergoing elective surgery for colorectal cancer., Methods: This retrospective UK-based multicentre data collection study identified patients having had colorectal cancer resection with curative intent between January 2013 to December 2016. Preoperative computed-tomography (CT) scans were used to measure psoas muscle characteristics. Clinical records provided postoperative morbidity and mortality data., Results: This study included 1122 patients. The cohort was separated into a combined group (patients with both sarcopenia and myosteatosis) and others group (either sarcopenia or myosteatosis, or neither). For the combined group, anastomotic leak was predicted on univariate (OR 4.1, 95% CI 1.43-11.79; p = 0.009) and multivariate analysis (OR 4.37, 95% CI 1.41-13.53; p = 0.01). Also for the combined group, mortality (up to 5 years postoperatively) was predicted on univariate (HR 2.41, 95% CI 1.64-3.52; p < 0.001) and multivariate analysis (HR 1.93, 95% CI 1.28-2.89; p = 0.002). A strong correlation exists between freehand-drawn region of interest-derived psoas density measurement and using the ellipse tool (R 2  = 81%; p < 0.001)., Conclusion: Measures of lean muscle quality and quantity, which predict important clinical outcomes, can be quickly and easily taken from routine preoperative imaging in patients being considered for colorectal cancer surgery. As poor muscle mass and quality are again shown to predict poorer clinical outcomes, these should be proactively targeted within prehabilitation, perioperative and rehabilitation phases to minimise negative impact of these pathological states., (© 2023. The Author(s).)

Background: This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis., Methods: A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented., Results: Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. -0.05 to 0.35))., Conclusions: Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)

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 that HIIT would enhance muscle microvascular blood flow and vascular reactivity to acute contractile activity in older adults, reflecting HIIT-induced vascular remodelling. In a randomised controlled-trial, twenty-five healthy older adults aged 65-85 years (mean BMI 27.0) were randomised to 6-week 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. HIIT led to improvements in anaerobic threshold (13.2 ± 3.4 vs. 15.3 ± 3.8 ml/kg/min, P < 0.001), dynamic exercise capacity (145 ± 60 vs. 159 ± 59 W, P < 0.001) and resting (systolic) blood pressure (142 ± 15 vs. 133 ± 11 mmHg, P < 0.01). Notably, HIIT elicited significant increases in microvascular blood flow responses to acute contractile activity (1.8 ± 0.63 vs. 2.3 ± 0.8 (arbitrary contrast units (AU), P < 0.01)), with no change in any of these parameters observed in the control group. Six weeks HIIT improves skeletal muscle microvascular responsiveness to acute contractile activity in the form of active hyperaemia-induced by a single bout of resistance exercise. These findings likely reflect reports of enhanced large vessel distensibility, improved endothelial function, and muscle capillarisation following HIIT. Moreover, our findings illustrate that HIIT may be effective in mitigating deleterious alterations in muscle microvascular mediated aspects of sarcopenia., (© 2021. The Author(s).)

Background: Hypertension is a risk factor for both cardiovascular and cerebrovascular disease, with an increasing incidence with advancing patient age. Exercise interventions have the potential to reduce blood pressure in older adults, however, rates of exercise uptake and adherence are low, with 'lack of time' a commonly cited reason. As such, there remains the need for time-efficient physical activity interventions to reduce blood pressure in older adults., Objective: To compare the effect of three, novel time-efficient physical activity interventions on resting blood pressure in older adults., Methods: Forty-eight, healthy, community-dwelling older adults (mean age: 71 years) were recruited to a 6-week randomised control trial. Resting blood pressure was measured before and after one of three supervised, time-efficient interventions: high-intensity interval training (HIIT) on a cycle ergometer; isometric handgrip training (IHG); unilateral, upper limb remote ischaemic preconditioning (RIPC) or non-intervention control., Results: Both HIIT and IHG led to a statistically significant reduction in resting systolic blood pressure (SBP) of 9 mmHg, with no significant change in the RIPC or control groups. There was no change in diastolic blood pressure or pulse pressure in any group., Conclusions: Supervised HIIT or IHG using the protocols described in this study can lead to statistically significant and clinically relevant reductions in resting SBP in healthy older adults in just 6 weeks., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Insulin resistance (IR) is a key feature in the development of numerous metabolic diseases. The cornerstone for treatment for IR remains diet and exercise, however these have poor rates of adherence. Beta-hydroxy-beta-methylbutyrate (HMB) is a nutraceutical with contentious effects on IR in animal models. The aim of this study was to evaluate the impact of acute HMB on IR in humans during an oral glucose tolerance test (OGTT). Young and older male volunteers underwent two 75 g OGTT with or without 3 g HMB. In young men, HMB significantly reduced the insulin area-under-the-curve (AUC), with no difference in glucose AUC, resulting in a numerical increase in the Cederholm index of insulin sensitivity. In older men, HMB had no effect on insulin or glucose responses. In conclusion, acute HMB may improve IR following a glucose load in young men; however, this does not appear to be sustained into older age., Competing Interests: The authors declare no conflicts of interest. JAR is an employee of Metabolic Technologies Inc., who supplied the free acid-HMB on a collaborative basis. Metabolic Technologies Inc., has patents pending on HMB-FA, and market HMB to nutrition companies., (© 2020 The Authors.)

Objective: High-intensity interval training (HIIT) has been shown to be more effective than moderate continuous aerobic exercise for improving cardiorespiratory fitness (CRF) in a limited time frame. However, the length of time required for HIIT to elicit clinically significant improvements in the CRF of older adults is currently unknown. The aim of this study was to compare changes in the CRF of older adults completing identical HIIT protocols of varying durations., Methods: Forty healthy, community-dwelling older adults completed a cardiopulmonary exercise test (CPET) before and after 2, 4, or 6 weeks of fully supervised HIIT on a cycle ergometer, or a no-intervention control period., Results: Anaerobic threshold (AT) was increased only after 4 (+1.9 [SD 1.1] mL/kg/min) and 6 weeks (+1.9 [SD 1.8] mL/kg/min) of HIIT (both P  < 0.001), with 6-week HIIT required to elicit improvements in VO 2 peak (+3.0 [SD 6] mL/kg/min; P  = 0.04). Exercise tolerance increased after 2 (+15 [SD 15] W), 4 (+17 [SD 11] W), and 6 weeks (+16 [SD 11] W) of HIIT (all P  < 0.001), with no difference in increase between the groups. There were no changes in any parameter in the control group., Conclusion: Improvements in exercise tolerance from HIIT precede changes in CRF. Just 4 weeks of a well-tolerated, reduced-exertion HIIT protocol are required to produce significant changes in AT, with a further 2 weeks of training also eliciting improvements in VO 2 peak., Competing Interests: Nothing to disclose., (© 2020 The Authors. Aging Medicine published by Beijing Hospital and John Wiley & Sons Australia, Ltd.)

Objectives: To quantify the economic and psychological impact of the cancellation of operations due to winter pressures on patients, their families and the economy., Design: This questionnaire study was designed with the help of patient groups. Data were collected on the economic and financial burden of cancellations. Emotions were also quantified on a 5-point Likert scale., Setting: Five NHS Hospital Trusts in the East Midlands region of England., Participants: We identified 796 participants who had their elective operations cancelled between 1 November 2017 and 31 March 2018 and received responses from 339 (43%) participants., Interventions: Participants were posted a modified version of a validated quality of life questionnaire with a prepaid return envelope., Main Outcome Measures: The primary outcome measures were the financial and psychological impact of the cancellation of elective surgery on patients and their families., Results: Of the 339 respondents, 163 (48%) were aged <65 years, with 111 (68%) being in employment. Sixty-six (19%) participants had their operations cancelled on the day. Only 69 (62%) of working adults were able to return to work during the time scheduled for their operation, with a mean loss of 5 working days (SD 10). Additional working days were lost subsequently by 60 (54%) participants (mean 7 days (SD 10)). Family members of 111 (33%) participants required additional time off work (mean 5 days (SD 7)). Over 30% of participants reported extreme levels of sadness, disappointment, anger, frustration and stress. At least moderate concern about continued symptoms was reported by 234 (70%) participants, and 193 (59%) participants reported at least moderate concern about their deteriorating condition., Conclusions: The cancellation of elective surgery during the winter had an adverse impact on patients and the economy, including days of work lost and health-related anxiety. We recommend better planning, and provision of more notice and better support to patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Current 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., Methods: A 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)., Results: One 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%., Conclusions: This 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.

The preservation of muscle power is crucial in aging for maintaining mobility and performing daily tasks. Resistance training involving high movement velocities represents a valid strategy to slow down the rate of sarcopenia, counteracting the loss of muscle mass and muscle power. Plyometric exercise may represent an effective training modality for increasing muscle power; however, its application in older populations has been sparingly investigated, as the high impact actions involved may reduce its feasibility for older individuals. By adopting a safer modality of plyometric training, we investigated if a 6-week plyometric training intervention could increase knee extensor muscle size, architecture, force and power in 14 young (YM, age = 25.4 ± 3.5 y; means ± SD) and nine older males (OM, age = 69.7 ± 3.4 y). Volunteers trained 3 times/week using a device similar to a leg press machine where the user was required to bounce against his body mass on a trampoline. Pre-to-post training changes in isometric maximum voluntary torque (MVT), leg extension power and vastus lateralis (VL) architecture were assessed. Muscle power increased in both groups (+27% OM - P < 0.001, 20% YM - P < 0.001), although the total external work performed during the training period was significantly lower for OM (i.e., ~-47%). Both groups showed significant increases in muscle thickness (MT) (+5.8 OM - P < 0.01 vs. +3.8% YM - P < 0.01), fascicle length (Lf) (+8% OM - P < 0.001 vs. +6% YM - P < 0.001), and pennation angle (PA) (+7.5% OM - P < 0.001 vs. +4.1% YM - P < 0.001). The current study shows that trampoline-based plyometric training is an effective intervention producing a rapid increase in muscle mass and power in both young and older individuals. The training modality used in this study seems to particularly benefit the older population, targeting the morphological and functional effects of sarcopenia in human muscle.

Background: 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 (PACS), universally available in the UK, may have advantages over methods requiring the use of additional specialist and often costly software. The aim of this study was to assess the association between radiologically defined sarcopenia measured by psoas density and postoperative outcome in patients having a colorectal cancer resection., Methods: All patients having a resection for colorectal cancer, discussed by 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 was analysed from preoperative computed tomography (CT) scans to define sarcopenia using the Picture Archiving and Communication Systems (PACS). 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 were 1.1% and 7.1%, respectively. Eighteen (10.7%) patients suffered a Clavien-Dindo grade 3 or 4 complication of which 6 (33%) were anastomotic leaks. In the whole cohort, sarcopenia was associated with an increased risk of Clavien-Dindo grade 3 or 4 complications [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 by measuring psoas density on preoperative CT scan using software universally available in the UK is highly predictive of postoperative morbidity in colorectal cancer patients.

The euphoric feeling described after running is, at least in part, due to increased circulating endocannabinoids (eCBs). eCBs are lipid signaling molecules involved in reward, appetite, mood, memory and neuroprotection. The aim of this study was to investigate whether activities other than running can increase circulating eCBs. Nine healthy female volunteers (mean 61 years) were recruited from a local choir. Circulating eCBs, haemodynamics, mood and hunger ratings were measured before and immediately after 30 min of dance, reading, singing or cycling in a fasted state. Singing increased plasma levels of anandamide (AEA) by 42% ( P < 0.05), palmitoylethanolamine (PEA) by 53% ( P < 0.01) and oleoylethanolamine (OEA) by 34% ( P < 0.05) and improved positive mood and emotions ( P < 0.01), without affecting hunger scores. Dancing did not affect eCB levels or hunger ratings, but decreased negative mood and emotions ( P < 0.01). Cycling increased OEA levels by 26% ( P < 0.05) and tended to decrease how hungry volunteers felt, without affecting mood. Reading increased OEA levels by 28% ( P < 0.01) and increased the desire to eat. Plasma AEA levels were positively correlated with how full participants felt ( P < 0.05). Plasma OEA levels were positively correlated with positive mood and emotions ( P < 0.01). All three ethanolamines were positively correlated with heart rate (HR; P < 0.0001). These data suggest that activities other than running can increase plasma eCBs associated with changes in mood or appetite. Increases in eCBs may underlie the rewarding and pleasurable effects of singing and exercise and ultimately some of the long-term beneficial effects on mental health, cognition and memory.

Background: Pilonidal 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., Methods: Fibrin 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., Results: One 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., Conclusions: Fibrin glue application following curettage of the sinus is a quick and effective procedure for first and second line treatment of PSD.

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 (<8 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 mL·kg·min, 95% confidence interval [CI] = 2.56-2.08). Overall HIIT provided added benefit to V˙O2peak over MCT (MD = 0.79 mL·kg·min, 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 mL·kg·min, 95% CI = 0.60-2.73; anaerobic threshold: MD = 1.61 mL·kg·min, 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.

Background: Random duodenal biopsy to exclude coeliac disease during upper gastrointestinal endoscopy for the investigation of iron deficiency anaemia remains a common procedure, but is expensive and time-consuming. Serological investigation for coeliac disease is also recommended, having excellent accuracy with the added benefit of lower cost. This study sought to examine the utility of duodenal biopsy and coeliac serology in the diagnosis of coeliac disease., Methods: A prospectively maintained database was interrogated to identify all patients having upper gastrointestinal endoscopy for the investigation of anaemia between January 01, 2016, and December 31, 2016., Results: Of the 1131 patients having an endoscopy, coeliac serology was measured in only 412 (36%) and was positive in 9 cases (2%), leading to 6 histological diagnoses of coeliac disease and 3 false positives. Two-hundred and seventy-four patients with negative serology had biopsies taken which were all negative. Only 2/451 (0.4%) patients who had biopsies performed in the absence of a serology test were histologically positive for coeliac disease. The cost per diagnosis of a case of coeliac disease in those with either negative or absent coeliac serology was £18,839 (US$25,244, €21,196)., Conclusions: Random duodenal biopsy is not a cost-effective method of diagnosing coeliac disease and should be replaced with pre-endoscopy coeliac serology.