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Background Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Methods Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons’ reports and assessors’ evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Results Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. Conclusion This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.

Acute ischemic stroke (AIS) can be a catastrophic complication of cardiac surgery previously without effective treatment. Endovascular thrombectomy (EVT) is a potentially life-saving intervention. We examined patients at our institution who had EVT to treat AIS post cardiac surgery.We retrospectively reviewed a stroke database from January 1, 2016 to October 31, 2021 to identify patients who had undergone EVT to treat AIS following cardiac surgery. Demographic data, operation type, stroke severity, imaging features, management and outcomes (mortality and modified Rankin Score (mRS)) were assessed.Of 5022 consecutive patients with AIS, 870 underwent EVT. Seven patients (0.8%) had EVT following cardiac surgery. Operations varied: two coronary artery bypass grafting (CABG), two transcatheter AVR, one redo surgical aortic valve replacement (AVR), one mitral valve repair and one patient with combined aortic and mitral valve replacements and CABG. Meantime postsurgery to stroke symptoms onset was 3 days (range 0-9 days). Median NIHSS was 26 (range 10-32). Five patients had middle cerebral artery occlusion and two internal carotid artery (n = 2). Median time between onset of symptoms and recanalization was 157 min (range 97-263). Two patients received Intra-arterial Thrombolysis. All patients survived and were discharged to another hospital (n = 3), home (n = 2), or rehabilitation facility (n = 2). Median 3-month mRS was 3 (range 0-6).We report the largest case series of EVT after cardiac surgery. EVT can be associated with excellent outcomes in these patients. Close neurological monitoring postoperatively to identify patients who may benefit from intervention is key.

Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross-sectional study determining relative impacts of COVID-19, gender, race, specialty and seniority on mental health of surgical trainees.Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire-2 and the effect on individual stress levels of training experiences affected by COVID-19. Predictors included trainee characteristics and local COVID-19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors.Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID-19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID-19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P 0.0001). Greater depression was associated with more seniority (P 0.0001). Greater COVID-19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002).This is the first study to specifically describe the relative impacts of COVID-19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale.

Background Accurate and thorough surgical ward round documentation is crucial for maintaining quality clinical care. Accordingly, checklists have been proposed to improve ward round documentation. This systematic review aimed to evaluate the literature investigating the use of checklists to improve surgical ward round documentation. Methods MEDLINE, EMBASE, and PsycINFO were searched on August 16, 2021. Study selection, data extraction, and risk of bias assessment were performed in duplicate. We included English studies that investigated the use of checklists during ward rounds in various surgical subspecialties compared to routine care, where the rates of documentation were reported as outcomes. We excluded studies that used checklists in outpatient, non-surgical, or pediatric settings. Due to heterogeneity of outcome measures, meta-analysis was precluded. This study was registered with PROSPERO (ID: CRD42021273735) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020) reporting guidelines. Results A total of 206 studies were identified, only 9 were suitable for inclusion. All included studies were single-center observational studies, spanning across seven surgical specialties. Rates of documentation on 4–23 parameters were reported. Documentation for all measured outcomes improved in 8/9 studies; however, statistical analyses were not included. There was a high risk of bias due to the nature of observational studies. Conclusion Ward round checklists can serve as a useful tool to improve inpatient care and safety. Currently, there is no high-level evidence showing the effectiveness of checklists on ward round documentation. The synthesis of results indicates that further high-quality research is imperative.

Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay.Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P 0.05.After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P 0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P 0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P 0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P 0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P = 0.0035).In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.

Patient centred communication ensures patients are well informed and educated, which is vital to providing the best care possible. By asking questions, patients can better understand their disease and make informed decisions regarding their health journey. We aimed to investigate factors that affect question asking behaviours in surgical outpatient consultations and to determine the typical question-asking by doctors, patients, and their companions.This is an observational cross-sectional study, where 182 video recordings of surgical consultations in the surgical outpatient setting at The Queen Elizabeth Hospital, Adelaide, South Australia were reviewed.A total of 3472 questions were asked. Most questions were asked by the surgeon, followed by the patient, and if present, their companion. Pre-surgical consultations resulted in the most questions asked by the patients, compared to post-surgical or follow-up consultations. When companions were present, patients asked more questions in consultants regarding malignant conditions. Interruptions increased the number of questions asked by the patient and their companion. Questions were commonly asked to clarify information given by the surgeon and often regarded the cause of the illness and the timing of the next step in disease management.Patients are generally interested in their health and ask questions during consultations. Companions have a positive effect on patient question asking behaviour and their presence in surgical consultations should be encouraged. Surgeons should develop strategies to encourage question asking and could review their own behaviours via surgical coaching and video review.

Despite advances in medical management and endoscopic therapy, gastrectomy remains an important yet high-risk procedure for a range of benign and malignant upper gastrointestinal pathologies. No study has previously analysed Australian gastrectomy perioperative mortality rate (POMR). This retrospective, population-based cohort study was conducted to determine the Australian national gastrectomy POMR, allowing state-based and regional trends and outcomes to be assessed.Logistic regression models were compared using de-identified procedural data between 1 July 2005 and 30 June 2017 from the Australian Institute of Health and Welfare. Codes relating to total and subtotal gastrectomy contained in the Australian Classification of Health Interventions were used to extract patient data. Mortality rates were risk adjusted for age and gender. Temporal trends and differences between states/territories and regions were investigated.The national average POMR throughout the study period was 2.1%. For subtotal gastrectomy, the national mean POMR was 1.1%, decreasing from 2.7% (2005) to 1.3% (2017). For total gastrectomy, the national mean POMR was 2.8%, decreasing from 3.3% (2005) to 1.7% (2017). POMR significantly reduced over time without variation between states or regions. Procedure volume steadily reduced in rural centres with a concomitant increase in metropolitan centres over time.Pleasingly, the Australian gastrectomy POMR is favourable when compared to international cohorts. Improved outcomes were consistent between states and territories, and metropolitan and regional centres. Progressive metropolitan centralization of gastrectomy was demonstrated without evidence of improved outcomes.

BackgroundThe number of clinical studies evaluating the benefit of cytokine-induced killer cell (CIK) therapy, an adoptive immunotherapy, for colorectal cancer (CRC) are increasing. In many of these trials CIK therapy was co-administered with conventional cancer therapy. The aim of this review is to systematically assess the available literature, in which the majority were only in Chinese, on CIK therapy for the management of CRC using meta-analysis, and to identify parameters associated with successful CIK therapy implementation.MethodsProspective and retrospective clinical studies which compared CIK therapy to non-CIK therapy in CRC patients were searched for electronically on MEDLINE, Embase, CNKI and Wanfang Data databases. The clinical endpoints of overall survival (OS), progression-free survival (PFS), OS and PFS rates, overall response rate (ORR) and toxicity were meta-analysed using hazard (HR) and relative ratios (RR), and subgroup analyses were performed using Chi-square (Chi2) test and I-square (I2) statistics for study design, disease stage, co-therapy type, and timing of administration.ResultsIn total, 70 studies involving 6,743 patients were analysed. CIK therapy was favoured over non-CIK therapy for OS (HR=0.59, 95% CI: 0.53-0.65), PFS (HR=0.55, 95% CI: 0.47-0.63), and ORR (RR=0.65, 95% CI: 0.57-0.74) without increasing toxicity (HR=0.59, 95% CI 0.16-2.25). Subgroup analyses on OS and PFS by study design (randomised versus non-randomised study design), disease stage (Stage I-III versus Stage IV), co-treatment with dendritic cells (CIK versus DC-CIK therapy), or timing of therapy administration (concurrent versus sequential with co-administered anti-cancer therapy) also showed that the clinical benefit of CIK therapy was robust in any subgroup analysis. Furthermore, co-treatment with dendritic cells did not improve clinical outcomes over CIK therapy alone.ConclusionsCompared with standard therapy, patients who received additional CIK cell therapy had favourable outcomes without increased toxicity, warranting further investigation into CIK therapy for the treatment of CRC.Key MessageWhat is already known on this topicCytokine-induced killer cell (CIK) therapy is an adoptive immunotherapy used to treat both solid and haematological cancers for over 20 years. It is predominantly used in China, with multiple studies reporting benefit in colorectal cancer (CRC) patients. Despite this, CIK therapy treatment regimens are not widely used, possibly due in part to the majority of the literature about CIK therapy in CRC being reported in Chinese. Further, CIK therapy is commonly combined with other therapies but it is currently not known if there is a specific combination or treatment regimen that is optimal for CRC.What this study addsWe report the most comprehensive systematic review to date of CIK therapy for CRC patients, combining both Chinese and English language reports. Patients with CRC who received additional CIK therapy had better survival outcomes than with standard therapy alone. We also showed that the addition of dendritic cells (DC) to CIK therapy, common for CRC treatment, did not provide any clinical benefit over CIK therapy alone, and that CIK therapy is effective whether given concurrently or sequentially to standard treatment regimens.How this study might affect research, practice, or policyOur systematic review of Chinese and English publications shows that CRC patients benefit from the addition of CIK therapy to standard treatment protocols and warrants further international studies.

Aim: Reviewing outcomes of regorafenib use in metastatic colorectal cancer using real-world data from the South Australian Metastatic Colorectal Cancer Registry. Methods: A retrospective review of the characteristics and outcomes of patients who received regorafenib in the Registry up to December 2018. The registry started in February 2006. Results: Fifty-three patients received regorafenib therapy since approved by the therapeutic goods administration in November 2013. The median age was 66 (range 34–82). 66% were male, 66% had stage IV disease at diagnosis, 53% had liver only involvement, whereas 13% had liver and lung disease and 6% had lung only involvement. 75% had left-sided primary. KRAS was available in 35/53 patients with 49% of them being WT. BRAF status was known in 8/53 with 25% of them having a mutated variant. MSI testing was known in 14 patients in whom 21% of them had MSI-High tumors. Prior lines of treatment received: one line 4%, two 9%, three 23%, four 26%, >four 37%. Prior biological use: bevacizumab 72%, anti-EGFR 100% (for RAS WT). Median survival from diagnosis was 3.3 years (95% CI, 2.8–3.8 years). Median survival from the start of regorafenib was 7.1 months (95% CI, 4.8–9.4 months) and the 12-month survival rate was 28%. Conclusion: The survival outcome for those patients from our population-based registry who access regorafenib is in keeping with reports from large, randomized trials. Thus, clinicians can quote local real world data when discussing efficacy and access to regorafenib therapy for mCRC patients. Refereed/Peer-reviewed

In under-resourced settings, general surgeons may be called upon to perform emergency operations within other specialties. Accordingly, we aimed to characterise patient outcomes after emergency neurosurgery performed by a general surgeon or general surgery trainee. PubMed, Embase and the Cochrane Library were searched to 30 May 2021 for observational studies reporting outcomes after emergency neurosurgery performed by a general surgeon. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, mortality rates and complications were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42021258097. From 632 records, 14 retrospective observational studies were included, covering a total sample of 1,988 operations. Four studies were from Australia, and the remaining 10 were, respectively, from 10 other countries. Most common operations performed were decompressive surgery with burr holes or craniectomy for head trauma and insertion of intracranial pressure monitors. Rural hospitals were the most common settings. Mortality rates for procedures performed by general surgeons at latest follow-up were heterogenous, ranging from 5% for evacuation of chronic subdural haematoma in Kenya to 81% in head injured patients in a Hong Kong study. This is the first systematic review that synthesises the literature to characterise patient outcomes after neurosurgical operations performed by a general surgeon. Findings from this study may benefit global surgery performed in rural, remote, military or humanitarian settings.

Background Variation in cut-off values for what is considered a high volume (HV) hospital has made assessments of volume-outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta-analysis comparing in-hospital mortality after PD in hospitals above and below HV thresholds of various cut-off values. Method PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in-hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random-effects model was used for meta-analysis, including meta-regressions. Registration: PROSPERO, CRD42021224432. Results From 1855 records, 17 observational studies of moderate quality were included. Median HV cut-off was 25 PDs/year (IQR: 20-32). Overall relative risk of in-hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in-hospital survival benefit in performing PDs at HV hospitals. Meta-regressions from included studies found no statistically significant associations between relative risk of in-hospital mortality and region (USA vs. non-USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut-off values. Significant inverse relationships were found between PD hospital volume and other outcomes. Conclusion In-hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut-off value or region. Future research is required to investigate regions where low-volume centres have specialized PD infrastructure and the potential impact on mortality.

Introduction The lack of an effective continuing professional development programme for qualified surgeons, specifically one that enhances non-technical skills (NTS), is an issue receiving increased attention. Peer-based coaching, used in multiple professions, is a proposed method to deliver this. The aim of this study was to undertake a systematic review of the literature to summarize the quantity and quality of studies involving surgical coaching of NTS in qualified surgeons. Methods A systematic search of the literature was performed through MEDLINE, EMBASE, Cochrane Collaboration and PsychINFO. Studies were selected based on predefined inclusion and exclusion criteria. Data for the included studies was independently extracted by two reviewers and the quality of the studies evaluated using the Medical Education and Research Study Quality Instrument (MERSQI). Results Some 4319 articles were screened from which 19 met the inclusion criteria. Ten studies involved coaching of individual surgeons and nine looked at group coaching of surgeons as part of a team. Group coaching studies used non-surgeons as coaches, included objective assessment of NTS, and were of a higher quality (average MERSQI 13.58). Individual coaching studies focused on learner perception, used experienced surgeons as coaches and were of a lower quality (average MERSQI 11.58). Individual coaching did not show an objective improvement in NTS for qualified surgeons in any study. Conclusion Surgical coaching of qualified surgeons’ NTS in a group setting was found to be effective. Coaching of individual surgeons revealed an overall positive learner perception but did not show an objective improvement in NTS for qualified surgeons.

Objectives Gastric cancer remains one of the most fatal cancers, despite an intensive treatment regime of chemotherapy–surgery–chemotherapy. Peritoneal metastatic disease is commonly diagnosed post treatment regime and once established, patients are likely to die in 3–9 months. Systemic chemotherapy does not increase survival for these patients due to the poor vascularisation of this area. We are proposing the addition of pressurised intraperitoneal aerosol chemotherapy (PIPAC) to the treatment regime for curative patients as a preventive measure to reduce the risk of peritoneal metastases occurring. Methods This is a prospective, single centre, non-randomised, open-label pilot trial evaluating the addition of PIPAC to the standard multimodal treatment pathway. Patients will undergo standard neoadjuvant chemotherapy with four cycles of fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT), then PIPAC, followed by gastrectomy. Four cycles of FLOT will be administered post-surgery. Primary outcome is safety and feasibility, assessed by perioperative morbidity and possible interruptions of the standard multimodal treatment pathway.

Current evidence and guidelines suggest a time-based approach to the perioperative administration of direct oral anticoagulants (DOAC). Quantifying haematological concentrations of DOACs is possible however, the evidence suggests a large inter-individual variation and unlike INR is to warfarin, it does no correlation with anticoagulant effect. There are multiple confounding factors that affect DOAC metabolism and may result in a cohort of patients who satisfy one guideline (time based) but are ruled out using an objective, serum quantity-based guideline. The unsubstantiated use of DOAC level testing to inform surgical triage and use of reversal agents preoperatively may increase harm to patients.

Non-technical skills complement technical skills in surgeons to provide best possible care for patients. The former is essential to promote patient engagement. Coaching has been introduced to surgeons as a method to improve non-technical skills. We aimed to investigate the impact of coaching for surgeons on patient engagement in the outpatient consultation setting.This was a single-centre cohort study conducted in South Australia. Consultant surgeons, suitable coaches, and patients were recruited. Coaches underwent further training by a human factors psychologist on being an effective coach. Outpatient consultations were recorded in an audio-visual format and analysed by investigators. Patient talking time, mutual eye gaze between surgeon and patient, and number of questions asked by the patient were measured as outcomes for patient engagement.182 patients, 12 surgeons, and 4 coaches participated in the study. Each surgeon underwent 3 coaching sessions, 5 to 6 weeks apart. There were 62 pre-coaching patient consultations, 63 patient consultations after one coaching session, and 57 patient consultations after two coaching sessions. The mean talking time of the patient increased significantly after a single coaching session (P 0.05) without making significant difference to the total consultation time (p = 0.76). Coaching sessions did not have a significant effect on mutual eye gaze or mean number of questions asked by the patient.Coaching of non-technical skills for surgeons appears to objectively improve patient engagement during the outpatient consultation. This would suggest that tailored coaching programs should be developed and delivered to surgeons to improve care delivery.

Effective pain control is crucial to postoperative recovery and is affected by biopsychosocial factors. This study aimed to evaluate how non-English primary language, gender, and marital status may influence pain, length of stay, and mortality after general surgery.Consecutive general surgical admissions over a two-year period to two tertiary hospitals were included. Multivariable logistic regression analyses were conducted to evaluate the relationship between non-English primary language, gender, and marital status, and pain scores, length of stay, and in-hospital mortality. Explanatory variables that were controlled for in these analyses included age, birth country, whether a religion was specified, socioeconomic percentile, Charlson comorbidity index, and time of admission.A total of 12 846 general surgery patients were included. When controlling for the aforementioned variables, including having a specified religion and being born overseas, having a non-English primary language was significantly independently associated with lower pain scores (odds ratio 0.61, 95% CI 0.52-0.71, P 0.001). Female gender was independently associated with an increased likelihood of higher pain scores (odds ratio 1.09, 95% CI 1.01-1.18, P = 0.024) and a lower likelihood of prolonged length of stay (odds ratio 0.88, 95% CI 0. 80-0.95, P = 0.002). None of the evaluated variables had a statistically significant association with in-hospital mortality.This study is the first to characterize an association between general surgery patients with a non-English primary language and lower levels of postoperative pain. It was also found that female gender was associated with higher postoperative pain but lower length of hospital stay.

Background Surgical outpatient consultations are demanding for the surgeon and patients without a definite formula for success. Various factors have been identified regarding factors that influence patient satisfaction and engagement. We aimed to examine the modern-day surgical outpatient consultation and report on these factors. Methods An observational cross-sectional study was performed by reviewing video recordings of 182 surgical consultations by 12 surgeons at The Queen Elizabeth Hospital, South Australia, Australia. Results The mean consultation time was 12.3 min, with pre-surgical consultations being the longest. There were 107 consultations for benign conditions (58%). Proportionally, the consultant spoke most (51.9% of total consultation time), followed by the patient (19.5%) and then companion (8.2%). Forty-eight (26.4%) patients brought a companion to the clinic but monopolisation of the consultation by the companion was rare. When a companion was present, there was more mutual eye gaze between the consultant and the patient. Interruptions were present in 23.6% of consultations and were associated with a significant increase of the length of the consultation. Table positioning did not seem to affect the dynamics of the outpatient consultation. Conclusion Companions are highly valuable for promoting patient engagement and their presence should be encouraged in surgical outpatients. Interruptions should be kept to a minimum to avoid unnecessary delays. Further studies should be conducted to investigate the effect of companions, interruptions and table positioning during a consultation on patient outcomes.

OBJECTIVE The objective of this review is to examine the reliability and measurement error of devices that measure transepidermal water loss. INTRODUCTION Transepidermal water loss is a physiological property of skin that increases when the epidermis is damaged. It is, therefore, a commonly utilized measure of skin barrier integrity. Devices measuring transepidermal water loss are available as open, semi-open, or closed chamber. Studies that examine the similarities and differences between transepidermal water loss measurement devices are available. However, there has not been a systematic review to comprehensively collate and critique these studies. The aim of this review will be to synthesize the data from these studies to aid in selection and use of transepidermal water loss measurement devices in clinical practice or research. INCLUSION CRITERIA Studies examining the reliability and/or measurement error of transepidermal water loss measurement devices will be included. Studies that examine a single device to demonstrate how different handling affects measurements will also be included. Studies that only report on measurement of transepidermal water loss outcomes without examination of reliability and/or measurement error will be excluded. METHODS The search strategy will aim to locate published and unpublished studies. Databases to be searched will include PubMed, Embase, CINAHL, and Web of Science, utilizing identified keywords and limited to studies in English. Gray literature sources will be searched to identify any unpublished documents. Study selection will adhere to the inclusion criteria and then be assessed by two reviewers for methodological quality utilizing COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) guidelines and risk of bias tools. Extracted data will be presented in a narrative synthesis and as tables and figures to aid data presentation.

Refereed/Peer-reviewed

Laparoscopic colorectal cancer surgery has been shown to produce comparable oncological long-term results as well as improved short-term outcomes compared to open surgery in multicentre trials. Limited information is available whether these results are reproduced in non-metropolitan surgery.Audit of prospectively collected follow-up data in a rural surgical centre in South Australia. Short- and long-term results of colorectal cancer patients undergoing elective laparoscopic surgery for cure. Outcomes are compared with results of open surgery.Survival and clinical data of 120 patients after laparoscopic resection were analysed and then benchmarked against results of 157 open resections. Conversion rate was 10.8% (N = 13). Mean patient age was 69.9 years. Mean number of lymph nodes analysed was 15.5. Mean follow-up is 53.0 months. Thirty-day mortality was 0.36% (n = 1) and 90-day mortality was 0.72% (n = 2). No differences in complications rates, long term survival or procedures performed were observed. This is a single centre audit of clinical and oncological outcomes and a number of exclusion criteria were applied. Patient gender, cancer stages as well as number of patients undergoing neoadjuvant radio-chemotherapy differ significantly between the study and the benchmarking group. Patients were not randomized and the benchmarking group is in part a historical control.This audit of clinical outcomes and survival after laparoscopic CRC resection for cure indicates that minimal invasive surgery may be suitable for adequately staffed and equipped rural centres.

Objective Coaching has been proposed as a potential form of continuing professional development (CPD) for surgeons. Our study aimed to elicit qualified surgeons’ perceptions of peer coaching as a form of CPD and to determine the effect of demographic factors on surgeons’ views. Methods A cross-sectional paper survey was conducted across 2 South Australian metropolitan hospitals from November 2018 to January 2019. This comprised 5 demographic questions and 6 Likert items eliciting views on peer-based coaching and was distributed at departmental unit meetings to surgical consultants and fellows. Participation was voluntary and a definition of “peer-based coaching” was provided. Results Hundred and eighteen surgeons of a possible 125 (94.4% response rate) from 8 surgical specialties completed the survey with 45.4% (n = 54) having received coaching since obtaining their fellowship. The majority of participants (72.9%, n = 86) reported consultant surgeons would benefit from peer coaching and that one-on-one coaching in an individual setting would be a useful CPD activity (73.7%, n = 87). Just over half the participants (53.4%, n = 63) felt that coaching by a nonsurgeon such as a psychologist would benefit their nonoperative skills. Many participants (61.8%, n = 73) felt more inclined to participate if CPD points were awarded. Despite the support in favor of coaching, a significant percentage of participants (45.8%, n = 54) wanted further evidence of its efficacy. Conclusions There is support amongst surgeons for peer coaching and its inclusion as a form of CPD, however, many require more evidence of its benefits, thus highlighting the need for ongoing research studies, consultation and pilot coaching programs.

BackgroundThe number of clinical studies evaluating the benefit of cytokine-induced killer cell (CIK) therapy, an adoptive immunotherapy, for colorectal cancer (CRC) is increasing. In many of these trials, CIK therapy was coadministered with conventional cancer therapy. The aim of this review is to systematically assess the available literature, in which the majority were only in Chinese, on CIK therapy for the management of CRC using meta-analysis and to identify parameters associated with successful CIK therapy implementation.MethodsProspective and retrospective clinical studies which compared CIK therapy to non-CIK therapy in patients with CRC were searched for electronically on MEDLINE, Embase, China National Knowledge Infrastructure, and Wanfang Data databases. The clinical endpoints of overall survival (OS), progression-free survival (PFS), OS and PFS rates, overall response rate (ORR), and toxicity were meta-analyzed using HR and relative ratio (RR), and subgroup analyses were performed using chi-square (χ2) test and I-squared (I2) statistics for study design, disease stage, cotherapy type, and timing of administration.ResultsIn total, 70 studies involving 6743 patients were analyzed. CIK therapy was favored over non-CIK therapy for OS (HR=0.59, 95% CI: 0.53 to 0.65), PFS (HR=0.55, 95% CI: 0.47 to 0.63), and ORR (RR=0.65, 95% CI: 0.57 to 0.74) without increasing toxicity (HR=0.59, 95% CI: 0.16 to 2.25). Subgroup analyses on OS and PFS by study design (randomized vs non-randomized study design), disease stage (Stage I–III vs Stage IV), cotreatment with dendritic cells (DCs) (CIK vs DC-CIK therapy), or timing of therapy administration (concurrent vs sequential with coadministered anticancer therapy) also showed that the clinical benefit of CIK therapy was robust in any subgroup analysis. Furthermore, cotreatment with DCs did not improve clinical outcomes over CIK therapy alone.ConclusionCompared with standard therapy, patients who received additional CIK cell therapy had favorable outcomes without increased toxicity, warranting further investigation into CIK therapy for the treatment of CRC.