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Background The evidence for treatment decision‐making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions. Methods Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non‐randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non‐surgical invasive or non‐invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist. Results The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty‐one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non‐randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty‐five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non‐surgical interventions. Fifty‐seven reviews (53·8 per cent) were rated as low risk of bias. Conclusion This overview of reviews highlights the need for more and better research in this field., Evidence still limited

BackgroundThe surgical post-take ward round is a complex multidisciplinary interaction in which new surgical patients are reviewed and management plans formulated. Its fast-paced nature can lead to poor communication and inaccurate or incomplete documentation with potential detriment to patient safety. Junior team members often do not fully understand the diagnosis and management plan.AimsThe aims of this project were to improve both communication and documentation on the surgical post-take ward round, influencing patient safety.MethodsThe ward round was deconstructed to identify individual roles and determine where intervention would have the most impact. Ten important points were identified that should be documented in the management of an acute surgical patient; observations, examination, impression, investigations, antibiotics, intravenous fluids, VTE assessment, nutrition status, estimated length of stay and ceiling of treatment. A ‘Take Ten’ checklist was devised with these items to be used as a ‘time out’ after each patient with the whole team for discussion, clarification and clear documentation. Four plan do study act cycles were completed over a period of a year. A retrospective review of post-take documentation preintervention and postintervention was performed, and the percentage of points that were accurately documented was calculated. For further clarification, 2 weekends were compared—one where the checklist was used and one where it was not.ResultsResults showed documentation postintervention varied between categories but there was improvement in documentation of VTE assessment, fluids, observations and investigations. On direct comparison of weekends the checklist showed improved documentation in all categories except length of stay. Junior team members found the checklist improved understanding of diagnosis and management plan, and encouraged a more effective ward round.ConclusionThe ‘Take Ten’ checklist has been well received. Three years on from its inception, the checklist has become an integral part of the post-take ward round, thanks to the multidisciplinary engagement in the project.

Previous studies have reported both positive and negative effects of culture of islets at high glucose concentrations on regulated insulin secretion. Here, we have re-examined this question in mouse islets and determined the role of changes in lipid synthesis in the effects of glucose. Glucose-stimulated insulin secretion (GSIS) and gene expression were examined in islets from C57BL/6 mice or littermates deleted for sterol-regulatory element binding protein-1 (SREBP1) after 4 days of culture at high glucose concentrations. Culture of control islets at 30 versus 8 mmol/1 glucose led to enhanced secretion at both basal (3 mmol/1) and stimulatory (17 mmol/1) glucose concentrations and to enhanced triacylglycerol accumulation. These changes were associated with increases in the expression of genes involved in glucose sensing (glucose transporter 2, glucokinase, sulfonylurea receptor 1, inwardly rectifying K + channel 6.2), differentiation (pancreatic duodenal homeobox 1), and lipogenesis (Srebp1, fatty acid synthase, acetyl-coenzyme A carboxylase 1, stearoyl-coenzyme A desaturase 1). When cultured at either 8 or 30 mmol/1 glucose, SREBP1-deficient (SREBP1 -/- ) islets displayed reduced GSIS and triacylglycerol content compared with normal islets. Correspondingly, glucose induction of the above genes in control islets was no longer observed in SREBP1 -/- mouse islets. We conclude that enhanced lipid synthesis mediated by SREBP1c-dependent genes is required for the adaptive changes in islet gene expression and insulin secretion at high glucose concentrations.

Children may have kidneys transplanted from donors larger than themselves. Abdominal wall closure may be difficult, with risks of abdominal compartment syndrome and graft compromise. Meshes used to facilitate closure may cause dense intra-abdominal adhesions, making further surgery or peritoneal dialysis difficult. We present five cases in which abdominal wall closure was facilitated by porcine dermal collagen implant. Five children (2-15 yr) received transplanted kidneys from adult donors of significantly greater weight. In four recipients, the kidney was transplanted onto the aorta and vena cava intra-abdominally using a midline incision. In the fifth, the kidney was anastomosed onto the iliac vessels. The skin overlying the implant was closed normally. Maximum follow-up was three yr. In all cases, primary closure was achieved. One child received a second intra-abdominal transplant as an emergency, which later failed. The other kidneys are functioning well. One recipient developed a small incisional hernia three yr post-transplant. Another developed a skin dehiscence over the implant 23 days post-operatively. The implant was removed and skin closed. The other two recipients recovered well. Porcine dermal collagen implant is a helpful adjunct to abdominal wall closure following organ transplantation in children with donor size discrepancy.

Over the past decade there has been a rapid and dramatic increase in the number of patients presenting to acute care services. This includes a >30% increase in the number of emergency admissions to hospitals.1 This has created an unsustainable rise in pressure on both acute medical and acute surgical services. It can be explained by a multitude of factors, including an increasingly older and comorbid population, a shortage of GP appointments, and higher patient expectations. There also appears to be a lack of public understanding about the provision and role of urgent and out-of-hours services. Many acute medical services (notably stroke and cardiology) have stepped up to this challenge to provide safe, rapidly accessible, and high-quality multidisciplinary units to address two of the biggest causes of mortality in the UK: stroke and myocardial infarction. However, acute general surgery still lags behind its medical counterparts. The traditional NHS model for acute admissions has followed a ‘consultant-led’ or ‘consultant-based’ service. In this model, although patients were admitted under a named consultant, the majority of daily patient care and interaction was delivered by junior members of the team, with a variable degree of consultant supervision and input. For surgical specialties, emergency services were not prioritised and so elective commitments ran side by side with emergency on-call because trusts feared losing out financially by abolishing their profitable elective services. In this model, the duty consultant may not have personally reviewed the patients admitted acutely under their care until 24 hours later, and thereafter in many cases will have had no further contact with them. The consultant would typically be kept informed of their patient’s status by their juniors while they carried on with elective work. However, there is now good evidence pointing to significant benefits for both trusts and patients by prioritising …

Background Recent guidance advocates daily consultant-led ward rounds, conducted in the morning with the presence of senior nursing staff and minimising patients on outlying wards. These recommendations aim to improve patient management through timely investigations, treatment and discharge. This study sought to evaluate the current surgical ward round practices in England. Methods Information regarding timing and staffing levels of surgical ward rounds was collected prospectively over a one-week period. The location of each patient was also documented. Two surgical trainee research collaboratives coordinated data collection from 19 hospitals and 13 surgical subspecialties. Results Data from 471 ward rounds involving 5622 patient encounters was obtained. 367 (77.9%) ward rounds commenced before 9am. Of 422 weekday rounds, 190 (45%) were consultant-led compared with 33 of the 49 (67%) weekend rounds. 2474 (44%) patients were seen with a nurse present. 1518 patients (27%) were classified as outliers, with 361 ward rounds (67%) reporting at least one outlying patient. Conclusion Recommendations for daily consultant-led multi disciplinary ward rounds are poorly implemented in surgical practice, and patients continue to be managed on outlying wards. Although strategies may be employed to improve nursing attendance on ward rounds, substantial changes to workforce planning would be required to deliver daily consultant-led care. An increasing political focus on patient outcomes at weekends may prompt changes in these areas.

Presently, sirolimus (rapamycin) is used as both induction and maintenance immunosuppression in solid organ transplants, including whole pancreas and kidney, and islet transplantation. Sirolimus has been suggested to have deleterious effects on islet beta-cell and renal function. We investigated the effect of sirolimus on the viability of islets, podocytes, and renal tubular cells. Sirolimus reduced the viability of islets and HK-2 human proximal renal tubular cells in vitro. This toxic effect was associated with a reduction of vascular endothelial growth factor (VEGF) release by islets but not the proximal tubular cells. Sirolimus reduced both viability and VEGF production by murine beta-cells, and blockade of VEGF-164 was associated with a reduction in viability. Transfection of murine islets with adenoviral VEGF-165 improved islet viability. These data are consistent with the hypothesis that sirolimus is toxic to islets and beta-cells by blockade of VEGF-mediated survival pathways.

A 79 year old woman was referred by her GP because of a 2×2 cm irregular mass at her umbilicus with a discoloured and rough surface⇓. …

Treatment of type 1 diabetes by islet transplantation is currently limited by loss of functional β-cell mass after transplantation. We investigated here whether adenovirus-mediated changes in AMP-activated protein kinase (AMPK) activity, previously shown to affect insulin secretion in vitro, might affect islet graft function in vivo. In isolated mouse and rat islets, insulin secretion stimulated by 17 (vs 3) mmol/l glucose was inhibited by 36.5% (PPPPPP=0.05) infected islets, versus null adenovirus-treated islets (0.68 ± 0.36% positive cells). Correspondingly, transplantation of islets expressing AMPK CA into streptozotocin-diabetic C57 BL/6 mice improved glycaemic control less effectively than transplantation with either null (PPin vivo and may represent a target for therapeutic intervention during islet transplantation.