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Background and purpose Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. Methods A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. Results In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). Conclusion COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Malignant pleural mesothelioma usually has a median survival of only nine months from diagnosis, with death usually due to thoracic disease. This has led to the belief in the past, that mesothelioma rarely has distant metastasis with cerebral metastasis accounting for only three percent. This is a unique case of known malignant mesothelioma with distant haemorrhagic metastasis to the brain. This article reviews the imaging evaluation of patients with suspected intracranial involvement and malignant pleural mesothelioma and describes typical imaging findings of parenchymal brain metastasis on computed tomography and magnetic resonance imaging. The incidence of haemorrhagic brain metastasis and various treatment option have also been briefly discussed.

Acute disseminated encephalomyelitis (ADEM) is a central nervous system demyelinating condition caused by viral or bacterial infections or immunizations. The postulated aetiology is an autoimmune reaction against myelin components; however, the mechanistic details are yet unknown. We present the imaging findings of a patient who passed away due to the manifestations of acute disseminated encephalomyelitis. The patient initially underwent surgical repair for type B aortic dissection. 2 weeks after he had poor GCS and no motor response following multiple attempts at sedation hold in the intensive care unit. On magnetic resonance imaging, haemorrhagic white matter abnormalities were noted throughout the cerebral hemisphere indicative of an inflammatory demyelinating process. Our case emphasizes the challenges involved in evaluating emerging neurological problems following a period of intubation /sedation amongst these patients. In addition, unlike children, 50% of adult patients do not have illness or immunisation as a trigger event for this condition.

BackgroundThe mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.ObjectiveTo describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.MethodsWe conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.ResultsThe total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).ConclusionCOVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Background: While there are reports of acute ischemic stroke (AIS) in COVID-19 patients, the overall incidence of acute ischemic stroke and clinical characteristics of large vessel occlusion in such patient remains to be established. Methods: A retrospective, international multicenter study of large vessel occlusion (LVO) was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Detailed data were collected on consecutive LVOs in hospitalized patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the incidence of AIS/LVO was measured. Among patients who underwent mechanical thrombectomy, stroke outcomes along with COVID-19 symptoms were reported. Results: Out of a total of 6698 COVID-19 patients admitted to 10 stroke centers, the incidence of stroke was found to be 1.3% (range 0.6-2.6%). The median age of patients who presented with LVO was 51 years (range 27-87) and in the US centers, African Americans comprised 28% of all patients. Ten patients (16 %) were less than 50 years of age with no significant risk factors for LVOs the vast majority. Among the LVOs eligible for MT, the average time to presentation from symptom onset to presentation was 9.3 hours. Successful revascularization was achieved in 81% of patients and the intracranial hemorrhage rate was 14% with no symptomatic hemorrhages. Twenty-one (50%) patients were either discharged to home or to acute rehabilitation facilities. Conclusion: LVOs was predominant in patients with AIS and COVID-19, occurring at a significantly younger age and affecting African Americans disproportionately.

BackgroundThe neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19.ObjectiveWe sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke.MethodsWe analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated.ResultsIncidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070).ConclusionsWe show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Background Mechanical thrombectomy was approved by NICE as a treatment for stroke in 2016. However, most of the evidence is from studies conducted during working hours. Only few centres in the UK perform thrombectomies out-of-hours. The Royal Stoke University Hospital (RSUH) has offered thrombectomies over 24 h (24/7) since 2010. The aim of this service review is to compare the outcomes for patients treated in regular working hours to those treated outside normal working hours within this unit. Methods This retrospective service analysis includes all patients treated with mechanical thrombectomy at RSUH since the start of the service in January 2010 to June 2019. Data on key demographics, timings, procedural complications, and long-term outcomes including death and disability at 90 days were collected. In-hours was defined as the time between 8:00–17:00 h, Monday to Friday; out-of-hours was defined as any time outside this period. Results In total, 516 mechanical thrombectomies were performed in this time period; data were available on 501 of these. Successful recanalization (TICI 2b/3) was achieved in 86% of patients. By 90 days 96 (19%) had died and 234 (47%) were functionally independent (modified Rankin Scale score ≤ 2). 211 (42%) of the procedures were performed in-hours and 290 (58%) out-of-hours. Door-to-CT and door-to-groin times were significantly longer out-of-hours than in-hours, but thrombectomy duration was significantly shorter. There were no significant differences in complications and short- and long-term outcomes. Conclusion Mechanical thrombectomy was delivered safely and effectively 24/7 in this UK hospital, with no difference in clinical outcomes.

In acute ischaemic stroke, ‘time is brain’, with 1.9 million neurones lost for every minute of untreated ischaemia, leading to death or disability.1 Recanalisation through mechanical thrombectomy has been shown to greatly improve outcomes in patients with large vessel occlusion.2 In the UK, few centres offer a 24/7 or out-of-hours thrombectomy service; however, many centres are planning on increasing their operating hours. For many conditions, there is strong evidence that treatment outside normal working hours results in poorer outcomes.3 This ‘weekend effect’ impacts the outcomes for many …

BACKGROUND While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear. OBJECTIVE To attempt to establish incidence of AIS in COVID-19 patients in an international cohort. METHODS A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers. RESULTS Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities. CONCLUSION LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA., Graphical Abstract Graphical Abstract

Interprofessional learning (IPL) was introduced for University of Nottingham 3rd year medical and nursing students at the Lincoln County Hospital. An evaluation of the subsequently implemented IPL intervention allowed us to ask the research question: can a single brief IPL intervention improve attitudes to IPL? A low fidelity simulation intervention was chosen as the mode of IPL, focusing on teamwork in the context of the assessment of the acutely ill patient. To assess the intervention’s effect on students’ attitudes, a validated questionnaire (RIPLS) was completed before and after the session. Nine of the nineteen questions in RIPLS had significantly different responses following the intervention. This reflected a more positive attitude to IPL following the intervention. This evaluation of this intervention suggests that IPL is valued by students and significantly improves attitudes to IPL, at least in the immediate post-intervention period.

s / International Journal of Surgery 8 (2010) 501–578 533 Aims: ERCP is usually performed in OGSD patients. Most patients are subsequently counselled for cholecystectomy. This may be associated with significant morbidity in elderly patients. This study aims to assess if cholecystectomy can be safely deferred in elderly patients following successful ERCP for OGSD. Methods: All patients >75 year-old with OGSD, who underwent ERCP (June 2004-2008) in 2 centres, were included. Information regarding stenting, complications (failure, bleeding, cholangitis and stent migration), 30-day mortality and symptoms recurrence was retrospectively collected. The median follow-up period was 9 (6-36) months. Difference in ERCP outcome between the 2 centres was assessed by two-tailed t-test. Results: Centre 1(n1⁄4 54) Centre 2(n1⁄4 51) Total (n1⁄4 105) Sphincterotomy only 33(61.1%) 29(56.9%) 62(59%) Stent insertion 21(38.9%) 22(43.1%) 43 (41%) Complications 3(5.6%) 7(13.7%) 10(9.5%) 30-day mortality 3(5.6%) 1 (2%) 4(3.8%) Symptoms recurrence 11(20.4%) 5(9.8%) 16(15.2%) Cholecystectomy 4(7.4%) 11(21.6%) 15(14.3%) Overall, 85.7% of patients did not require cholecystectomy during the follow-up period. There was no difference between centres regarding number of stents inserted and 30day mortality (p>0.05). Centre 2 had a higher cholecystectomy and ERCP complication rate (p < 0.05%). Conclusions: The preliminary data suggests that cholecystectomy is not required in themajority of elderly patients with OGSD following successful ERCP. Longer follow-up is needed to determine if ERCP offers definitive treatment. ROLE OF ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE (USTAP) BLOCK IN ANALGESIC SUPPLEMENTATION FOR LAPAROSCOPIC RADICAL PROSTATECTOMY. PRELIMINARY FINDINGS Sashi Kommu, Anna Crosby, Zafar Hashim, Anurag Golash, Christopher Luscombe, Albin Augustine. University Hospital of North Staffordshire Introduction: Ultrasound Guided Transversus Abdominis Plane (USTAP) Block is a new regional anaesthetic technique that aims to block the abdominal neural afferents by instillation of local anaesthetic into the neurofascial plane that lies between the transversus abdominis and internal oblique musculature. We conducted a preliminary evaluation of the analgesic efficacy of this approach for Laparoscopic Radical Prostatectomy (LRP). Methods: Forty men undergoing LRP were given different modes of analgesia. Group 1 had general anaesthetic (GA) alone, Group 2 had GA and epidural, Group 3 had GA and patient controlled analgesia and Group 4 had bilateral USTAP Block. Post-operatively all groups received acetaminophen and non-steroidal anti-inflammatories as required. Each patient was objectively assessed at 24 hours. Results: The percentages of patients requiring morphine in the first 24 hours / the mean visual analogue pain scores at 24 hours were: Group 1 – 47/3.5; Group 2 – 100/3.0; Group 3 – 100/2.0; Group 4 – 47/1.2. Conclusions: USTAP Block offers satisfactory analgesic effects for patients undergoing LRP and appears to be safe with no complications. The role of USTAP in LRP and other minimally invasive urological procedures should be explored further. THE ROLE OF BONE SCAN AND PSA IN PATIENTS WITH NEWLY DIAGNOSED PROSTATE CANCER A. Damola , C. Lockett , B. Pettersson . 1 Countess of Chester Hospital NHS Foundation Trust; 2 Edith Cavell Hospital, Peterborough and Stamford Hospitals, NHS foundation Trust. Objective: To determine if bone scanning is necessary in newly diagnosed cases of prostate cancer with PSA < 20ng/ml. Material and methods: We analyzed the data of all our 246 patients with newly diagnosed prostate cancer from January 2007 to January 2009. We excluded 18 of these patients without histology or bone scan leaving 228 patients. Results: 44 patients had a positive bone scan, of which 37 were confirmed with further radiological imaging. Out of these 37 patients; there were 11 (8%) with PSA

Introduction: Acquiring skills for Laparoendoscopic Single-Site Surgery (LESS) is complex and shown to have a very steep learning curve. We aimed to develop and test the novel concept of Time-Lag for LESS skill acquisition using an ex-vivo training module. Methods: We used a Time-Lag Camera-Monitor System that allows for a 2.0 second delay between real-time hand movement and the perception of the movement on the monitor. We tested the impact of time-lag on the time taken to learn to perform a simulated Vesicourethral Anastomosis (VUA) by taking two groups of 3 novices and training the first group to perform the procedure with the time-lag system, and the second without the time-lag. Once each novice could perform the procedure satisfactorily, each group was timed in performing the VUA in a real-time setting. Results: The group who had initially trained with the time-lag system performed the final VUA 1.8 times faster than the second group. Video analysis showed that novices who trained using the time-lag system had reduced intention anxiety compared to the second group. Conclusions: The Time-Lag model has potential application in acquiring skills for LESS. It could be used for preliminary skill acquisition in other laparoscopic procedures during training.

s / International Journal of Surgery 8 (2010) 501–578 517 Methods: We studied patients with colorectal cancer (n 1⁄4 11,74 11y) and age-matched healthy controls (n 1⁄4 8,64 3y). We measured plasma myoglobin concentration, leg muscle mass (LMM) by dual-energy X-ray absorptiometry (DXA) and psoas muscle cross-sectional area (CSA) by computerized axial tomography (CT) (at the L3 vertebra). Results: Plasma myoglobin concentration was 31.2 9.6 vs. 42.9 8.71 ng/ml in patients with cancers and healthy controls, respectively. LMM was 6.49 1.94 vs. 6.42 1.62 kg in patients and controls respectively; Psoas CSA in the patients with colorectal cancer was 3363 1631 mm2 i.e. not significantly different from that in 56 previously examined patients (2873 1103 mm2) in who had normal diagnostic CT. There was no significant correlation betweenmyoglobin and psoas CSA (r21⁄4 0.0074; P1⁄4 0.87) (CT) or LMM (r2 1⁄4 0.4684; P 1⁄4 0.80) in patients. Conclusion: In early colorectal cancer, the extent of muscle wasting cannot be assessed by measuring plasma myoglobin concentration. BLADDER SPHINCTER VERGE URETHRAL PRESSURE REDUCES PAIN SCORES IN MEN UNDERGOING FIRST EVER FLEXIBLE CYSTOSCOPY Sashi S. Kommu, Zafar Hashim, David Cartlidge, Thomas Finnigan, Anurag Golash, Christopher J. Luscombe, Samson Liu, Mark F. Saxby, Jerry B. Emtage. University Hospital North Staffordshire, Stoke-on-trent, UK Introduction: Flexible cystoscopy (FC) is the most common endourological procedure done and is a source of significant discomfort/pain in men. We previously developed a novel scoring system to establish those at high risk of pain (Kommu et al. J Endourol 2006). We developed and tested the technique of Bladder Sphincter Verge Urethral Pressure (BSVUP) and its impact on pain scores in high risk men undergoing FC. Methods: All patients were given a single shot of Instillagel . A fluid bag at a standard height had pressure applied it as the cystoscope passed the Bladder Verge. A total of 200 patients were studied (100 had no BSVUP;100 had BSVUP). Pain scores were recorded during the procedure via visual analogue score. Results: The mean pain score among patients who had BSVUP was 2 (range: 2–8) compared with 4 (range: 3–10) for those who had no BSVUP. Eight patients in the in the Non-BSVUP arm found the procedure unbearable and a general anaesthetic cystoscopy. Conclusions: Bladder Sphincter Verge Urethral Pressure during flexible cystoscopy in ‘high risk for pain’ men, halves the pain scores. This is a simple readily applicable technique with no additional morbidity to the patient and at no additional cost. PLANNED COMPUTED TOMOGRAPHY AND ENDOSCOPY DURING FOLLOW UP OF PATIENTS WHO HAVE HAD RESECTION FOR OESOPHAGEAL CARCINOMA – IS THERE A SURVIVAL BENEFIT? N.C. Carter, S. Mercer, T. Geldart, M. Bayne, N. Davies. Royal Bournemouth Hospital Aims: Follow-up practice varies for patients undergoing osophagectomy and there is no published evidence about the contribution of planned imaging and endoscopy to survival. This paper aims to assess their contribution to survival. Methods: Patients undergoing oesophagectomy during a 6 year period were studied. Roughly half had “Planned” endoscopy and CT carried out at 1 year and CT alone at 2 years. Differences between the two groups were compared. Results: 127 patients had a minimum of 12 months follow-up. 26 developed symptomatic recurrence proven by CT within the first year. 59 asymptomatic patients underwent CT at 1 year, of which 53 (90%) were normal and 6 (10%) detected a recurrence. 47 asymptomatic patients underwent OGD at 1 year, none revealed any recurrence. 35 asymptomatic patients underwent CT at 2 years, of which 34 (97%) were normal and 1 (3%) detected recurrence. Long-rank analysis did not show any survival difference between the two groups at 1 and 2 years (p 1⁄4 0.318 and 0.447). Conclusions: The yield of CT scanning and OGD during follow-up after oesophagectomy is low for asymptomatic patients and does not appear to improve survival. Our data suggests that post operative imaging and endoscopy should be symptom-driven rather than planned. THE EFFECT OF DIETARY INTAKE OF OMEGA 3 AND OMEGA 6 POLYUNSATURATED FATTY ACIDS ON EARLY-ONSET PROSTATE CANCER RISK Joanna Lobaz, Nicholas Baylem, John Britton. University of Nottingham Background: In theUK, prostate cancer accounts for 24%of allmale cancers. Incidence varies globally, suggesting that modifiable risk factors exist. Objectives: Examine the effect of consuming omega 3 and 6 (U3&6) polyunsaturated fatty acids (PUFAs) on risk of early onset prostate cancer. It is hypothesized that high dietary intake of U3 decreases risk, while U6 increases risk. Methodology: 2088 patients were recruited into this case-control study. 805 men, aged 0.43 g /100 g food, OR 1⁄4 1.45, 95%CI 1⁄4 1.08-1.95, p 1⁄4 0.01). Conclusions: Omega3 derivatives may protect against early onset prostate cancer. Omega6 derivatives may increase risk. Further study is warranted. OSTEOGENIC DIFFERENTIATION OF HUMAN EMBRYONIC STEM CELLS IN-VITRO; FUTURE PROSPECTS FOR BONE TISSUE ENGINEERING IN ORTHOPAEDIC SURGERY Omair Shariq , Stephen Adshead , Eleftherios Tsiridis , Athanasios Mantalaris . 1 Imperial College London, UK; University of Leeds, UK Background and Aims: Replacing irreversible bone loss poses a significant challenge for orthopaedic surgeons. With an ageing population and shortage of donor material worldwide, tissue engineering has emerged as a state-of-the-art approach to providing 'off-the-shelf' bone substitutes. Human embryonic stem cells (hESCs) have a capacity for unlimited selfrenewal and pluripotency, making them an ideal material for tissue engineering. However, the osteogenic differentiation of hESCs is a labourintensive process, complicated further by unpredictable apoptosis in-vitro. This study reports the techniques used to differentiate hESCs into the