Robotic-assisted knee replacement surgery & infection: A historical foundation, systematic review and meta-analysis.

Background: An increasing proportion of Knee arthroplasty is performed using robotic-assisted surgical techniques. This study sought to use a meta-analytical approach to establish summary rates of surgical site infection in robotic-assisted procedures and compare the rate of deep infections to those seen in conventional knee arthroplasty. Methods: This study performed a literature search across four online databases to establish a summary rate of surgical site infection across two categories: deep infection and superficial and pin-site infections. This was processed with the aid of a bespoke data-extraction tool. Risk of Bias analysis was performed using the Cochrane RoB2 tool. Meta-analysis was then performed with tests for heterogeneity and a DerSimonian-Laird random effects model. Results: A total of 17 studies were identified as appropriate for inclusion in the meta-analysis. The summary rate of overall surgical site infections within one year of robotic knee arthroplasty was found to be 0.568% (SE = 0.183, 95% CI = 0.209-0.927). Deep infections fell to 0.154% (SE = 0.069, 95% CI = 0.018-0.290) and to 0.347% (SE = 0.109, 95% CI = 0.133-0.561) in superficial and pin-site infections. Conclusion: The surgical site infection rates were found to be low across robotic knee arthroplasty. Further research is required to prove its superiority compared to the conventional, non-robotic technique.

Fournier's gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas's NHS Foundation Trust.

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Oncological and functional outcomes of organ-preserving cystectomy versus standard radical cystectomy: A systematic review and meta-analysis.

Introduction: Radical cystectomy (RC) is historically considered the gold standard treatment for muscle invasive and high-risk non-muscle invasive bladder cancer. However, this technique leaves the majority of patients of both sexes with poor sexual and urinary function. Organ-sparing cystectomy (OSC) techniques are emerging as an alternative to the standard procedure to preserve these functions, without compromising the oncological outcomes. We present a systematic review and meta-analysis of the published literature. Methods: MEDLINE, Embase and Web of Science were systematically searched for eligible studies on 6 April 2021. Primary outcomes studied were both oncological outcomes, specifically overall recurrence, and functional outcomes, specifically sexual function, and daytime and nighttime continence. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. The PROSPERO registration reference number was CRD42018118897. Results: From 13 894 identified abstracts, 19 studies (1886 male and 305 female patients) were eligible for inclusion in this review. These studies included patients who underwent either whole prostate, prostate capsule, seminal vesicle, nerve, uterus, ovary, vagina and fallopian tube sparing techniques. Four studies included only female patients.Thirteen studies reported oncological outcomes, and overall recurrence rate was similar between the two groups (five studies; OR 0.73; 95% CI 0.38-1.40, p = 0.34). Thirteen studies reported on male sexual function. In men, OSC had significantly greater odds of retaining potency (five studies; OR 9.05; 95% CI 5.07-16.16, p < 0.00001). Fourteen studies (13 on males and 1 female) reported urinary outcomes. In men, OSC demonstrated greater odds of daytime (seven studies; OR 2.61; 95% CI 1.74 to 3.92, p < 0.00001) and nighttime continence (seven studies; OR 2.62; 95% CI 1.76 to 3.89, p < 0.00001). Conclusion: In carefully selected patients, OSC allows the potential to provide better sexual and urinary function without compromising oncological outcomes. There remains, however, a paucity of OSC studies in females. Further studies are required to make recommendations based on robust clinical evidence.

Clinician and computer: a study on doctors' perceptions of artificial intelligence in skeletal radiography.

BACKGROUND: Traumatic musculoskeletal injuries are a common presentation to emergency care, the first-line investigation often being plain radiography. The interpretation of this imaging frequently falls to less experienced clinicians despite well-established challenges in reporting. This study presents novel data of clinicians' confidence in interpreting trauma radiographs, their perception of AI in healthcare, and their support for the development of systems applied to skeletal radiography. METHODS: A novel questionnaire was distributed through a network of collaborators to clinicians across the Southeast of England. Over a three-month period, responses were compiled into a database before undergoing statistical review. RESULTS: The responses of 297 participants were included. The mean self-assessed knowledge of AI in healthcare was 3.68 out of ten, with significantly higher knowledge reported by the most senior doctors (Specialty Trainee/Specialty Registrar or above = 4.88). 13.8% of participants reported an awareness of AI in their clinical practice. Overall, participants indicated substantial favourability towards AI in healthcare (7.87) and in AI applied to skeletal radiography (7.75). There was a preference for a hypothetical system indicating positive findings rather than ruling as negative (7.26 vs 6.20). CONCLUSIONS: This study identifies clear support, amongst a cross section of student and qualified doctors, for both the general use of AI technology in healthcare and in its application to skeletal radiography for trauma. The development of systems to address this demand appear well founded and popular. The engagement of a small but reticent minority should be sought, along with improving the wider education of doctors on AI.

Dynamic hip screws versus cephalocondylic intramedullary nails for unstable extracapsular hip fractures in 2021: A systematic review and meta-analysis of randomised trials.

Background: Extracapsular hip fractures comprise approximately half of all hip fractures and the incidence of hip fractures is exponentially increasing. Extramedullary fixation using a dynamic hip screw (DHS) has been the gold standard method of operative treatment for unstable extracapsular fractures, however, in recent years, intramedullary nails (IMN) have become a popular alternative. IMN versus DHS is continuously discussed and debated in literature. Therefore, the purpose of this systematic review and meta-analysis is to directly compare the peri- and post-operative outcomes of these two techniques to provide an up-to-date analysis of which method of fixation is superior. Methods: The MEDLINE/PubMed, Embase and Web of Science Database were searched for eligible studies from 2008 to April 2022 that compared peri- and post-operational outcomes for patients undergoing IMN or DHS operations for fixation of unstable extracapsular hip fractures (PROSPERO registration ID:CRD42021228335). Primary outcomes included mortality rate and re-operation rate. Secondary outcomes included operation time, blood loss, transfusion requirement, complication, and failure of fixation rate. The risk of bias and quality of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE analysis tool, respectively. Results: Of the 6776 records identified, 22 studies involving 3151 patients were included in the final review. Our meta-analysis showed no significant differences between mortality rates (10 studies, OR 0.98; 95% CI 0.80 to 1.22, p = 0.88) or re-operation rates (10 studies, OR 1.03; 95% CI 0.64 to 1.64, p = 0.91) between the two procedures. There were also no significant differences found between complication rates (17 studies, OR 1.29; 95% CI 0.79 to 2.12, p = 0.31) and failure of fixation rates (14 studies, OR 1.32; 95% CI 0.74 to 2.38, p = 0.35). However, DHS operations had a significantly longer operation time (p < 0.0001) and blood loss (p < 0.00001) than IMN operations. Conclusion: Overall, based on the outcomes assessed, this review has demonstrated that there is no significant difference in the post-operative outcomes for DHS vs IMN, however a significant difference exists in two of the intraoperative outcomes assessed in this review.

Global impact of COVID-19 on surgeons and team members (GlobalCOST): a cross-sectional study.

OBJECTIVES: To investigate the impact of COVID-19 on the well-being of surgeons and allied health professionals as well as the support provided by their institutions. DESIGN: This cross-sectional study involved distributing an online survey through medical organisations, social media platforms and collaborators. SETTING: It included all staff based in an operating theatre environment around the world. PARTICIPANTS: 1590 complete responses were received from 54 countries between 15 July and 15 December 2020. The average age of participants was 30-40 years old, 64.9% were men and 32.5% of a white ethnic background. 79.5% were surgeons with the remainder being nurses, assistants, anaesthetists, operating department practitioners or classified other. MAIN OUTCOME MEASURES: Participants that had experienced any physical illness, changes in mental health, salary or time with family since the start of the pandemic as well as support available based on published recommendations. RESULTS: 32.0% reported becoming physically ill. This was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82 to 7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18 to 2.06; p=0.002). Those with a decrease in salary (29.0%) were more likely to have an increase in anxiety (OR 1.50; CI 1.19 to 1.89; p=0.001) and depression (OR 1.84; CI 1.40 to 2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression (OR 1.74; CI 1.34 to 2.26; p<0.001). Only 36.0% had easy access to occupational health, 44.0% to mental health services, 16.5% to 24/7 rest facilities and 14.2% to 24/7 food and drink facilities. Fewer measures were available in countries with a low Human Development Index. CONCLUSIONS: This work has highlighted a need and strategies to improve conditions for the healthcare workforce, ultimately benefiting patient care.

Long-term outcomes of outpatient laser ablation for recurrent non-muscle invasive bladder cancer: A retrospective cohort study.

Objectives: The objective of this study is to determine the long-term efficacy and safety of office-based Holmium:YAG laser ablation for the treatment of recurrent non-muscle-invasive bladder cancer (NMIBC). Methods: We retrospectively reviewed the medical records of all consecutive patients who underwent office-based laser ablation for recurrent bladder cancer between 2008 and 2016. The following data were collected: original histology, date of original histology, date of laser ablation, number of repeat laser ablation procedures required, date of tumor recurrence or progression, number of general anesthesia procedures (transurethral resection or cystodiathermy) required after first laser ablation, and number and severity of complications. Kaplan-Meier survival curves were produced for recurrence-free survival, progression-free survival, and overall survival. Results: A total of 97 patients, with an average age of 84 (62-98) years and an average Charlson Comorbidity Index of 6.9 (4-13), were included. The median follow-up was 61 (2-150) months. Fifty-five (56.7%) patients presented with tumor recurrence, and the median recurrence-free survival time was 1.69 years (95% CI 1.20-2.25). Only 9 (9.3%) patients had evidence of tumor progression to a higher grade or stage, 8 (89%) of which initially had low-grade tumors; however, no patient progressed to muscle-invasive disease. The median progression-free survival time was 5.70 years (95% CI 4.10-7.60), and the median overall survival time was 7.60 years (95% CI 4.90-8.70). No patient required emergency inpatient admission after laser ablation. Conclusion: Office-based Holmium:YAG laser ablation offers a safe and effective alternative method for treating low-volume, low-grade recurrent NMIBC, especially in elderly patients with significant co-morbidity, while avoiding general anesthesia and inpatient admission.

Evaluating the utility of an international webinar as a platform to educate students and doctors on the UK core surgical training portfolio.

BACKGROUND: Core Surgical Training (CST) is a competitive two-year postgraduate training program in the UK that is scored based on three equally weighted stations: management, clinical and portfolio. Preparing a surgical portfolio can start in medical school, however, there is limited guidance on what forms a competitive portfolio with the majority of advice coming from university resources and national societies which are variable throughout the country. Our aim was to assess the utility of a webinar to educate students and doctors on the CST portfolio to address this disparity. METHODS: Pre- and post-event questionnaires that included demographic data, 10-point Likert scales to self-report confidence on the understanding of the CST portfolio and its domains, and questions on utilising webinars were distributed to attendees. Pre- and post-event responses were paired, and scores were assessed for normality via the Shapiro-Wilk test; the Mann-Whitney U test was used to assess statistical significance. Cohen's d effect sizes were calculated to report standardised differences between pre-and post-event scores. RESULTS: A total of 177 participants from over 24 countries responded to both questionnaires. A statistically significant improvement in awareness of how to score maximum points was demonstrated across all nine CST domains (p < 0.0001). Regardless of whether they were UK-based or international, approximately half of the participants stated a preference for a webinar over an in-person format. Interestingly, most attendees did not feel that their university had provided them with adequate information on preparing for a surgical career with over half of the attendees stating that they had to attend events by external organisations to obtain such information. CONCLUSIONS: This study has demonstrated that a webinar can be effectively utilised to educate students and doctors on the various domains of the CST portfolio and how to maximise points in each section. Such events could address the variability of university resources and national societies across the country and provide equal opportunities for students. Further studies that directly compare webinars with in-person events and investigate long-term outcomes, such as success in CST applications, are required.

Assessing the utility of virtual OSCE sessions as an educational tool: a national pilot study.

BACKGROUND: Objective Structured Clinical Examinations (OSCEs) are a common form of assessment used across medical schools in the UK to assess clinical competence and practical skills and are traditionally held in an in-person format. In the past, medical students have often prepared for such exams through in-person peer-assisted learning (PAL), however, due to the recent Covid-19 pandemic, many in-person teaching sessions transitioned to online-based formats. There is currently a paucity of research on the utility of virtual PAL OSCE sessions and thus, we carried out a national pilot study to determine the feasibility of virtual OSCE teaching via feedback from participants and examiners. METHODS: A total of 85 students from 19 UK-based medical schools with eight students based internationally attended the series of online OSCE workshops delivered via Zoom®. All students and examiners completed a feedback questionnaire at the end of each session regarding parameters, which included questions on pre-and post-workshop confidence in three OSCE domains: history-taking, communication and data interpretation. A Likert scale using 5 Likert items was used to self-report confidence, and the results were analysed using the Mann-Whitney U test after assessing for normality using the Shapiro-Wilk test. RESULTS: Results from student feedback showed an increase in confidence for all three OSCE domains after each event (p < 0.001) with 69.4% agreeing or strongly agreeing that online OSCE sessions could sufficiently prepare them for in-person exams. Questionnaire feedback revealed that 97.6% of students and 86.7% of examiners agreed that virtual OSCE teaching would be useful for preparing for in-person OSCE examinations after the pandemic. CONCLUSION: Most participants in the virtual OSCE sessions reported an improvement in their confidence in history-taking, communication and data interpretation skills. Of the participants and examiners that had also experienced in-person OSCE examinations, the majority also reported that they found virtual OSCE sessions to be as engaging and as interactive as in-person teaching. This study has demonstrated that virtual OSCE workshops are a feasible option with the potential to be beneficial beyond the pandemic. However, more studies are required to assess the overall impact on student learning and to determine the value of virtual OSCE workshops on exam performance.

Decisions around Deceased Organ Donation in Young South Asian Individuals in the United Kingdom.

There is a large disparity between the demand and availability of organs for transplantation from within the UK's ethnic minority groups. Our aims were to identify the perceptions, knowledge of and level of engagement with organ donation since the law changed in England in 2020. A questionnaire survey using Google Forms was designed based on prior literature and information on NHSBT website. It was distributed through media outlets and cultural/professional organizations. Status on Organ Donation Registry and Quiz scores were analyzed against multiple variables. Three hundred and sixty-five people between 18 and 24 years old completed the questionnaire. 72.3% were female, 57% were health-care students, 86.3% were of South Asian ethnicity, and 11% were immigrant respondents. Overall, 43.6% were registered to donate. South Asian groups, particularly those of Pakistani ethnicity and migrant students, were less likely to register to donate. Being more knowledgeable about the organ donation process, females, nonreligious groups, and health-care students are more likely to be registered to donate. This study identified barriers around deceased organ donation decisions and demonstrates the need for further targeted and continual education to the young South Asians individuals, to produce positive associations that will percolate to older and future generations.

A Systematic Review of the Efficacy and Safety of Outpatient Bladder Tumour Ablation.

CONTEXT: Management of non-muscle-invasive bladder cancer (NMIBC) is costly and associated with negative health-related quality-of-life effects, in part because of the frequent need for repeated transurethral resections under general/regional anaesthesia. Outpatient-based diathermy or laser ablation is another option, but evidence for its efficacy is mixed and its use is controversial. OBJECTIVE: To systematically review evidence regarding the efficacy and safety of outpatient diathermy and laser ablation for the treatment of recurrent NMIBC. EVIDENCE ACQUISITION: The EMBASE, MEDLINE/PubMed, and Cochrane Library were searched from inception to June 26, 2020. All studies evaluating the use of diathermy or laser ablation for bladder tumours (new or recurrent) in an outpatient setting under local anaesthetic were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. The quality of evidence and risk of bias were assessed using the GRADE and ROBINS-I tools. EVIDENCE SYNTHESIS: The search yielded 1328 studies. After excluding duplicates, 1319 titles and abstracts were screened and 17 studies (1584 patients) were eligible for inclusion in the final review. The majority of patients had small, low-grade tumours, but there was heterogeneity in the inclusion criteria. Overall, laser ablation and diathermy resulted in mean recurrence rates of 47% and 32% at follow-up of 22-38 mo, respectively, with a mean progression rate of 3-12% (low certainty of evidence). Both procedures were well tolerated, with low pain scores and low periprocedural complication rates (moderate certainty of evidence). CONCLUSIONS: Outpatient diathermy and laser ablation have good short-term efficacy in patients with low-grade NMIBC and reduce the need for intervention under general/regional anaesthesia. The procedures are well tolerated with low complication rates. The overall certainty of evidence is low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for randomised trials with long-term follow-up using standardised risk classification and outcome measures. Despite these limitations, the findings will aid in patient counselling regarding this less invasive treatment option that avoids the morbidity of transurethral resection. PATIENT SUMMARY: Outpatient diathermy and laser ablation have good success rates in treating recurrent low-grade bladder tumours in the short term, avoiding the need for more invasive procedures under general/regional anaesthesia, with low rates of side effects. Further studies are needed to determine whether these treatments remain safe and effective in the long term.

Trapeziectomy versus joint replacement for first carpometacarpal (CMC 1) joint osteoarthritis: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis directly compares joint replacement (JR) and trapeziectomy techniques to provide an update as to which surgical intervention is superior for first carpometacarpal (CMC-1) joint osteoarthritis. METHODS: In August 2020, MEDLINE, Embase and Web of Science were searched for eligible studies that compared these two techniques for the treatment of CMC-1 joint osteoarthritis (PROSPERO registration ID: CRD42020189728). Primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH), QuickDASH (QDASH) and pain visual analogue scale (VAS) scores. Secondary outcomes, such as total complication, dislocation and revision surgery rates, were also measured. RESULTS: From 1909 studies identified, 14 studies (1005 patients) were eligible. Our meta-analysis found that post-operative QDASH scores were lower for patients in the JR group (five studies, p = 0.0004). Similarly, significantly better postoperative key pinch strength in favour of JR was noted (three studies, p = 0.001). However, pain (VAS) scores were similar between the two groups (five studies, p = 0.21). Moreover, JR techniques had significantly greater odds of overall complications (12 studies; OR 2.12; 95% CI 1.13-3.96, p = 0.02) and significantly greater odds of revision surgery (9 studies; OR 5.14; 95% CI 2.06-12.81, p = 0.0004). CONCLUSION: Overall, based on very low- to moderate-quality evidence, JR treatments may result in better function with less disability with comparable pain (VAS) scores; however, JR has greater odds of complications and greater odds of requiring revision surgery. More robust RCTs that compare JR and TRAP with standardised outcome measures and long-term follow-up would add to the overall quality of evidence.