What should be included in case report forms? Development and application of novel methods to inform surgical study design: a mixed methods case study in parastomal hernia prevention.

OBJECTIVES: To describe the development and application of methods to optimise the design of case report forms (CRFs) for clinical studies evaluating surgical procedures, illustrated with an example of abdominal stoma formation. DESIGN: (1) Literature reviews, to identify reported variations in surgical components of stoma formation, were supplemented by (2) intraoperative qualitative research (observations, videos and interviews), to identify unreported variations used in practice to generate (3) a 'long list' of items, which were rationalised using (4) consensus methods, providing a pragmatic list of CRF items to be captured in the Cohort study to Investigate the Prevention of parastomal HERnias (CIPHER) study. SETTING: Two secondary care surgical centres in England. PARTICIPANTS: Patients undergoing stoma formation, surgeons undertaking stoma formation and stoma nurses. OUTCOME MEASURES: Successful identification of key CRF items to be captured in the CIPHER study. RESULTS: 59 data items relating to stoma formation were identified and categorised within six themes: (1) surgical approach to stoma formation; (2) trephine formation; (3) reinforcing the stoma trephine with mesh; (4) use of the stoma as a specimen extraction site; (5) closure of other wounds during the procedure; and (6) spouting the stoma. CONCLUSIONS: This study used multimodal data collection to understand and capture the technical variations in stoma formation and design bespoke CRFs for a multicentre cohort study. The CIPHER study will use the CRFs to examine associations between the technical variations in stoma formation and risks of developing a parastomal hernia. TRIAL REGISTRATION NUMBER: ISRCTN17573805.

Multidisciplinary perspective on the management of appendiceal adenocarcinoma: case review of 10 patients from a university hospital and current considerations.

BACKGROUND: Adenocarcinoma of the vermiform appendix is rare. It constitutes less than 0.5% of all gastrointestinal malignancies. Pathologically, appendiceal neoplasms are categorized into various subtypes depending on cell lineage. PATIENTS AND METHODS: We considered a case series of appendiceal invasive adenocarcinomas from 2004 to 2013 managed in a teaching hospital. We discuss our management dilemmas, given the lack of randomized controlled trial data that exist. A detailed look at the histopathology, case series, and literature is presented. RESULTS: Ideal standards ought to be constructed for the management of this rare pathology, with a particular focus on exploring the indications and potential benefits, as well as difficulties, of ileocolic lymphadenectomy. CONCLUSION: Appendiceal adenocarcinoma ought to be managed in the same way as a cecal adenocarcinoma.

Administration of analgesia for acute abdominal pain sufferers in the accident and emergency setting.

BACKGROUND: Recent trials suggest that the early administration of analgesia in patients with acute abdominal pain facilitates examination and does not delay diagnosis. We investigated current practice regarding analgesia for these patients. METHODS: All patients admitted via the accident and emergency department with abdominal pain were included. The main outcome measures evaluated were waiting time for analgesia and its relationship to subjective visual analogue pain scores and clinical diagnoses. RESULTS: Data from 107 consecutive patients were investigated; seven patients were excluded. Forty-two per cent were male. The mean age was 40.1 years (6-85). The mean overall waiting time for analgesia was 1.4 h (2 min to 14 h). Sixty-seven per cent received analgesia within one hour, although 22% waited 2-14 h after presentation. Those with mild pain waited significantly longer for analgesia (mean 247 min) than those with severe pain (mean 82 min; P=0.01). Those with moderate pain had intermediate waiting times (mean 111 min), although they were not statistically different from the severe group (P=0.43). Female patients had to wait longer (mean 129 min) than male patients (mean 69 min; P=0.09 analysis of variance). Of 64% who were general practitioner referrals, only 11% (all severe group, P=0.02) received analgesia in the community. Neither clinical diagnosis nor age influenced the timing of analgesia. Seventy-three per cent received analgesia in the casualty department (mean 0.5 h; range 0.02-3.2), whereas those admitted in the ward without receiving analgesia in casualty had to wait significantly longer for their pain relief (mean 5 h; 1.2-14). CONCLUSION: This study shows the need for standardized protocols for analgesia usage in patients presenting with acute abdominal pain.

Phyllodes tumor of breast.

Phyllodes tumors account for 0.3%-0.5% of all the breast tumors. They are usually benign but malignant variants exist and have the potential to metastasize. Surgery is the mainstay of treatment as there is no proven benefit of adjuvant chemotherapy or radiotherapy. Wider excision with 1 cm clear margins is recommended in cases where the resection margins are involved. Simple mastectomy is recommended even for large benign tumors as there is increased likelihood of recurrence. We are presenting a case of 42 years old female with benign phyllodes tumor and a brief review of literature on the subject.