Formation of a conceptual framework during the development of a patient-reported outcome measure for early gastrointestinal recovery: phase I of the PRO-diGi study.

AIM: Patients admitted to hospital for abdominal surgery often experience gastrointestinal dysfunction. Many studies have reported outcomes following gastrointestinal dysfunction, yet there is no unified definition of recovery or a validated patient-reported outcome measure (PROM). The first stage of PROM development requires formation of a conceptual framework to identify key themes to patients. The aim of this study was to utilize semistructured interviews to identify core themes and concepts relevant to patients to facilitate development of a conceptual framework. METHOD: Adult patients admitted to hospital for major gastrointestinal, urological or gynaecological surgery, in an emergency or elective setting, were eligible to participate. Patients treated nonoperatively for small bowel obstruction were also eligible. Interviews were conducted by telephone, audio-recorded, transcribed, coded and analysed using NVivo software by two researchers and reviewed by lay members of the steering group. Interviews continued until data saturation was reached. Ethical approval was gained prior to interviews (21/WA/0231). RESULTS: Twenty nine interviews were completed (17 men, median age 64 years) across three specialties (20 gastrointestinal, six gynaecological, three urological). Two overarching themes of 'general recovery' and 'gastrointestinal symptoms' were identified. General recovery included three themes: 'life impact', 'mental impact', including anxiety, and 'physical impact', including fatigue. Gastrointestinal symptoms included three themes: 'abdominal symptoms' such as pain, 'diet and appetite' and 'expulsory function', such as stool frequency. A total of 18 gastrointestinal symptoms were identified during patient recovery-many of which lasted several weeks following discharge. CONCLUSION: This study reports a range of gastrointestinal and nongastrointestinal symptoms experienced by patients during early gastrointestinal recovery. Identified symptoms have been synthesized into a conceptual framework to enable development of a definitive PROM for early gastrointestinal recovery.

Surgical site infections after emergency hernia repair: substudy from the Management of Acutely Symptomatic Hernia (MASH) study.

INTRODUCTION: Acutely symptomatic abdominal wall and groin hernias (ASH) are a common acute surgical presentation. There are limited data to guide decisions related to surgical repair technique and use of antibiotics, which can be driven by increased risk of surgical site infection (SSI) in this group. This study aims to report rates of SSI following ASH repair and explore the use of patient-reported outcome measure reporting in this setting. METHODS: An 18-week, UK-based, multicentre prospective cohort study (NCT04197271) recruited adults with ASH. This study reports operatively managed patients. Data on patient characteristics, inpatient management, quality of life, complications, and wound healing (Bluebelle score) were collected. Descriptive analyses were performed to estimate event rates of SSI and regression analysis explored the relationship between Bluebelle scores and SSI. The 30 and 90-day follow-up visits assessed complications and quality of life. RESULTS: The MASH study recruited 273 patients, of whom 218 were eligible for this study, 87.2 per cent who underwent open repair. Mesh was used in 123 patients (50.8 per cent). Pre- and postoperative antibiotics were given in 163 (67.4 per cent) and 28 (11.5 per cent) patients respectively. There were 26 reported SSIs (11.9 per cent). Increased BMI, incisional, femoral, and umbilical hernia were associated with higher rates of SSI (P = 0.006). In 238 patients, there was a difference in healthy utility values at 90 days between patients with and without SSI (P = 0.025). Also, when analysing 191 patients with Bluebelle scores, those who developed an SSI had higher Bluebelle values (P < 0.001). CONCLUSION: SSI is frequent in repair of acutely symptomatic hernia and correlates with BMI and site of hernia.

Management of Acutely Symptomatic Hernia (MASH) study.

BACKGROUND: Acutely symptomatic abdominal wall and groin hernias are a common reason for acute surgical hospital admissions. There are limited data to guide the treatment of these patients. This study aimed to assess outcomes of emergency hernia surgery and identify common management strategies, to improve care for these high-risk patients. METHODS: A 20-week, national multicentre, collaborative, prospective cohort study (NCT04197271) recruited adults with acutely symptomatic abdominal wall and groin hernias across the UK. Data on patient characteristics, inpatient management, quality of life, complications, and wound healing were collected. Follow-up telephone calls at 30 and 90 days were used to assessed complications and quality of life. Descriptive analyses were undertaken to describe the population and outcomes. RESULTS: Twenty-three hospitals recruited 272 eligible patients. Inguinal (37.8 per cent) and umbilical (37.1 per cent) hernias were the most common. Some 13.9 per cent were awaiting elective surgery and 12.8 per cent had previously declined intervention. CT was performed in 47.1 per cent and 81.3 per cent underwent surgical management. Open repairs were carried out in 93.5 per cent, and 92.5 per cent of these were performed under general anaesthesia. Four of 13 laparoscopic procedures were converted to open surgery. Mesh was used in 55.1 per cent of repairs, typically synthetic non-absorbable (87.4 per cent). Complications were infrequent; surgical-site infection (9.4 per cent), delirium (3.2 per cent), and pneumonia (2.3 per cent) were the most common. The 90-day mortality rate was 4.9 per cent. Immediate surgical management was associated with a significant improvement in quality of life at 30 days (median score 0.73-0.82). CONCLUSION: There is variation in the investigation, management, and surgical technique used to treat acutely symptomatic abdominal wall and groin hernias in the UK. The optimal management strategy for specific acute presentations remains to be established. Presented to the Association of Surgeons in Training Conference, Birmingham, UK, March 2021, the Association of Surgeons of Great Britain and Ireland Congress, May 2021, the World Society of Emergency Surgery, Edinburgh, UK, September 2021, and the European Hernia Society Congress, Copenhagen, Denmark, October 2021.

Expression of fungal diacylglycerol acyltransferase2 genes to increase kernel oil in maize.

Maize (Zea mays) oil has high value but is only about 4% of the grain by weight. To increase kernel oil content, fungal diacylglycerol acyltransferase2 (DGAT2) genes from Umbelopsis (formerly Mortierella) ramanniana and Neurospora crassa were introduced into maize using an embryo-enhanced promoter. The protein encoded by the N. crassa gene was longer than that of U. ramanniana. It included 353 amino acids that aligned to the U. ramanniana DGAT2A protein and a 243-amino acid sequence at the amino terminus that was unique to the N. crassa DGAT2 protein. Two forms of N. crassa DGAT2 were tested: the predicted full-length protein (L-NcDGAT2) and a shorter form (S-NcDGAT2) that encoded just the sequences that share homology with the U. ramanniana protein. Expression of all three transgenes in maize resulted in small but statistically significant increases in kernel oil. S-NcDGAT2 had the biggest impact on kernel oil, with a 26% (relative) increase in oil in kernels of the best events (inbred). Increases in kernel oil were also obtained in both conventional and high-oil hybrids, and grain yield was not affected by expression of these fungal DGAT2 transgenes.