Consensus demonstrates four indicators needed to standardize burn wound infection reporting across trials in a single-country study (ICon-B study).

INTRODUCTION: Evidence-based interventions are needed to treat burn wound infection (BWI). Evidence syntheses have been limited by heterogeneity of indicators used to report BWI across trials. Consistent reporting of BWI would be facilitated by an agreed minimum set of indicators. The Infection Consensus in Burns study aimed to achieve expert consensus about a core indicator set (CIS) for BWI. METHODS: The CIS was established through development of a long list of BWI indicators identified from a systematic review and expert input. In a Delphi survey, UK expert participants rated the indicators according to use in everyday practice, importance for diagnosis and frequency of observation in patients with BWI. Indicators were included in the CIS if ≥75% of participants agreed it was important for diagnosis and used in everyday practice, and ≥50% of participants rated it as frequently observed in patients with BWI. RESULTS: One hundred and ninety-five indicators were identified from the systematic review and reduced to 29 survey items through merging of items with the same meaning. Seventy-five UK experts participated in the Delphi survey. Following a single survey round and a consensus meeting with an expert panel, four items were included in the CIS: pyrexia, spreading erythema, change in white cell count, and presence of pathogenic microbes. DISCUSSION AND CONCLUSIONS: To facilitate evidence synthesis, a single-country systematic, expert-informed approach was taken to develop a CIS to be reported consistently across trials reporting BWI as an outcome. Future work requires verification of the CIS with international experts.

Systematic review of therapeutic nipple-sparing versus skin-sparing mastectomy.

Background: The use of nipple-sparing mastectomy (NSM) is increasing, despite unproven oncological safety in the therapeutic setting. The aim of this systematic review was to determine the safety and efficacy of NSM compared with skin-sparing mastectomy (SSM). Methods: A literature search of all original studies including RCTs, cohort studies and case-control studies comparing women undergoing therapeutic NSM or SSM for breast cancer was undertaken. Primary outcomes were oncological outcomes; secondary outcomes were clinical, aesthetic, patient-reported and quality-of-life outcomes. Data analysis was undertaken to explore the relationship between NSM and SSM, and preselected outcomes. Heterogeneity was assessed using the Cochrane tests. Results: A total of 690 articles were identified, of which 14 were included. There was no statistically significant difference in 5-year disease-free survival and mortality for NSM and SSM groups, where data were available. Local recurrence rates were also similar for NSM and SSM (3·9 versus 3·3 per cent respectively; P = 0·45). NSM had a partial or complete nipple necrosis rate of 15·0 per cent, and a higher complication rate than SSM (22·6 versus 14·0 per cent respectively). The higher overall complication rate was due to the rate of nipple necrosis in the NSM group (15·0 per cent). Conclusion: In carefully selected cases, NSM is a viable choice for women with breast cancer who need to have a mastectomy. More research is needed to help further refine which surgical approaches to NSM optimize outcomes.

Spatial-temporal survey of Microcystis oligopeptide chemotypes in reservoirs with dissimilar waterbody features and their relation to genetic variation.

The ability of cyanobacteria to produce toxins and other secondary metabolites is patchily distributed in natural populations, enabling the use of cellular oligopeptide compositions as markers to classify strains into ecologically-relevant chemotypical subpopulations. The composition and spatiotemporal distribution of Microcystis chemotypes within and among waterbodies was studied at different time scales by analyzing (i) Microcystis strains isolated between 1998 and 2007 from different Spanish reservoirs and (ii) individual Microcystis aeruginosa colonies collected from pelagic and littoral habitats in Valmayor reservoir (Spain) during a bloom. No agreement between chemotypes and both morphotypes and genotypes (based on cpcBA-IGS, 16S-23S rRNA ITS and mcyB genes) was found, suggesting that oligopeptide profiles in individual strains evolve independently across morphospecies and phylogenetic genotypes, and that the diversity of microcystin variants produced cannot be explained by mcyB gene variations alone. The presence of identical chemotypes in spatially-distant reservoirs with dissimilar trophic state, lithology or depth indicate that waterbody characteristics and geographical boundaries weakly affect chemotype composition and distribution. At smaller spatiotemporal scales (i.e. during bloom), M. aeruginosa populations showed high number of chemotypes, as well as marked differences in chemotype composition and relative abundance among the littoral and pelagic habitats. This indicates that the factors influencing chemotype composition, relative abundance and dynamics operate at short spatial and temporal scales, and supports emerging hypotheses about interactions with antagonistic microorganisms as possible drivers for widespread chemical polymorphisms in cyanobacteria.

Intralesional excision with topical intralesional cryotherapy improves the treatment of keloid scarring in a paediatric patient.

Recurrent keloid scarring has a significant impact on quality of life. Management is complex, particularly for scars resistant to conventional treatments and in paediatric cases where radiotherapy is not a suitable adjunct to surgical excision. We present the case of a nine-year-old African Caribbean girl with multiple large and recurrent keloid scars on both ears and bilateral sensorineural deafness. Following repeated intralesional excisions, corticosteroid and botulinum toxin injections, she continued to experience rapid recurrence of her keloids, worsening pain and pruritus. She was no longer able to wear her hearing aids because of the large size of the keloids. We employed a novel technique using topical intralesional cryotherapy, applying liquid nitrogen intraoperatively to the inside of the skin flaps immediately post-intralesional keloid excision and before wound closure. At 26-month follow-up a good aesthetic and symptomatic result was achieved, with minimal hypopigmentation, significantly reduced scar volume and significantly slowed recurrence. We discuss this case and review the current literature on the use of topical intralesional cryotherapy for keloid scarring.

Impact of the SCARE guideline on the reporting of surgical case reports: A before and after study.

INTRODUCTION: The SCARE guideline was developed in 2016 through an expert Delphi consensus exercise. It aimed to improve the quality of reporting of surgical case reports. The aim of this study was to assess the impact of introducing the SCARE guideline for surgical on reporting of case reports submitted to a single journal. METHODS: A total of 20 case reports published in the International Journal of Surgery Case Reports (IJSCR) and Annals of Medicine and Surgery (AMS) in July and August 2016, prior to the introduction of the SCARE guideline (the pre-SCARE period), were randomly identified and scored against the SCARE criteria. Two independent teams performed the scoring giving a total score out of a theoretical maximum of 34 for each case report, the 'SCARE score' (expressed as a percentage). The scores for the two teams were then compared and consensus was reached to achieve a final sore set. This process was repeated for the January and February 2017 issues of the journal, post implementation of the guideline (the post-SCARE period). SCARE scores were compared between the pre- and post-SCARE periods. RESULTS: The mean pre-SCARE score was 75.0% (standard deviation ± 6.29, Range 62-84), and the mean post-SCARE score was 82.6% (standard deviation ± 8.02, range 66-99), a 10% relative increase in compliance which was statistically significant (P < 0.001). The Cohen's Kappa score between teams A and B was 0.871, implying very substantial agreement. CONCLUSION: Implementation of the SCARE guideline resulted in a 10% improvement in the reporting quality of surgical case reports published in a single journal. Adherence to SCARE reporting guidelines by authors, reviewers and editors should be improved to boost reporting quality. Journals should develop their policies, submission processes and guide for authors to incorporate the guideline.

Impact of the PROCESS guideline on the reporting of surgical case series: A before and after study.

INTRODUCTION: The PROCESS guideline was developed in 2016 through expert Delphi consensus. It aimed to improve the quality of reporting of surgical case series. This study assessed the impact of the introduction of the PROCESS guideline on reporting for surgical case series submitted to three journals. METHODS: 20 case series published in the International Journal of Surgery Case Reports (IJSCR), the International Journal of Surgery (IJS) or the Annals of Medicine and Surgery (AMS) in September to December 2016, prior to the introduction of the PROCESS guideline (the pre-PROCESS period), were randomly identified and scored against the PROCESS criteria. Two authors independently scored each article a total score out of 29, the 'PROCESS score' (expressed as a percentage). Scores for the two researchers were compared and consensus was reached to achieve a final score set. The process was repeated for the January 2017 to April 2017 issues of the three journals, post PROCESS implementation (the post-PROCESS period). RESULTS: The mean PROCESS score was 80% (range 66-90%) for the pre-PROCESS period and 84% (range 72-95%) for the post-PROCESS period, a 4% relative increase [STATS]. The Cohen's Kappa score between researchers was 0.907 implying very substantial agreement. CONCLUSION: Implementation of the PROCESS guideline resulted in a 5% improvement in the reporting quality of surgical case series published in three journals. Further research is needed to identify and successfully navigate existing barriers to greater compliance. Authors, reviewers and editors should adhere to the guidelines to boost reporting quality. Journals should develop their policies and guide for authors to incorporate the guideline and mandate compliance.

An assessment of the compliance of Randomised controlled trials published in craniofacial surgery journals with the CONSORT statement: A systematic review protocol.

INTRODUCTION: The role of clinical trials in medicine is expanding, particularly in surgery. Randomised controlled trials (RCTs) represent the gold standard evidence for high-quality assessment of healthcare interventions. The Consolidated Standards of Reporting Trials (CONSORT) guidance has been published to maximise RCT reporting transparency. This paper outlines the study protocol for a systematic review that will assess the current compliance of RCTs published within craniofacial surgery with the CONSORT criteria. The aims are to identify areas where reporting can be improved to ensure craniofacial surgery is guided by high-quality evidence. METHODS AND ANALYSIS: This protocol is compliant with the Preferred Reporting Items for Systematic Review and meta-Analysis protocols (PRISMA-P) guidelines. Craniofacial surgery RCTs will be identified by searching within craniofacial surgery journals. Five journals from the Thomson Reuters Impact Factor Report 2016 included 'cranio' in their title and were included. MEDLINE PubMed will be used to search all RCTs published in these journals. The search strategy is described within this protocol. It will be limited to articles written in English, conducted on humans, and published in the last five years. Two independent researchers will assess each study for inclusion and will perform the data extraction. The researchers will assess compliance of each RCT with the 25-item CONSORT Statement checklist as the primary outcome. Discrepancies will be resolved through consensus or third author arbitration. Secondary outcomes to be extracted include the pathology and interventions examined, and indices of RCT quality. The systematic review will be compliant with PRISMA guidelines. The review has been registered a priori with the Registry of Systematic Reviews/meta-analyses (UIN: reviewregistry219). ETHICS AND DISSEMINATION: This systematic review will be conducted in line with the Cochrane Handbook for Systematic Reviews and Interventions. The intent is to publish in a peer-reviewed journal and present the data at relevant conferences.

Systematic review of the methodological and reporting quality of case series in surgery.

BACKGROUND: Case series are an important and common study type. No guideline exists for reporting case series and there is evidence of key data being missed from such reports. The first step in the process of developing a methodologically sound reporting guideline is a systematic review of literature relevant to the reporting deficiencies of case series. METHODS: A systematic review of methodological and reporting quality in surgical case series was performed. The electronic search strategy was developed by an information specialist and included MEDLINE, Embase, Cochrane Methods Register, Science Citation Index and Conference Proceedings Citation index, from the start of indexing to 5 November 2014. Independent screening, eligibility assessments and data extraction were performed. Included articles were then analysed for five areas of deficiency: failure to use standardized definitions, missing or selective data (including the omission of whole cases or important variables), transparency or incomplete reporting, whether alternative study designs were considered, and other issues. RESULTS: Database searching identified 2205 records. Through the process of screening and eligibility assessments, 92 articles met inclusion criteria. Frequencies of methodological and reporting issues identified were: failure to use standardized definitions (57 per cent), missing or selective data (66 per cent), transparency or incomplete reporting (70 per cent), whether alternative study designs were considered (11 per cent) and other issues (52 per cent). CONCLUSION: The methodological and reporting quality of surgical case series needs improvement. The data indicate that evidence-based guidelines for the conduct and reporting of case series may be useful.

An expanding forearm phlegmon and subsequent compartment syndrome.

We present the case of a young, fit woman who developed a forearm phlegmon with subsequent compartment syndrome. Further investigation found her to be suffering from endocarditis and she had had recent dental work. Presentation and management is discussed, with learning points highlighted.

Practical guide to the Idea, Development and Exploration stages of the IDEAL Framework and Recommendations.

BACKGROUND: Evaluation of new surgical procedures is a complex process challenged by evolution of technique, operator learning curves, the possibility of variable procedural quality, and strong treatment preferences among patients and clinicians. Preliminary studies that address these issues are needed to prepare for a successful randomized trial. The IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) Framework and Recommendations provide an integrated step-by-step evaluation pathway that can help investigators achieve this. METHODS: A practical guide was developed for investigators evaluating new surgical interventions in the earlier phases before a randomized trial (corresponding to stages 1, 2a and 2b of the IDEAL Framework). The examples and practical tips included were chosen and agreed upon by consensus among authors with experience either in designing and conducting IDEAL format studies, or in helping others to design such studies. They address the most common challenges encountered by authors attempting to follow the IDEAL Recommendations. RESULTS: A decision aid has been created to help identify the IDEAL stage of an innovation from literature reports, with advice on how to design and report the IDEAL study formats discussed, along with the ethical and scientific rationale for specific recommendations. CONCLUSION: The guide helps readers and researchers to understand and implement the IDEAL Framework and Recommendations to improve the quality of evidence supporting surgical innovation.

Norman Barrett (1903-1979): Unorthodox pioneer of thoracic and oesophageal surgery.

It is an interesting quirk of medical history that the legacy of Norman Barrett most ostensibly lies in the name of a disease the he was quite emphatically wrong about, at least when he first described it. Indeed, there are those who argue to remove the eponym in favour of the title 'Columnar Lined Epithelium', in part because of what little Barrett actually had to do with the correct initial characterisation of this disease. Yet the sum of Norman Barrett's contributions to modern medicine is much more than a mistaken characterisation of a pathological process. Barrett was truly a pioneer of chest surgery in the UK - a speciality in its embryonic stages when he first qualified. He was also renowned as a teacher and academic of the highest calibre. In tracing the story of his life we can see how his natural attributes, life experiences and keen appreciation of the arts (especially history) facilitated personal success and such sharp insight into the vagaries of modern academic medicine.

The reporting quality of parallel randomised controlled trials in ophthalmic surgery in 2011: a systematic review.

PURPOSE: Randomised controlled trials (RCTs) represent a gold standard for evaluating therapeutic interventions. However, poor reporting clarity can prevent readers from assessing potential bias that can arise from a lack of methodological rigour. The Consolidated Standards of Reporting Trials statement for non-pharmacological interventions 2008 (CONSORT NPT) was developed to aid reporting. RCTs in ophthalmic surgery pose particular challenges in study design and implementation. We aim to provide the first assessment of the compliance of RCTs in ophthalmic surgery to the CONSORT NPT statement. METHOD: In August 2012, the Medline database was searched for RCTs in ophthalmic surgery reported between 1 January 2011 and 31 December 2011. Results were searched by two authors and relevant papers selected. Papers were scored against the 23-item CONSORT NPT checklist and compared against surrogate markers of paper quality. The CONSORT score was also compared between different RCT designs. RESULTS: In all, 186 papers were retrieved. Sixty-five RCTs, involving 5803 patients, met the inclusion criteria. The mean CONSORT score was 8.9 out of 23 (39%, range 3.0-14.7, SD 2.49). The least reported items related to the title and abstract (1.6%), reporting intervention adherence (3.1%), and interpretation of results (4.7%). No significant correlation was found between CONSORT score and journal impact factor (R=0.14, P=0.29), number of authors (R=0.01, P=0.93), or whether the RCT used paired-eye, one-eye, or two-eye designs in their randomisation (P=0.97). CONCLUSIONS: The reporting of RCTs in ophthalmic surgery is suboptimal. Further work is needed by trial groups, funding agencies, authors, and journals to improve reporting clarity.

Norman Barrett (1903-79): unorthodox pioneer of thoracic and oesophageal surgery.

It is an interesting quirk of medical history that the legacy of Norman Barrett most ostensibly lies in the name of a disease the he was quite emphatically wrong about, at least when he first described it. Indeed, there are those who argue to remove the eponym in favour of the title 'Columnar Lined Epithelium', in part because of what little Barrett actually had to do with the correct initial characterization of this disease. Yet the sum of Norman Barrett's contributions to modern medicine is much more than a mistaken characterization of a pathological process. Barrett was truly a pioneer of chest surgery in the UK - a specialty in its embryonic stages when he first qualified. He was also renowned as a teacher and academic of the highest calibre. In tracing the story of his life we can see how his natural attributes, life experiences and keen appreciation of the arts (especially history) facilitated personal success and such sharp insight into the vagaries of modern academic medicine.

Outcome of pregnancy in type 1 diabetes mellitus (T1DMP): results from combined diabetes-obstetrical clinics in Dublin in three university teaching hospitals (1995-2006).

OBJECTIVE: To compare the pregnancy outcomes in all T1DMP attending at combined (diabetes-obstetric) outpatients clinics in three university teaching hospitals in Dublin from 1995 to 2006 with a non-diabetic control population (C) attending at antenatal outpatient clinics at the same hospitals over the same period. METHODS: T1DMP (n = 600) were compared with control non-diabetic pregnancies (n = 142,498). RESULTS: The spontaneous abortion rate was 15% in T1DMP versus 8% in C (p < 0.0001). Perinatal mortality rate was 3.3% in T1DMP compared to 0.9% in C (p < 0.001). The incidence of foetal macrosomia was 29% in T1DMP versus 16% in C (p < 0.001). CONCLUSIONS: Pregnancy outcomes in T1DMP remain worse than in the general population despite management of T1DMP in combined obstetric/diabetes clinics in a single centre using similar management protocols. These outcomes in our study population of T1DMP in Dublin appear better than some previously reported studies.