Postoperative surveillance after surgery for colorectal liver metastasis: a cross-sectional study.

INTRODUCTION: Colorectal liver metastases (CRLM) are associated with a high recurrence rate after surgery. There is paucity of high-quality evidence regarding the nature and overall benefit of surveillance after hepatectomy for CRLM. As part of a broader programme of research, this study aimed to assess current strategies for surveillance after liver resection for CRLM and outline surgeons' opinions regarding the benefit of postoperative surveillance. METHODS: An online survey was sent to clinicians performing surgery for CRLM at tertiary hepatobiliary centres in the UK. RESULTS: There were responses from a total of 23 centres (88% response rate); 15/23 centres used standardised surveillance protocols for all patients. Most centres followed patients up at six months, but there is variation in postoperative surveillance at 3, 9, 18 and beyond 60 months. Patient comorbidities, indeterminate findings on imaging, margin status and assessment of recurrence risk were identified as the major factors influencing personalised surveillance strategies. There was clear clinician equipoise regarding the costs and benefits of surveillance. CONCLUSION: There is heterogeneity in postoperative follow-up for CRLM in the UK. High-quality prospective studies and randomised trials are necessary to elucidate the value of postoperative surveillance and identify optimal follow-up strategies.

Emergency department presentations with suicide and self-harm ideation: a missed opportunity for intervention?

AIMS: Suicidal ideation constitutes a central element of most theories of suicide and is the defining facet separating suicide from other causes of death such as accidents. However, despite a high worldwide prevalence, most research has focused on suicidal behaviours, such as completed suicide and suicide attempts, while the greater proportion who experienced ideation, which frequently precedes suicidal behaviour, have received much less attention. This study aims to examine the characteristics of those presenting to EDs with suicidal ideation and quantify the associated risk of suicide and other causes of death. METHODS: Retrospective cohort study was performed based on population-wide health administration data linked to data from the Northern Ireland Registry of Self-Harm and centrally held mortality records from April 2012 to December 2019. Mortality data, coded as suicide, all-external causes and all-cause mortality were analysed using Cox proportional hazards. Additional cause-specific analyses included accidental deaths, deaths from natural causes and drug and alcohol-related causes. RESULTS: There were 1,662,118 individuals aged over 10 years, of whom 15,267 presented to the ED with ideation during the study period. Individuals with ideation had a 10-fold increased risk of death from suicide (hazard ratio [HRadj] = 10.84, 95% confidence interval [CI] 9.18, 12.80) and from all-external causes (HRadj = 10.65, 95% CI 9.66, 11.74) and a threefold risk of death from all-causes (HRadj = 3.01, 95% CI 2.84, 3.20). Further cause-specific analyses indicated that risk of accidental death (HRadj = 8.24, 95% CI 6.29, 10.81), drug-related (HRadj = 15.17, 95% CI 11.36, 20.26) and alcohol-related (HRadj = 10.57, 95% CI 9.07, 12.31) has also significantly increased. There were few socio-demographic and economic characteristics that would identify which of these patients are most at risk of suicide or other causes of death. CONCLUSIONS: Identifying people with suicidal ideation is recognized to be both important but difficult in practice; this study shows that presentations to EDs with self-harm or suicide ideation represent an important potential intervention point for this hard-to-reach vulnerable population. However, and unlike individuals presenting with self-harm, clinical guidelines for the management and recommended best practice and care of these individuals are lacking. Whilst suicide prevention may be the primary focus of interventions aimed at those experiencing self-harm and suicide ideation, death from other preventable causes, especially substance misuse, should also be a cause of concern.

Valve-sparing root replacement after the Ross procedure.

OBJECTIVES: The Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients. METHODS: Patients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared. RESULTS: Forty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement. CONCLUSIONS: Valve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed.

Parental mental health and risk of poor mental health and death by suicide in offspring: a population-wide data-linkage study.

AIMS: Suicide is a major public health concern. Identifying those most at risk is vital to ensure the implementation of effective interventions. Mental health (MH) is known to have a genetic component and parental MH is associated with offspring MH. However, little is known about the effect of parental psychopathology on offspring suicide risk. The aim of this study is to determine if children living with parents with poor MH are at an increased risk of poor MH, or death by suicide. METHODS: This population-wide cohort study linked data from the 2011 Northern Ireland Census to 6 years' death records (2011-2016). Information on MH status, in addition to other individual and household-level attributes, was derived from the 2011 Census. Logistic regression was utilised to examine the association between parental poor MH and offspring MH and suicide risk, with adjustment for socio-demographic characteristics. RESULTS: Overall, 11.6% of the cohort of 618 970 individuals were residing with parents who reported poor MH; 1.6% reported poor MH themselves, and 0.04% (n = 260) died by suicide. Living with a parent with poor MH increased the odds of offspring poor MH (OR = 2.80, 95% CI 2.59-3.03). After adjustment for age, gender, physical illness, socio-economic status and own MH, children living with 1 parent with poor MH were 76% more likely to die by suicide compared to children of parents who did not report poor MH (OR = 1.76, 95% CI 1.31-2.36). The effect size increased for children living with 2 parents with poor MH, and was higher in children aged under 24 years. CONCLUSIONS: Living with a parent with poor MH is a significant risk factor for offspring poor MH and suicide, even after adjustment for personal MH status. When treating mental ill-health in parents, potential interventions for their children should also be considered.

Lessons from the use of telemedicine in the austere military environment and the implications for deployed surgical teams.

Over the last 20 years, there have been significant changes in UK surgical training. Civilian surgical training may no longer prepare military surgeons for the range of skills they require on operations. One method to address gaps in knowledge or experience is to use telemedicine to facilitate specialist consultations from UK-based specialists to deployed medical teams. In the UK Defence Medical Services (DMS), this capability is called real-time clinical support (RTCS). RTCS provides a direct audio-visual link from a deployed location anywhere in the world to a supporting medical specialist in the UK. RTCS is currently delivered via a combination of off-the-shelf hardware and commercially available software. This article will outline the current use of RTCS, with emphasis on deployed surgical teams in austere environments, and discuss the advantages and limitations of this capability. However, it must be emphasised that no technology can be a substitute for clinical training and experience. Although several limitations remain, the authors believe that RTCS offers potential benefits for the DMS and could be an important tool aiding deployed clinicians. It can also be argued that by engaging with the concept now, the DMS can shape future developments in this sphere.

Investigating the association between COVID-19 vaccination and care home outbreak frequency and duration.

OBJECTIVES: At the end of 2020, many countries commenced a vaccination programme against SARS-CoV-2. Public health authorities aim to prevent and interrupt outbreaks of infectious disease in social care settings. We aimed to investigate the association between the introduction of the vaccination programme and the frequency and duration of COVID-19 outbreaks in Northern Ireland (NI). STUDY DESIGN: We undertook an ecological study using routinely available national data. METHODS: We used Poisson regression to measure the relationship between the number of RT-PCR confirmed COVID-19 outbreaks in care homes, and as a measure of community COVID-19 prevalence, the Office for National Statistics COVID-19 Infection Survey estimated the number of people testing positive for COVID-19 in NI. We estimated the change in this relationship and estimated the expected number of care home outbreaks in the absence of the vaccination programme. A Cox proportional hazards model estimated the hazard ratio of a confirmed COVID-19 care home outbreak closure. RESULTS: Care home outbreaks reduced by two-thirds compared to expected following the introduction of the vaccination programme, from a projected 1625 COVID-19 outbreaks (95% prediction interval 1553-1694) between 7 December 2020 and 28 October 2021 to an observed 501. We estimated an adjusted hazard ratio of 2.53 of the outbreak closure assuming a 21-day lag for immunity. CONCLUSIONS: These findings describe the association of the vaccination with a reduction in outbreak frequency and duration across NI care homes. This indicates probable reduced harm and disruption from COVID-19 in social care settings following vaccination. Future research using individual level data from care home residents will be needed to investigate the effectiveness of the vaccines and the duration of their effects.

Gait speed is a preoperative indicator of postoperative events after elective proximal aortic surgery.

OBJECTIVE: The study objective was to evaluate whether 5-m gait speed, an established marker of frailty, is associated with postoperative events after elective proximal aortic surgery. METHODS: We performed a retrospective review of 435 patients aged more than 60 years who underwent elective proximal aortic surgery, defined as surgery on the aortic root, ascending aorta, or aortic arch through median sternotomy. Patients completed a 5-m gait speed test within 30 days before surgery. We evaluated the association between categoric (slow, ≤0.83 m/s and normal, >0.83 m/s) and continuous gait speed and the likelihood of experiencing the composite outcome before and after adjustment for European System for Cardiac Operative Risk Evaluation II. The composite outcome included in-hospital mortality, renal failure, prolonged ventilation, and discharge location. Secondary outcomes were 1-year mortality and 5-year survival. RESULTS: Of the study population, 30.3% (132/435) were categorized as slow. Slow walkers were significantly more likely to have in-hospital mortality, prolonged ventilation, and renal failure, and were less likely to be discharged home (all P < .05). The composite outcome was 2 times more likely to occur for slow walkers (gait speed categoric adjusted odds ratio, 2.08; 95% confidence interval, 1.27-3.40; P = .004). Moreover, a unit (1 m/s) increase in gait speed (continuous) was associated with 73% lower risk of experiencing the composite outcome (odds ratio, 0.27; 95% confidence interval, 0.11-0.68; P = .006). CONCLUSIONS: Slow gait speed is a preoperative indicator of risk for postoperative events after elective proximal aortic surgery. Gait speed may be an important tool to complement existing operative risk models, and its application may identify patients who may benefit from presurgical and postsurgical rehabilitation.

Multimorbidity among persons aged 25-64 years: a population-based study of social determinants and all-cause mortality.

BACKGROUND: Despite increasing multimorbidity across the lifespan, little is known about the co-occurrence of conditions and risk factors among younger adults. This population-based study examines multimorbidity, social determinants and associated mortality among younger and middle-age adults. METHOD: Analysis was based on the Northern Ireland population aged 25-64 years enumerated in the 2011 Census (n = 878 345), with all-cause mortality follow-up to 2014 (8659 deaths). Logistic regression was used to examine social determinants and Cox proportional hazards models in the analysis of associated mortality. RESULTS: Prevalence of multimorbidity was 13.7% in females and 12.7% in males. There was a strong association between multimorbidity that included mental/cognitive illness and deprivation. Among those never married, multimorbid physical conditions were less likely [relative risk ratios (RRR) = 0.92: 95% confidence interval (CI) = 0.88, 0.95 for males; and RRR = 0.90: 0.87, 0.94 for females]. Rurality was associated with lower physical multimorbidity (RRR = 0.92: 0.89, 0.95) but higher mental/cognitive multimorbidity (RRR = 1.35: 1.12, 1.64) among females. All multimorbid categories were associated with elevated risk of mortality. CONCLUSION: The health and economic challenges created by multimorbidity should be addressed further 'upstream'. Future multimorbidity research should include younger adults to inform the development of preventative interventions and align health and social care services more closely with patients' needs.

Cardiorespiratory Fitness After Open Repair for Acute Type A Aortic Dissection - A Prospective Study.

Cardiorespiratory fitness (as measured by peak oxygen consumption [VO2peak]) is an independent predictor of cardiovascular disease and all-cause mortality. Limited data exist on VO2peak following repair for an acute type A aortic dissection (ATAAD) or proximal thoracic aortic aneurysm (pTAA). This study prospectively evaluated VO2peak, functional capacity, and health-related quality of life (HR-QOL) following open repair. Participants with a history of an ATAAD (n = 21) or pTAA (n = 43) performed cardiopulmonary exercise testing (CPX), 6-minute walk testing, and HR-QOL at 3 (early) and 15 (late) months following open repair. The median age at time of surgery was 55-years-old and 60-years-old in the ATAAD and pTAA groups, respectively. Body mass index significantly increased between early and late timepoints for both ATAAD (p = 0.0245, 56% obese) and pTAA groups (p = 0.0045, 54% obese). VO2peak modestly increased by 0.8 mLO2·kg-1·min-1 within the ATAAD group (p = 0.2312) while VO2peak significantly increased by 2.2 mLO2·kg-1·min-1 within the pTAA group (p = 0.0003). Anxiety significantly decreased in the ATAAD group whereas functional capacity and HR-QOL metrics (social roles and activities, physical function) significantly improved in the pTAA group (p values < 0.05). There were no serious adverse events during CPX. Cardiorespiratory fitness among the ATAAD group remained 36% below predicted normative values >1 year after repair. CPX should be considered post-operatively to evaluate exercise tolerance and blood pressure response to determine whether mild-to-moderate aerobic exercise should be recommended to reduce future risk of morbidity and mortality.

Administrative Data Research Northern Ireland (ADR NI).

BACKGROUND: The Administrative Data Research Northern Ireland (ADR NI), is a partnership between academia and the local statistics agency to advance the access to and use of administrative data in Northern Ireland. These goals are currently being advanced by undertaking a series of demonstrator Strategic Impact Projects developed to provide input to departmental areas of research interest and the current draft Programme for Government. APPROACH: ADR NI does not currently operate as a data repository but will negotiate access to and link subsets of administrative data from other departments and agencies as required for specific and approved projects. It is, however, anticipated that this model will broaden with the creation and retention of large linked datasets that could be used to address questions across a range of policy areas. At present accredited researchers can access the anonymised data only from within the safe setting situated in Belfast, although consideration is being given to using the Office for National Statistics Secure Researcher Service to access data more widely within the UK. ADR NI is currently being used to inform policy in a wide array of areas including health, education, environmental and urban planning. DISCUSSION: ADR NI continues to develop and change. The growing confidence amongst data owners which has been supported by new and facilitating UK legislation has increased the willingness and ability to share and link administrative data. However, the associated logistical and administrative processes for accessing data will need further streamlining so that the timelines become more efficient and predictable. The evidence for the potential utility of research based on administrative data to influence policy continues to grow. CONCLUSION: Over the last decade we have demonstrated to data owners and the different publics that it is safe and acceptable to link administrative data for public benefit. The evolution and maturation of the ADR NI progresses apace and we continue to learn from developments in our sister organisations throughout the UK and throughout the world. We look forward to greater access to and use of administrative data both within Northern Ireland and across the UK.

Relationship of Ventricular Morphology and Atrioventricular Valve Function to Long-Term Outcomes Following Fontan Procedures.

BACKGROUND: The influence of ventricular morphology on Fontan outcomes is controversial. OBJECTIVES: This study hypothesized that dysfunction of the single right ventricle (RV) and right atrioventricular valve regurgitation (AVVR) increases over time and adversely impacts late outcomes following a Fontan operation. A single-center retrospective study was performed. METHODS: From 1985 through 2018, 1,162 patients underwent the Fontan procedure at our center and were included in this study. Transplant and takedown free survival, ventricular, and atrioventricular valve dysfunction after Fontan were analyzed. Death or heart transplantation information was obtained from the National Death Index and the Scientific Registry of Transplant Recipients. RESULTS: The follow-up rate was 99%. Morphologic RV was present in 58% of patients. Transplant and takedown free survival were 91%, 75%, and 71% at 10 years, 20 years, and 25 years, respectively. Morphologic RV was an independent risk factor for transplant, takedown free survival (hazard ratio: 2.4; p = 0.008). The AVVR, which preceded ventricular dysfunction in most cases, was associated with the development of ventricular dysfunction after Fontan (odds ratio: 4.3; 95% confidence interval: 2.7 to 6.7; p < 0.001). Furthermore, AVVR and ventricular dysfunction progressed over time after Fontan, especially in the RV (AVVR: p < 0.0001, ventricular dysfunction: p < 0.0001). CONCLUSIONS: Morphologic RV is negatively associated with the long-term survival following the Fontan, possibly due to a tendency toward progressive AVVR and deterioration of the single ventricle function. Additional volume overload caused by AVVR may be one of the main factors accelerating the dysfunction of the single RV, implying that early valve intervention may be warranted.

Does physical ill-health increase the risk of suicide? A census-based follow-up study of over 1 million people.

AIMS: Mental ill-health is a known risk factor for suicide mortality. However, the relationship between physical ill-health and suicide is less clear. This study examined the relationship between different aspects of physical ill-health and the risk of suicide death. METHODS: Data for 1 196 364 adults (aged 18 years and over) were identified from the 2011 Northern Ireland Census and linked to death registrations until the end of 2015. Multivariate logistic regression was used to construct models to test associations with likelihood ratio tests for interactions. RESULTS: Over one in eight individuals (13.7%) reported multimorbidity (⩾2 physical health conditions) and one in four (25.4%) identified having limitation of daily activities. During follow-up, 51 672 individuals died; 877 due to suicide. The gradient in suicide risk by number of physical conditions disappeared following adjustment for activity limitation. Individuals with a lot of activity limitation were over three times more likely to die by suicide (OR = 3.13, 95% CI 2.50-3.93) compared to those with no limitations though this was reduced to OR = 1.72 (95% CI 1.35-2.20) with adjustment for poor mental health. The relationship between activity limitation and suicide was most pronounced at younger ages (18-34 years). CONCLUSIONS: This study suggests that it is the effect that physical illness has on a person's life, in terms of disruption to daily activity, rather than the number of conditions that predicts suicide risk, especially at younger ages. Improved awareness and better management of mental wellbeing of individuals with physical health conditions may help to reduce suicides, especially in younger people.