Abstract Aims Oesophageal Cancer (OC) treatment levies substantial financial burden on health services with potentially curative surgery with or without neoadjuvant offered to patients with locoregional disease. This study aimed to examine treatment costs related to Quality Adjusted Life-Years (QALYs) gained in patients that have potentially curative treatment (oesophagectomy) and those receiving best supportive care (BSC). Methods Consecutive 365 patients undergoing potentially curative treatment (median age 64.5 years, 308 male, 57 female, 331 adeno ca, 32 squamous cell ca, 2 high grade dysplasia, 263 neoadjuvant therapy) were studied. The cost of one-year’s treatment from referral was calculated based on current management standards within a regional cancer network and primary outcome was overall survival. Results QALY-adjusted survival for stage I was 48 months, stage II 30.6 months, stage III 23.0 months, and stage IV 13.0 months, with cost per QALY of £6038, £13412, £14606, and £20002 respectively. QALY-adjusted survival for patients receiving BSC was 2.24 months, with a cost per QALY of £60225. This gives an Incremental Cost-Effectiveness Ratio (ICER) per QALY for stages I to IV of £3385, £9714, £8740 and £17763 respectively. Conclusion Cost per QALY of potentially curative OC treatment for each stage was below national thresholds of readiness to pay per QALY, while BSC likely exceeds this. Regarding ICER-defined cost effectiveness, treatment of stage I was five-fold cheaper than stage IV OC, supporting early diagnosis as being most cost-effective.

INTRODUCTION:Core Surgical Training (CST) programs are associated with high burnout. This study aimed to assess the influence of Enhanced Stress Resilience Training (ESRT) over a 2-year period in a single UK Statutory Education Body. METHOD:CSTs participated in 5-weeks of formal ESRT to address work stressors. The primary outcome measure was career progression related to curriculum metrics and National Training Number (NTN) appointment. Secondary measures related to burnout using validated psychological inventories. RESULTS:Of 42 CSTs, 13 engaged fully with ESRT (31.0%; male 8, female 5, median age 28 year.), 11 engaged partially, and 18 did not. ESRT engagement was associated with better NTN appointment (ESRT 8/13 (61.5%) vs. not 1/18 (5.6%), p = 0.025), less burnout [aMBI; mean 5.14 (SD ± 2.35) vs. 3.14 (±2.25), F 6.637, p = 0.002, ηp2=0.167], less stress [PSS-10; 19.22 (±5.91) vs. 15.79 (±5.47), F 8.740, p < 0.001, ηp2=0.200], but more mindfulness [CAMS-R; 19.22 (±5.91) vs. 20.57 (±2.93), F 3.201, p = 0.047, ηp2=0.084]. On multivariable analysis, Improving Surgical Training (run-through CST) program (OR 5.2 (95% CI 1.42-28.41, p = 0.022), MRCS pass (OR 17.128 (95% CI 1.48-197.11, p = 0.023) and ESRT engagement (OR 13.249, 95% CI 2.08-84.58, p = 0.006) were independently associated with NTN success. DISCUSSION:ESRT was associated with less stress and burnout, better mindfulness, and most importantly 13-fold better career progression.

Introduction This study aimed to evaluate differential attainment during higher surgical training (HST; all specialties) related to three ethnic cohorts: White UK (WUKG), Black and Minority Ethnic UK Graduates (BMEUKG), and International Medical Graduates (IMG). Method Anonymised records of 266 HSTs (126 WUKG, 65 BMEUKG, 75 IMG; 7 years) in a single UK Statutory Education Body were examined. Primary effect measures were Annual Record of Competency Progression Outcome (ARCPO) and Fellowship of the Royal College of Surgeons (FRCS) pass. Results ARCPOs related to ethnicity and specialty were similar with the exception of general surgery (GS) trainees, four of whom received ARCPO 4 (GS 4.9% (75% BME; p=0.025) vs all other 0%). ARCPO 3 was commoner in women (22/76, (28.9%) than men 27/190 (14.2%), OR 2.46, p=0.006). FRCS pass rates (WUKG vs BMEUKG vs IMG) were 76.9%, 52.9% and 53.9% respectively (p=0.064) but unrelated to gender (M 70.4% vs F 64.3%). On multivariable analyses: ARCPO 3 was associated with Female gender and Maternity Leave (OR 8.05, p=0.001); FRCS pass with ethnicity (OR 0.21, p=0.028) and Hirsch Indices of ≥5 (OR 11.17, p=0.001). Conclusion Differential attainment was plain with BMEUKG FRCS performance almost a third poorer than WUKG, and women twofold more likely to receive adverse ARCPOs, with return from statutory leave independently associated with training extension. Focused counter measures targeted at non-operative technical skills (including academic reach), Keeping in Touch, Return to Work, and re-induction programmed support are urgently needed for trainees at risk.

BACKGROUND:This study aimed to evaluate core surgical training (CST) differential attainment related to coronavirus disease 2019 (COVID-19), gender and ethnicity. The hypothesis was that COVID-19 adversely influenced CST outcomes.METHODS:A retrospective cohort study of 271 anonymised CST records was undertaken at a UK Statutory Education Body. Primary effect measures were Annual Review of Competency Progression Outcome (ARCPO), Membership of the Royal College of Surgeons (MRCS) examination pass and Higher Surgical Training National Training Number (NTN) appointment. Data were collected prospectively at ARCP and analysed with non-parametric statistical methods in SPSS.RESULTS:CSTs numbering 138 completed training pre-COVID and 133 peri-COVID. ARCPO 1, 2 and 6 were 71.9% pre-COVID versus 74.4% peri-COVID ( P =0.844). MRCS pass rates were 69.6% pre-COVID versus 71.1% peri-COVID ( P =0.968), but NTN appointment rates diminished (pre-COVID 47.4% vs. peri-COVID 36.9%, P =0.324); none of the above varied by gender or ethnicity. Multivariable analyses by three models revealed: ARCPO was associated with gender [m:f 1:0.87, odds ratio (OR) 0.53, P =0.043] and CST theme (Plastics vs. General OR 16.82, P =0.007); MRCS pass with theme (Plastics vs. General OR 8.97, P =0.004); NTN with the Improving Surgical Training run-through programme (OR 5.00, P <0.001). Programme retention improved peri-COVID (OR 0.20, P =0.014) with pan University Hospital rotations performing better than Mixed or District General-only rotations (OR 6.63, P =0.018).CONCLUSION:Differential attainment profiles varied 17-fold, yet COVID-19 did not influence ARCPO or MRCS pass rates. NTN appointment fell by one-fifth peri-COVID, but overall training outcome metrics remained robust despite the existential threat.

discharged from A&E. 80% of these discharged patients had an Oakland Score >8. 21 (17.2%) of admitted patients received an inpatient lower GI endoscopy; 19% of which received endoscopic therapy. The most commonly identified cause of LGIB was diverticulosis (23.8%). Overall, 82.8% of admitted patients received no inpatient lower GI endoscopy and were managed conservatively. Comparing those who underwent LGI endoscopy versus a watch and wait approach, there was no difference in inpatient mortality (0% vs 4%, p=1.0) or 30-day re-admission rate (9.5% vs 22.8%, p= 0.24). However, undergoing inpatient LGI endoscopy was associated with greater median length of stay (8 days vs 3 days, p=0.0002)

Abstract Background Upper Gastro Intestinal (UGI) cancer surgery carries considerable risk and cost in terms of human and financial resource. Reported complication rates after oesophagectomy and gastrectomy are 65% and 42% respectively and can range from relatively minor morbidity to major life-threatening events, all with the potential to increase Length of Stay (LoS) and cost which can be graded by the Clavien-Dindo (CD) system. This study aimed to study the impact of complications on LoS and quantify the associated economic costs. Methods Consecutive 754 patients with UGI cancer (420 oesophageal, 334 gastric), undergoing potentially curative treatment (median age 67 yr., 590 m, 164 f, 684 Adeno Ca, 36 SCC, 205 Ivor-Lewis oesophagectomy, 146 Trans Hiatal oesophagectomy, 142 total gastrectomy, 134 subtotal gastrectomy, 97 open and close, 11 Three-stage oesophagectomy, 10 salvage resections, 8 oesophagogastrectomy) were studied. The cost of each night’s stay was limited to direct costs, including ward and medical staff expenditure. Results Median LoS was 13 (IQR-7) days. The number of patients related to CD score were; Zero-326, I-41, II-224, IIIa-44, IIIb-28, IVa-36, IVb-4 and V-16, with median LoS of 11, 14, 14, 23, 25, 32, 44 and 9 days respectively. The added LoS for each complication cohort was 3 days for CD I and II, then 12, 14, 21, and 33 days for CD IIIa, IIIb, IVa and IVb respectively. Average added cost for each grade of complication per patient was £844.44 for CD I and II, £3,377.76 for IIIa, £8,519.40 for IIIb, £14,927.70 for IVa and £36,047.85 for IVb. Conclusions Overall hospital and CC LoS increased related to complication grade, other than CD V, with an average ward cost per additional day of £281.48 and CC cost of £1426.15. Average cost of an uncomplicated oesophagectomy or gastrectomy was estimated to be £16,544. As well as the adverse impact on patients’ recovery and well-being, complications have a large fiscal impact on healthcare systems and in many cases can dwarf the first treatment cost. These findings illustrate a strong clinical and business case for investment in effective strategies to boost complication free surgery including pre-habilitation.

Abstract Aim The optimal operation for Siewert type II cancers is unclear, with both oesophagectomy and total gastrectomy being undertaken. This study aimed to investigate the overall survival and associated operative outcomes of both approaches. Method A retrospective cohort study was performed of all Siewert type II Gastro-Oesophageal Junctional (GOJ) resections from a single oesophagogastric centralised service between 2010 and 2017. The primary outcome was 5-year overall survival (OS). Secondary outcomes were recurrence rate and operative morbidity. Results A total of 163 patients were included; 127 (77.9%) oesophagectomy vs. 36 (22.1%) gastrectomy. The 5-year OS for oesophagectomy vs. gastrectomy were 50.4% vs 41.7% with a median survival of 57 months vs. 31 months respectively (p = 0.062). No differences in the rate of recurrence (44.9% vs. 33.3%, p = 0.216) or overall rate of complications (63.8% vs. 63.9%, p = 0.990) were identified. Yet, significantly more major (Clavien-Dindo III+) complications occurred in the gastrectomy compared to the oesophagectomy cohort (38.9% vs. 20.5%, p = 0.012), driven partially by a higher anastomotic leak rate (19.4% vs 9.4%, p = 0.099). Cox regression revealed no significant difference in the 5-year OS between the two groups when accounting for confounders (HR 0.906, 95% CI 0.339-2.060, p = 0.814). Only age (HR 0.971, 95% CI 0.944-0.999, p = 0.046) and pT stage (HR 1.794, 95% CI 1.097-2.935, p = 0.020) were determinants of 5-year OS. Conclusions When accounting for confounders there were no significant differences in the overall survival based on the two approaches. Further multi-centre prospective studies would be advantageous to establish a consensus on the best approach.

PURPOSE OF THE STUDY:Drivers at work (DW) and Learning Styles (LS) refer to contentious theories that aim to account for differential career development yet seldom feature in assessment. This study aimed to quantify the influence of core surgical trainees' (CST) DW and LS on career progress.STUDY DESIGN:DW questionnaires and Kolb LS inventories were distributed to 168 CSTs during five consecutive induction boot camps in a single-statutory education body. Primary outcome measures were membership of the Royal College of Surgeons (MRCS) examination and national training number (NTN) success.RESULTS:Of 108 responses received (response rate 64.3%), 64.8% were male and 35.2% female (p=0.003). DW spectrum was: please people (25.0%), be perfect (21.3%), hurry up (18.5%), be strong (13.9%) and try hard (0%, p<0.001). DW was either equivocal (n=14) or not provided (n=9) by 21.3% of CSTs. LS were: converging (34.3%), accommodating (28.7%), diverging (23.1%) and assimilating (13.9%, p=0.021). Men were more likely to be convergers (29/70, 41.4%), and women divergers (15/38, 39.5%, p=0.018) also preferring team-based LS (accommodating/diverging, 26/38 (68.4%) vs 30/70 (42.9%), p=0.010). MRCS success was not associated with DW (p=0.329) or LS (p=0.459). On multivariable analysis, NTN success was associated with LS (accommodators 64.5%, divergers 32.0%, OR 10.90, p=0.014), scholarly activity (OR 1.71, p=0.001), improving surgical training programme (OR 36.22, p=0.019) and universal ARCP 1 outcome (OR 183.77, p<0.001).CONCLUSIONS:LS are associated with important differences in career progress with accommodator twofold more likely than diverger to achieve NTN.

Introduction Surgical career progression is determined by examination success and Annual Review of Competence Progression (ARCP) outcome, yet data on organisational skills are sparse. This study aimed to determine whether organisational skills related to Core Surgical Training (CST) outcome. Primary outcome measures include operative experience, publications, examination success (Membership of the Royal College of Surgeons or the Diploma in Otolaryngology-Head and Neck Surgery (MRCS/DO-HNS)) and ARCP outcome. Methods The study was conducted prospectively at three consecutive CST induction boot camps (2017-2019) providing clinical and simulation training for 125 trainees. Arrival time at course registration was the selected surrogate for organisational skills. Trainees were advised to arrive promptly at 8:45 for registration and that the course would start at 9:00. Trainee arrival times were grouped as follows: early (before 8:45), on time (8:45-8:59am) or late (after 9:00). Arrival times were compared with primary outcome measures. Setting Health Education and Improvement Wales' School of Surgery, UK. Results Median arrival time was 8:53 (range 7:55-10:03), with 29 trainees (23.2%) arriving early, 63 (50.4%) on-time and 33 (26.4%) late. Arrival time was associated with operative experience (early vs late; 206 vs 164 cases, p=0.012), publication (63.2% vs 18.5%, p=0.005), MRCS/DO-HNS success (44.8% vs 15.2%, p=0.029), ARCP outcome (86.2% vs 60.6% Outcome 1, p=0.053), but not National Training Number success (60.0% vs 53.3%, p=0.772). Conclusions Better-prepared trainees achieved 25% more operative experience, were four-fold more likely to publish and pass MRCS, which aligned with consistent desirable ARCP outcome. Timely arrival at training events represents a skills-composite of travel planning and is a useful marker of strategic organisational skills.

Background A competition ratio (CR) indicates the ratio of total applications for a training post when compared with numbers of specialty posts available. This study aimed to evaluate CRs’ influence on National Training Number (NTN) selection in a single UK Statutory Education Body. Methods Consecutive core surgical trainees numbering 154 (105 men, 49 women; median years since graduation: four) were studied over a 6-year period. Annual specialty specific CRs were obtained from Health Education England’s website, and primary outcome measure was UK NTN appointment. Results Overall NTN appointment was 45.5%. Median CR was 2.36; range Oral & Maxillofacial Surgery 0.70 (2020) to Neurosurgery 22.0 (2020). Multivariable analysis revealed that NTN success was associated with: CR (OR 0.46, p=0.003), a single scientific publication (OR 6.25, p=0.001), cohort year (2019, OR 12.65, p=0.003) and Universal Annual Review of Competence Progression Outcome 1 (OR 45.24, p<0.001). CRs predicted NTN appointment with a Youden index defined critical ratio of 4.42; 28.6% (n=8) versus 49.2% (n=62), p=0.018. Conclusion CRs displayed 30-fold variation, with CRs below 4.42 associated with twofold better NTN promotion, but strong clinical competence and academic reach again emerged as the principal drivers of career advancement.

Background and study aims Virtual reality endoscopic simulation training has the potential to expedite competency development in novice trainees. However, simulation platforms must be realistic and confer face validity. This study aimed to determine the face validity of high-fidelity virtual reality simulation (EndoSim, Surgical Science, Gothenburg), and establish benchmark metrics to guide the development of a Simulation Pathway to Improve Competency in Endoscopy (SPICE). Methods A pilot cohort of four experts rated simulated exercises (Likert scale score 1-5) and following iterative development, 10 experts completed 13 simulator-based endoscopy exercises amounting to 859 total metric values. Results Expert metric performance demonstrated equivalence ( P = 0.992). In contrast, face validity of each exercise varied among experts (median 4 (interquartile range [IQR] 3-5), P < 0.003) with Mucosal Examination receiving the highest scores (median 5 [IQR 4.5-5], P = 1.000) and Loop Management and Intubation exercises receiving the lowest scores (median 3 [IQR 1-3], P < 0.001, P = 0.004), respectively. The provisional validated SPICE comprised 13 exercises with pass marks and allowance buffers defined by median and IQR expert performance. Conclusions EndoSim Face Validity was very good related to early scope handling skills, but more advanced competencies and translation of acquired clinical skills require further research within an established training program. The existing training deficit with superadded adverse effects of the COVID pandemic make this initiative an urgent priority.

This study aimed to analyse the degree of relative variation in speciality-specific competencies required for Certification of Completion of Training (CCT) set by the UK Joint Committee for Surgical Training (JCST) 2021 curriculum. Regulatory body guidance related to operative and non-operative surgical skill competencies required for CCT were analysed and compared. Wide inter-speciality variation was demonstrated in the minimum number of logbook cases (median 815; range 54 to 2100), indexed operations (8; 5 to 24) and procedure-based assessments (35; 6 to 110). Academic competencies related to peer-reviewed publications, communications to learned societies and audits were aligned at zero, zero and three across specialities, respectively. Mandatory courses have been standardised with Advanced Trauma Life Support being the sole pre-requisite CCT for all. JCST certification guidelines have broadly standardised competency domains, yet large discrepancies persist regarding operative indicative numbers and assessments. This article serves as a definitive CCT guide regarding prevailing changes.

Familial transthyretin amyloidosis (ATTR) is an autosomal dominant disorder associated with a variant form of the plasma carrier protein transthyretin (TTR). Amyloid fibrils consisting of variant TTR, wild-type TTR, and TTR fragments deposit in tissues and organs. The diagnosis of ATTR relies on the identification of pathologic TTR variants in plasma of symptomatic individuals who have biopsy proven amyloid disease. Previously, we have developed a mass spectrometry-based approach, in combination with direct DNA sequence analysis, to fully identify TTR variants. Our methodology uses immunoprecipitation to isolate TTR from serum, and electrospray ionization and matrix-assisted laser desorption/ionization mass spectrometry (MS) peptide mapping to identify TTR variants and posttranslational modifications. Unambiguous identification of the amino acid substitution is performed using tandem MS (MS/MS) analysis and confirmed by direct DNA sequence analysis. The MS and MS/MS analyses also yield information about posttranslational modifications. Using this approach, we have recently identified a novel pathologic TTR variant. This variant has an amino acid substitution (Phe --> Cys) at position 33. In addition, like the Cys10 present in the wild type and in this variant, the Cys33 residue was both S-sulfonated and S-thiolated (conjugated to cysteine, cysteinylglycine, and glutathione). These adducts may play a role in the TTR fibrillogenesis.

Background: Bibliometric and Altmetric analyses provide different perspectives regarding research impact. This study aimed to determine whether Altmetric score was associated with citation rate independent of established bibliometrics. Methods: Citations related to a previous cohort of 100 most cited articles in surgery were collected and a 3-year interval citation gain calculated. Citation count, citation rate index, Altmetric score, 5-year impact factor, and Oxford Centre for Evidence-Based Medicine levels were used to estimate citation rate prospect. Results: The median interval citation gain was 161 (i.q.r. 83-281); 74 and 62 articles had an increase in citation rate index (median increase 2.8 (i.q.r. -0.1 to 7.7)) and Altmetric score (median increase 3 (0-4)) respectively. Receiver operating characteristic (ROC) curve analysis revealed that citation rate index (area under the curve (AUC) 0.86, 95 per cent c.i. 0.79 to 0.93; P<0.001) and Altmetric score (AUC 0.65, 0.55 to 0.76; P=0.008) were associated with higher interval citation gain. An Altmetric score critical threshold of 2 or more was associated with a better interval citation gain when dichotomized at the interval citation gain median (odds ratio (OR) 4.94, 95 per cent c.i. 1.99 to 12.26; P=0.001) or upper quartile (OR 4.13, 1.60 to 10.66; P=0.003). Multivariable analysis revealed only citation rate index to be independently associated with interval citation gain when dichotomized at the median (OR 18.22, 6.70 to 49.55; P<0.001) or upper quartile (OR 19.30, 4.23 to 88.15; P<0.001). Conclusion: Citation rate index and Altmetric score appear to be important predictors of interval citation gain, and better at predicting future citations than the historical and established impact factor and Oxford Centre for Evidence-Based Medicine quality descriptors.

OBJECTIVES:To compare proportional representation of healthcare specialty workers, in receipt of New Year Honours (NYHs) and examine system bias.DESIGN:Observational study of UK honours system including comparative analysis of proportional representation of the UK medical workforce.PARTICIPANTS:Recipients of NYHs from 2010 to 2019.MAIN OUTCOME MEASURES:Absolute risk of receiving an NYH, related to medical specialty, gender and geographical region. Relative risk (RR) of receiving an NYH for services to healthcare related to specialty.RESULTS:11 207 NYHs were bestowed, with 368 (3.3%) awarded to healthcare professionals: 212 (57.6%) women, 156 (42.4%) men. The RR of a healthcare professional receiving an NYH was 0.76 (95% CI 0.68 to 0.84, p<0.001) when compared with the remaining UK workforce. Doctors received most NYHs (n=181), with public health, clinical oncology and general medicine specialties most likely to be rewarded (RR 20.35 (95% CI 9.61 to 43.08, p<0.001), 8.43 (95% CI 2.70 to 26.30, p<0.001) and 8.22 (95% CI 6.22 to 10.86, p<0.001)), respectively; anaesthetists received fewest NYHs (RR 0.52 (95% CI 0.13 to 2.10), p=0.305). Men were more likely to receive NYHs than women (OR 0.44, 95% CI 0.36 to 0.54; p<0.001). Two hundred and fifty-four NYHs (69.0%) were bestowed on residents of England (60, 16.3% London), 49 (13.3%) Scotland (p=0.003), 39 (10.6%) Wales (p<0.001) and 26 (7.1%) Northern-Ireland (p<0.001).CONCLUSIONS:Relative risk of receiving an NYH varied over 150-fold by specialty, twofold by gender and threefold by geographical location. Public health physicians are perceived to be the pick of the parade.

Editor—We would like to report on our work investigating the impact of full personal protective equipment (PPE) on perioperative anxiety on children and young people undergoing surgery during the coronavirus disease 2019 (COVID-19) pandemic. Perioperative anxiety in paediatrics occurs in 50–75% of patients and is associated with negative outcomes postoperatively including increased pain, nausea and vomiting, prolonged recovery. and dysfunctional behaviours in up to 60% of patients: difficulty sleeping, nightmares, eating disorders, and nocturnal enuresis.1Kain Z.N. Mayes L.C. Caldwell-Andrews A.A. Karas D.E. McClain B.C. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery.Pediatrics. 2006; 118: 651-658Crossref PubMed Scopus (368) Google Scholar The mental health of children and adolescents has already been negatively affected by the pandemic,2Loades M.E. Chatburn E. Higson-Sweeney N. et al.Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19.J Am Acad Child Adolesc Psychiatr. 2020; 59: 1218-1239Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar and we hypothesised that PPE could lead to increased anxiety and worsen outcomes in this already vulnerable population. Our policy is to wear full PPE for aerosol-generating procedures regardless of COVID-19 status because of high regional prevalence. We performed a service evaluation to investigate the impact of PPE on perioperative fear and anxiety. A prospective observational cohort study of consecutive cases was performed by six paediatric anaesthetists at Alder Hey Children's Hospital (Liverpool, UK) with a postoperative survey of families presenting for day-surgery to determine their perceptions about PPE. Our single-centre study is part of wider multicentre work by the Procedure Induced Anxiety Network UK (PIANo-UK). The data collection period lasted from June 22, 2020 to July 5, 2020. Patients <24 months, for critical care, or with acute reduction in Glasgow Coma Scale (GCS) were excluded. Validated tools used for evaluation included the Induction Compliance Checklist (ICC), which scored anxiety behaviour in the anaesthetic room. This project was registered prospectively with the local quality and governance committee (registration number 6086). Consent was obtained as part of the patient survey. Data were analysed with Google Sheets (Google LLC, Mountain View, CA, USA). The anaesthetist survey included 63 cases meeting inclusion criteria of 86 screened cases. Patient characteristics were as follows: patients had a median age of 9 (inter-quartile range [IQR], 1–12) yr, 38/63 (60%) male and 25/63 (40%) female, 60/63 (95%) ASA physical status 1–2, and 3/63 (5%) ASA physical status 3–4. There were 22/63 urgent or emergency procedures and 41/63 elective procedures. The median ICC score was 1 (IQR, 0–1), with a score of 0 indicating perfect induction in 31/63 (49%). The median ICC score if a sedative premedication was given was 1 (IQR, 0–1), showing no significant difference in ICC with premedication (P=0.38). Heterogenous PPE was worn in the anaesthetic room: filtering face piece 3 (FFP3) masks, half-face respirators, and powered air-purifying respirators. Distraction was used in 27/63 (60%) cases. The patient and family survey comprised 45 responses, with 23/45 (50%) including responses from patients older than 5 yr who were willing and able to answer. In 29/45 (64%) families, they reported their child was scared or anxious as a concern about coming into hospital; 42/45 families expected staff to be wearing PPE; and 15/23 (65%) of children selected the words happy and safe as descriptors of how PPE made them feel, with no children selecting anxious, nervous, or scared. Parents overestimated a child's fear of PPE as shown in Figure 1. Although we know that both perioperative anxiety and COVID-19 impact the mental health of children and young people, as yet we do not have a good understanding of how these intersect. Strategies to support child mental health for parents have been outlined during the pandemic as a whole3Ashikkali L. Carroll W. Johnson C. The indirect impact of COVID-19 on child health.Paediatr Child Health. 2020; 30: 430-437Abstract Full Text Full Text PDF Scopus (13) Google Scholar; however, there is a lack of information about coming into hospital during the pandemic. Our service evaluation suggests that PPE does not contribute to perioperative anxiety in children and adolescents. Most patients experienced extremely low levels of anxiety at induction (median ICC score, 1/8). PPE provided reassurance and increased a child's confidence in anaesthesia: 65% reported staff PPE made them feel safe and happy, and 0% reported being scared by PPE. Evidence suggests that children desire information about the perioperative process4Fortier M.A. MacLaren Chorney J. Yaffa Zisk Rony R. et al.Children’s desire for perioperative information.Anesth Analg. 2009; 109: 1085-1090Crossref PubMed Scopus (57) Google Scholar; we found that 93% were expecting to see staff in PPE. We propose that provision of detailed information about what PPE children should expect will empower them and is related to the low levels of anxiety seen. At the time of our work, as elective surgery resumed after the first COVID-19 wave, the wearing of face masks was not mandatory in public places; however, PPE was widely depicted throughout the media, and this will have impacted the expectations of children and young people about seeing staff wearing PPE. The use of heterogeneous PPE by different staff members precludes further analysis of whether specific types of PPE elicited different responses from patients. Mask-wearing has been highlighted as hindering communication in paediatric anaesthesia.5Crowe A.M.L. Communication skills with children in paediatric anaesthesia: challenges while wearing a face mask.BMJ Paediatr Open. 2020; 4e000846Crossref PubMed Scopus (5) Google Scholar In our experience, although powered air-purifying respirators allow patients to visualise staff faces without obstruction, improving visual cues, this benefit is pitted against the background noise of the respirator creating communication difficulties. This is more keenly felt with anxious patients who might be softly spoken. We remain concerned that the softer skills associated with improving the patient experience are hindered by the requirement for full PPE. Distraction techniques remain a mainstay of paediatric anaesthetic practice, used in 60% of cases. Psychological interventions including distraction have been consistently shown to be effective.6Birnie K.A. Noel M. Chambers C.T. Uman L.S. Parker J.A. Psychological interventions for needle-related procedural pain and distress in children and adolescents.Cochrane Database Syst Rev. 2018; 10CD005179PubMed Google Scholar In our pre-COVID practice, bubble blowing was the most commonly used distraction technique in younger patients, which we now achieve using a spare powered air-purifying respirator blower unit. Other options for distraction remain available including use of videos and interactive games, which have been shown to be beneficial.7Manyande A. Cyna A.M. Yip P. Chooi C. Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children.Cochrane Database Syst Rev. 2015; 7CD006447Google Scholar Our work is limited by the absence of pre-COVID-19 data or a control group; however, it highlights a probable psychological shift to a ‘new normal’ that warrants further study, and is the focus of extensive work by PIANo-UK. PPE will likely remain commonplace in anaesthesia even after the pandemic, so this is an issue that remains pertinent for our future practice. We conclude that contrary to our expectations at the start of the pandemic, full PPE does not generate anxiety, and in fact children most frequently report it making them feel happy and safe. This is supported by their behaviour during induction of anaesthesia. No funding was received.

discharged from A&E. 80% of these discharged patients had an Oakland Score >8. 21 (17.2%) of admitted patients received an inpatient lower GI endoscopy; 19% of which received endoscopic therapy. The most commonly identified cause of LGIB was diverticulosis (23.8%). Overall, 82.8% of admitted patients received no inpatient lower GI endoscopy and were managed conservatively. Comparing those who underwent LGI endoscopy versus a watch and wait approach, there was no difference in inpatient mortality (0% vs 4%, p=1.0) or 30-day re-admission rate (9.5% vs 22.8%, p= 0.24). However, undergoing inpatient LGI endoscopy was associated with greater length of stay (8 days vs 3 days, p=0.0002) four experts rated simulated exercises by Likert-scale (1-5). Following iterative development, 10 experts completed a 13-exercise simulator-based curriculum, with 35 individual amounting to 858 total metric values. Stat-istical analysis for non-parametric data was used: where multiple comparisons were made, Bonferroni calculation was performed which altered the standard significance of p<0.05 to p<0.0014. Conclusions Short segment Barrett ’ s can be difficult to assess accurately. In our analysis, cases that did not meet the criteria for Barrett ’ s diagnosis on endoscopy, had segment < 1cm or an atypical Z line. We have shown a potential 49% reduction in unnecessary gastroscopies, which could result in avoidance of unnecessary health and procedural anxiety for patients, and cut waiting lists and associated costs. In addition, we suggest that patients with previous sus-pected Barrett ’ s should be evaluated on dedicated surveillance lists, by endoscopists with expertise in Barrett ’ s assessment.

Objectives Stress and burn-out among surgical trainees has been reported most prevalent in core surgical trainees (CST) and female trainees in particular. This study aimed to identify factors perceived by CSTs to be associated with stress and burnout in those at risk.Design An open-ended questionnaire was distributed to 79 CSTs and two researchers categorised responses independently, according to Michie’s model of workplace stress.Setting A UK regional postgraduate medical region (Wales).Participants Sixty-three responses were received; 42 males, 21 females. The response rate was 79.7%.Results Inter-rater reliability was good (k=0.792 (79.2%), p<0.001). The most common theme of Michie’s model related to CST stress and burnout was career development, with most statements associated with curriculum, examination and academic demands required to attain a CST certificate of completion of training, and higher surgical national training number appointment. This was closely followed by those intrinsic to the job with recurrent discussion around the difficulties balancing work perceived to be service provision (ward work and on-calls), outpatient clinic and operative experience. Conversely, the most common themes relevant to stress and burnout among female trainees were associated with relationships at work (primarily the male-dominated nature of surgery), extraorganisational factors (family–work life balance) and individual characteristics (personality and physiological differences).Conclusion CSTs’ perceptions regarding the causes of National Health Service related stress and burnout are numerous, and these findings provide a basis for the development of targeted stressor counter-measures to improve training and well-being.

Abstract Aims No employment sector has been more heavily pressed by COVID-19 than healthcare. This study aimed to characterise surgical trainee burnout related to the pandemic, following a previous observational cohort study reporting 59% burnout. Methods A 36-point survey, including the 22-point Maslach Burnout Inventory evaluated emotional exhaustion, depersonalisation, and personal accomplishment amongst all surgical trainees within a UK Statutory Education Body, with responses received from 121 (75 Core (CST), 46 Higher Surgical Trainees (HST)). Results High burnout levels were evident across one, two, or all three domains in 60.3% (n = 73), 32.2% (n = 39) and 13.2% (n = 16), respectively. Median emotional exhaustion, depersonalisation and personal accomplishment scores were 19 (range 0-48), 7 (0-25) and 36 (6-48), respectively. Median emotional exhaustion score was related to age (25-29yr 25 vs. >40yr 4; p = 0.016), trainee grade (CST 23 vs. HST 13; p = 0.001) and parenthood (parents 13 vs. not parents 21; p = 0.011), as was depersonalisation: 9 (25-29yr) vs. 1 (>40yr; p = 0.001), 8 (CST) vs. 6 (HST; p = 0.006) and 5 (parents) vs. 8 (not parents; p < 0.001), respectively. COVID-19 induced curriculum working pattern disruption was observed in 82.6% (n = 100), with 31.4% (n = 38) redeployed away from surgery. Barriers to training and career development were the commonest stressors (71.9%) and more prevalent among younger trainees (25-29yr. 76.8% vs. >40yr. 28.6%; p = 0.045) and CST (80.0% vs. HST 58.7%; p = 0.011). Clinical workload concerns were associated with emotional exhaustion (OR 3.12; p = 0.008). Conclusions Burnout endures, though unique adverse clinical work environments may have boosted resilience. Countermeasures including Enhanced Stress Resilience Training remain a priority.

Abstract Background Oesophageal Cancer (OC) treatment levies substantial financial burden on Health Services and Best Supportive Care (BSC) outcomes are poor. Potentially Curative Surgery with or without Chemotherapy is offered to patients with locally advanced disease and this study aimed to examine treatment costs related to life-years gained in patients having potentially curative treatment (oesophagectomy) and those receiving Best Supportive Care (BSC). Methods Consecutive 179 patients diagnosed with potentially curative adenocarcinoma of the oesophagus between 2010 and 2017 were classified according to treatment modality by intention to treat (surgery vs. neoadjuvant/adjuvant chemotherapy). Cost calculations for one-year’s treatment from referral were made according to network diagnostic, staging, and treatment algorithms. Primary outcome was Overall Survival (OS). Results OC median survival after BSC is reported to be 3 months costing £4391 compared with Oesophagectomy median survival (all stages) of 44 months costing an average of £26,652 for one year’s treatment: BSC cost per QALY £92,448 compared with £12,207.20 for potentially curative surgery. Cost incurred for stage I OC was £25,153.09, stage II £26,795.17, stage III £28,781.81, and stage IV £28,592.64. Based on these values, the cost per Quality Adjusted Life Year (QALY) for stage I OC was - £8,361, II - £12,319, III - £21,998 IV - £35,011. Conclusions Potentially curative treatment that included oesophagectomy improved OS fifteen-fold compared with BSC and was cost effective at national thresholds of readiness to pay per QALY.