ABSTRACT Background There is great potential to improve outcomes of arteriovenous fistulas (AVFs) by focusing more on the preoperative period of AVF creation. We aim to systematically review the evidence on safety and efficacy of various preoperative interventions that have been tried to improve AVF maturation and success rate. Methods We searched five databases: PubMed, Embase, CINAHL, Cochrane Library and King's Fund Library. Experimental studies that investigated the effect of various preoperative interventions to improve AVF outcomes among advanced chronic kidney disease (CKD) patients were searched. The effect size for primary outcome was calculated as the weighted mean difference in the final vessel calibre, rate of AVF maturation or primary failure between the intervention and control arm. We also assessed adverse effects and dropout rates. This review was preregistered in the International Prospective Register of Systematic Reviews (CRD42020193257). Results Eight eligible studies were identified involving three types of intervention: hand exercise (n = 6), cholecalciferol supplementation (n = 1) and pneumatic compression of the arm using a Fist Assist device (n = 1). The overall effect size of hand exercise on distal cephalic vein calibre was 0.24 mm [95% confidence interval (CI) 0.03–0.45] on meta-analysis of hand exercise studies. On restricting analysis to two randomized controlled trials (RCTs) that had independent control groups, the effect size was higher, at 0.29 mm (95% CI 0.11–0.47). Hand exercise was a well-tolerated intervention, especially when confined to the first 4 weeks. Discussion Hand exercise is the predominant intervention tried in the preoperative period of AVF creation, although there is methodological heterogeneity. Intermittent pneumatic compression using a Fist Assist device is a novel intervention that has shown some promise. Well-designed prospective RCTs are needed on preoperative interventions among advanced CKD patients, aimed at improving AVF outcomes.

Introduction Fabry disease (FD) is a lysosomal storage disorder characterised by a deficiency in the enzyme α-galactosidase A resulting in sphingolipid deposition which causes progressive cardiovascular manifestations. Angina is common in FD due to multiple mechanisms, including thickening of fibrocellular intima, narrowing of myocardial capillaries due to sphingolipid inclusion bodies, and demand-supply mis-match in hypertrophy. With improved care, patients are surviving to an age when atherosclerotic disease may contribute to morbidity and mortality. Aims and Methods In a contemporary cohort of FD, the aims of this study are: 1.To examine risk factor profile and control of classical risk factors for atherosclerosis 2.To determine frequency of coronary calcification and obstructive coronary artery disease (CAD)We therefore conducted a retrospective analysis of 47 patients with genotypically confirmed FD established on ERT to assess for conventional risk factors for CAD and prevalence of CAD. Results Demographic characteristics for the cohort are illustrated in Table 1. The average age was 52.4 years (47% female). In total, 13/47 (28%) patients had stage 3–5 CKD and 14/47 (30%) with stage 2 CKD. 32/47 (68%) were on anti-hypertensive medication, 18/47 (38%) were on a statin, and 12/47 (26%) had a total Cholesterol > 5 mmol/L. Within our cohort, 25/47 (53%) patients had a formal assessment of their coronary arteries (see Table 2). 12/47 (26%) underwent an invasive coronary angiogram (ICA) and 13/47 (28%) underwent a computed tomography coronary angiogram (CTCA). Of those who underwent an ICA, 7/12 (58%) had no flow-limiting CAD with the remaining 5 having significant CAD, defined as >50% coronary artery stenosis and/or revascularisation (3/12 required coronary artery bypass grafting (CABG) and 2/12 required percutaneous coronary intervention (PCI)). Although none of the patients studied by CTCA had flow-limiting or significant CAD, 7/13 (54%) had either mild or moderate coronary calcification. 9/13 (69%) had no coronary calcium. Five patients underwent a Technetium-99 m single photon emission computed tomography scan with CT attenuation, 3 of which were normal and 2 which demonstrated fixed perfusion defects in a non-ischaemic pattern in patients without known coronary artery disease (see Figure 1). Conclusions There is high frequency of conventional risk factors in adults with FD It is likely these contribute to accelerated atherosclerosis via a conventional pathophysiological process. This emphasises the clinical importance of control of conventional risk factors. References 1. Roy A, Umar H, Ochoa-Ferraro A, Warfield A, Lewis N, Geberhiwot T, et al. Atherosclerosis in Fabry Disease-A Contemporary Review. J Clin Med. 2021;10(19). Conflict of Interest NONE

INTRODUCTION:Coronary artery perforation (CP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI). This study aimed to assess the incidence, management and outcomes of CP over time.METHODS:A single-centre retrospective cohort study of all PCIs performed between January 2010 and December 2020. Patients with CP were divided into two cohorts (A+B), representing the two halves of the 11-year study.RESULTS:The incidence of CP was 68 of 9701 (0.7%), with an increasing trend over the two 5.5-year periods studied (24 of 4661 (0.5%) vs 44 of 5040 (0.9%); p=0.035). Factors associated with CP included chronic total occlusions (CTOs) (16 of 68 (24%) vs 993 of 9633 (10%); p<0.001), type C lesions (44 of 68 (65%) vs 4280 of 9633 (44%); p<0.001), use of intravascular ultrasound (IVUS) (12 of 68 (18%) vs 541 of 9633 (6%); p<0.001), cutting balloon angioplasty (3 of 68 (4%) vs 98 of 9633 (1%); p<0.001) and hydrophilic wires (24 of 68 (35%) vs 1454 of 9633 (15%); p<0.001). Cohorts A and B were well matched with respect to age (69±11 vs 70±12 years; p=0.843), sex (males: 13 of 24 (54%) vs 31 of 44 (70%); p=0.179) and renal function (chronic kidney disease: 1 of 24 (4%) vs 4 of 44 (9%); p=0.457). In cohort A, CP was most frequently caused by post-dilatation with non-compliant balloons (10 of 24 (42%); p=0.009); whereas in cohort B, common causes included guidewire exits (23 of 44 (52%)), followed by stent implantation (10 of 44 (23%)). The most common treatment modality in cohorts A and B was balloon inflation, which accounted for 16 of 24 (67%) and 13 of 44 (30%), respectively. The use of covered stents (16%) and coronary coils (18%) during cohort B study period did not impact all-cause mortality, which occurred in 2 of 24 (8%) and 7 of 44 (16%) (p=0.378) in cohorts A and B, respectively.CONCLUSION:The incidence of CP is increasing as more complex PCI is performed. Factors associated with perforation include CTO or type C lesions and use of IVUS, cutting balloon angioplasty or hydrophilic wires.

Burn dressings play a vital role in protecting the patient from infection and aiding in the wound healing process. At present, the best burn wound dressing remains unknown. This study aimed to assess the efficacy of honey versus silver sulfadiazine dressing (SSD) for the treatment of superficial and partial thickness burns. We performed a systematic review and meta-analysis using the PubMed, MEDLINE and Embase databases to find relevant randomised control trials (RCTs) for inclusion. The outcomes measures included complete burn wound healing time, the proportion of wounds rendered sterile and subjective pain relief associated with the respective dressing type. This review was completed in line with PRISMA guidelines and has been registered with PROSPERO (Study ID: CRD42022337433). All studies in the English language that assessed honey versus SSD for patients with superficial or partial thickness burns were included. Quality and risk of bias assessments were performed using the Cochrane RoB2 tool. Seven studies were identified: totalling a population of 582 patients. From three studies, meta-analysis showed no significant difference in complete wound healing time (p = 0.06). Meta-analysis from five studies highlighted an overall significant difference favouring honey dressing in the proportion of wounds rendered sterile at day 7 post-injury (OR 10.80; 95% CI [5.76, 20.26]; p < 0.00001; I2 = 88%). We conclude that honey dressings may be as or more effective than SSD in the treatment of superficial and partial thickness burn injuries. However, due to the low quality of available studies in this field, further research is necessary to establish the optimum burn dressing. Ideally, this should be conducted in the form of prospective three-arm RCTs in accordance with the CONSORT statement.

Fabry disease (FD) is a lysosomal storage disorder characterised by a deficiency in the enzyme α-galactosidase A resulting in sphingolipid deposition which causes progressive cardiac, renal, and cerebral manifestations. The case illustrates a patient with FD who died suddenly, and medical examination demonstrated myocardial scarring and prior infarction. Angina is a frequent symptom in FD. Our own data are consistent with registry data indicating a high prevalence of risk factors for coronary artery disease (CAD) in FD that may accelerate conventional atherosclerosis. Patients with FD also have a higher high-density lipoprotein (HDL)/total cholesterol (T-Chol) ratio which may further accelerate atherosclerosis through expression of early atherosclerotic markers. Patients with FD may develop CAD both via classical atherosclerosis and through formation of thickened fibrocellular intima containing fibroblasts with storage of sphingolipids. Both mechanisms occurring together may accelerate coronary stenosis, as well as alter myocardial blood flow. Our data supports limited data that, although coronary flow may be reduced, the prevalence of epicardial coronary stenosis is low in FD. Microvascular dysfunction and arterial wall stress from sphingolipid deposition may form reactive oxygen species (ROS) and myeloperoxidase (MPO), key atherosclerotic mediators. Reduced myocardial blood flow in FD has also been demonstrated using numerous imaging modalities suggesting perfusion mismatch. This review describes the above mechanisms in detail, highlighting the importance of modifying cardiovascular risk factors in FD patients who likely develop accelerated atherosclerosis compared to the general population.

Despite trauma-related injuries being a leading cause of death worldwide, low- and middle-income countries (LMICs) lack the infrastructure and resources required to offer immediate surgical care, further perpetuating the risk of morbidity and mortality. In high-income countries, trauma surgery simulation courses are routinely delivered to surgeons, teaching the fundamental skills of operative trauma. This study aimed to assess whether similar courses are beneficial in LMICs and how they can be improved. We performed a systematic review and meta-analysis using MEDLINE, Embase and Google Scholar, analysing studies evaluating trauma surgery simulation in LMICs. The outcomes measured included clinical knowledge improvement, participant confidence and general course-feedback. The review was carried out in-line with PRISMA guidelines. Five studies were included, summating a population of 172 participants. In three studies, meta-analysis showed an overall significant weighted mean improvement of knowledge post-course by 22.91% (95%CI 19.53, 26.29; p < 0.00001; I2 = 0%). One study reported a significant increase in participant confidence for 20/22 of operative skills taught (p < 0.04). We conclude that these courses are beneficial in LMICs; however, further research is necessary to establish the optimum course design, and whether patient outcomes are improved following their implementation. Collaboration between international trauma institutions is essential for closing the educational resource inequality gap between higher- and lower-income countries.

We thank Bass and colleagues for their interest in our paper on “Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: A systematic review and meta-analysis” [ [1] Kamarajah S.K. Gujjuri R.R. Elhadi M. et al. Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: a systematic review and meta-analysis. Eur J Surg Oncol. 2021; (Mar 27)https://doi.org/10.1016/j.ejso.2021.02.030 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ]. We appreciate the comments given and following are our responses. Increased perioperative morbidity and mortality following oesophagectomy in older patients: Time for a patient-centered conversationEuropean Journal of Surgical OncologyVol. 47Issue 10PreviewWe read with interest “Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: A systematic review and meta-analysis”, recently published in the Journal. Kamarajah and colleagues set out to synthesize published evidence to determine an impact of advanced age on postoperative outcomes following esophagectomy for malignancy.[1] The optimal management of elderly patients with oesophageal cancer assumes increasing importance in an aging population demographic, and the authors are to be commended for their contribution to this conversation. Full-Text PDF

ABSTRACT Background Patients receiving dialysis for end-stage kidney disease (ESKD) commonly co-exhibit risk factors for hepatic impairment. This systematic review and meta-analysis aimed to quantify the coexistence of chronic liver disease (CLD) and characterize risk factors and outcomes. Methods We searched the following databases from inception to May 2021: CINAHL, Cochrane Library, Embase, Kings Fund Library, MEDLINE and PubMed. The protocol was pre-registered on PROSPERO (study ID: CRD42020206486). Studies were assessed against three inclusion criteria: adults (>18 years) with ESKD receiving dialysis, primary outcome involving CLD prevalence and publications in English. Moderator analysis was performed for age, gender, study size and publication year. Sensitivity analysis was performed where applicable by removing outlier results and studies at high risk of bias. Results Searches yielded 7195 articles; of these 15 met the inclusion criteria. A total of 320 777 patients were included. The prevalence of cirrhosis and non-alcoholic fatty liver disease (NAFLD) was 5% and 55%, respectively. Individuals with CLD had 2-fold higher mortality than those without {odds ratio [OR] 2.19 [95% confidence interval (CI) 1.39–3.45]}. Hepatitis B [OR 13.47 (95% CI 1.37–132.55)] and hepatitis C [OR 7.05 (95% CI 4.00–12.45)], but not diabetes, conferred increased cirrhosis risk. All studies examining NAFLD were judged to be at high risk of bias. We found no data on non-alcoholic steatohepatitis (NASH). Deaths from CLD, cancer and infection were greater among cirrhotic patients. Conclusions CLD is prevalent in dialysis patients. Hepatitis B and C confer increased risk of CLD. The impact of NAFLD and NASH cirrhosis requires further study. CLD is associated with an increased risk of mortality in this setting.

Background Coronary artery perforation (CAP) is a life-threatening complication of percutaneous coronary intervention (PCI). This study aims to identify CAP predictors using contemporary data. Methods Retrospective cohort study on all PCIs performed at the Queen Elizabeth Hospital, Birmingham between January 2010 and October 2020. Patient demographics, comorbidities, modified Ellis perforation class and perforation treatments were collected. The CAP population was split into two cohorts (1 and 2), representing the first and second 5-year period in the decade. Results During a 10-year period, 9,504 PCI procedures were performed with CAP occurring in 66 cases. According to the Ellis criteria, 4.5% of CAPs were type I, 13.6% type II, 45,5% type III, and 34.8% type V. Definitive management included balloon inflation only in 27%, covered stents 20%, conservative 20%, balloon inflation with heparin reversal 12%, coronary coils 12%, heparin reversal 4.5%, emergency surgery 3%, coil and covered stent 1.5%. Overall mortality within the total perforation cohort was 14%. Emergency pericardiocentesis was required in 13 patients; in this group mortality was 46%.The difference in trends is illustrated in the table 1. Conclusion The data demonstrates increased incidence of CAP and mortality in the second half of the decade. This may be explained by an increase in CTO, rotablation and IVUS use (surrogates for complex PCI) and an older population with more comorbidities. Cardiac tamponade was associated with a higher mortality in those with CAP. Conflict of Interest none

Background: Although oesophagectomy remains technically challenging and associated with high morbidity and mortality, it is now increasingly performed in an ever-ageing population with improvement in perioperative care. However, the risks in the elderly population are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of oesophagectomy for cancer in the elderly population compared to younger patients. Method: A systematic literature search of PubMed, EMBASE and the Cochrane Library databases was conducted including studies reporting oesophagectomy for cancer in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were pulmonary and cardiac complications, anastomotic leaks, overall and disease-free survival. Results: This review identified 37 studies incorporating 30,836 patients. Increasing age was significantly associated with increased rates of overall complications (OR 1.67, CI95%: 1.42-1.96), pulmonary complications (OR 1.87, CI95%: 1.48-2.35), and cardiac complications (OR: 2.22, CI95%: 1.95-2.53). However, there was no increased risk of anastomotic leak (OR: 0.98, CI95%: 0.85-1.18). Elderly patients were significantly more likely to have lower rates of 5-year overall survival (OR: 1.36, CI95%: 1.11-1.66) and 5-year disease-free survival (OR: 1.72, CI95%: 1.51-1.96). Conclusion: Elderly patients undergoing oesophagectomy for cancer are at increased risk of overall, pulmonary and cardiac complications, irrespective of age subgroups, albeit no difference in anastomotic leaks. Therefore, they represent high-risk patients warranting implementation of preoperative pathways such as prehabilitation to improve cardiopulmonary fitness prior to surgery, although benefit of prehabilitation is yet to be proven. This information will also aid future pre-operative counselling and informed consent. (C) 2021 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

The General Medical Council (GMC) and Medical Leadership Competency Framework (MLCF) recommend that medical students should be taught about core management and leadership (MLM) topics, such as service evaluation which includes audits and quality improvement projects (QIP). This study, based on an audit cycle, aimed to assess whether medical students receive formal teaching on MLM topics such as audits and whether a student-led society could successfully provide supplementary teaching for MLM topics. An online teaching session was run by Birmingham Medical Leadership Society (BMLS), led by two medical students with extensive experiences with service evaluation. An anonymous evaluation form was used to measure pre- and post-session understanding of service evaluation. This was done via a 5-point Likert scale to self-rate theoretical and practical knowledge. A statistical analysis was then conducted, including a two-tailed t-test. In attendance were 97 people, most (n=89) were medical students from all year groups and universities from the UK and abroad. 91% of participants completed the form and stated they had never had formal teaching, with 89% having not previously completed an audit/QIP. Self-reported prior knowledge was low (mean 2.3/5), with practical knowledge lower than theoretical (mean 1.9/5 vs 2.9/5). Post-session, participants knowledge statistically significantly (p<0.001) increased by 87% (mean 2.3/5 to 4.3/5) with a greater self-reported increase in practical knowledge compared to theoretical (109%: 56.6%). Most students highlighted they had not received formal teaching on service evaluation as part of their curriculum, despite GMC and MLCF guidance. The study suggests that student-led medical societies can successfully help to deliver and complement teaching on these topics. With various medical students attending from across various institutions in attendance, this demonstrates the importance and interest of students to engage with service evaluation.