Early Closure Research Articles

Clinical and Oncological Impact of a Protective Ileostomy in Rectal Cancer Patients Undergoing Adjuvant Chemotherapy.

During low anterior rectal resection for rectal cancer, a protective ileostomy (PI) is routinely created to reduce the severity of anastomotic complications. The aim of this study was to investigate the side-effects of PI during adjuvant chemotherapy. A retrospective cohort of patients was operated on for non-metastatic rectal cancer with a PI during 2005-2022. Patients treated with adjuvant chemotherapy (AC) were compared with those not receiving AC. A subgroup analysis compared patients with early PI closure (<10 weeks) and those with a PI in place during chemotherapy. A total of 242 patients were included: 178 (73.6%) without adjuvant chemotherapy and 64 (26.4%) with. History, tumour location, neoadjuvant treatment and postoperative follow-up were similar for both groups. Patients treated with AC had a greater risk of renal failure (37.5% vs. 14.6%, p=0.0002), ionic disorders (45.3% vs. 26.9% p=0.008), malnutrition (23.4% vs. 5.6%, p=0.0002) and rehospitalization (35.9% vs. 18.5% p=0.007). Patients treated with AC needed significant dose adjustments of oxaliplatin in 40.6% of cases, this adjustment being higher in patients with a PI compared to patients with early closure (47.1 vs. 9.1%, p=0.021). Presence of a PI during chemotherapy predisposes to increased episodes of renal failure, and requires major adaptation of chemotherapy doses, especially of oxaliplatin.

Impact of the laparoscopic approach, early closure and preoperative stimulation on outcomes of ileostomy closure after rectal resection

AimTo evaluate the clinical outcome of early closure of a protective ileostomy and preoperative stimulation of the efferent limb in a cohort of patients with rectal cancer treated surgically, primarily using the laparoscopic approach. MethodsWe performed an observational retrospective cohort study in a prospectively recorded series of patients with rectal cancer who underwent laparoscopic surgery with a protective loop ileostomy between 2017 and 2022. Ileostomy closure was programmed for within 3 months after surgery. All patients underwent stimulation of the efferent limb. Primary outcomes were morbidity and mortality, length of stay (LOS), and re-admission. ResultsBetween 2017 and 2022, 108 patients underwent resection for rectal cancer and protective ileostomy. The laparoscopic approach was performed in 84.3% of patients (n = 91). Permanent ileostomy was performed in 5 patients (4.6%). Ileostomy closure was thus performed in 95.4% of patients (n = 103). Median time to closure was 74.5 days (range 57–113). In 63.1% (n = 65) of patients, reconstructive surgery was performed within 90 days. Prior to closure, efferent limb stimulation was performed in 77.8% (n = 84) of patients. Global morbidity was 26.2% (n = 27) (85.19%, n = 23 Clavien-Dindo I and 7.41%, n = 2 Clavien-Dindo II). The main causes of morbidity were postoperative ileus (10.7%, n = 11) and rectal bleeding (8.7%, n = 9). Anastomosis leakage occurred in 2 patients. Median hospital stay was 6 days (5–7). Readmission was needed in 6.8% (n = 7) of patients. ConclusionA previous laparoscopic approach, early closure and stimulation of the efferent limb could be a useful strategy to reduce the morbidity and mortality of temporary ileostomy closure.

Cleft Lip and Palate Correction: The Utah Protocol.

Cleft repair remains a contentious issue in craniofacial surgery, especially regarding the optimal timing and techniques. This study aims to present our institutions' current protocol for cleft lip and palate repair, including alveolar bone grafting (ABG). A total of 17 patients (20 clefts) treated with the latest protocol from 2016 to 2023 were evaluated. Demographic and clinical data were obtained from electronic charts. The protocol includes lip repair at 3 months, soft palate repair at 1 year, and hard palate closure with concurrent ABG at 2 years. Mean graft height and thickness scores were 2.3 and 2.2, respectively. Three clefts showed scores marginally below the threshold for thickness, potentially requiring regrafting. Malocclusion was minimal with no significant crossbites or velopharyngeal insufficiency. Our modified protocol, emphasizing early hard palate closure with ABG, yields satisfactory outcomes in terms of graft height and thickness. Although long-term follow-up is warranted, our approach seems safe and efficient, potentially improving outcomes compared with traditional methods.

Oxygen-generating hydrogels combined with electrical stimulation: A dual approach for promoting diabetic wound healing

Chronic wounds resulting from hyperglycemia and hypoxia are common complications in diabetic patients, posing significant challenges for clinical treatment. In this study, we developed a hydrogel (PVNP-SP) using [VBIM]Br, NIPAM, PEGDA, and spirulina, which exhibited strong antioxidant properties. The incorporation of [VBIM]Br endowed the hydrogel with electrical conductivity, allowing it to activate voltage-gated ion channels under an external electric field, thereby promoting cell survival and migration. The hydrogel also enhanced cellular antioxidant capacity by providing sustained oxygenation, inhibiting HIF-1α nuclear translocation, and activating the Nrf2/HO-1 pathway. Notably, in a chronic wound model, the combined effects of oxygen production and electrical stimulation from the PVNP-SP hydrogel significantly reduced wound inflammation, promoted collagen deposition and angiogenesis, and facilitated early wound closure. This therapeutic strategy, which mitigates hypoxia while integrating electrical stimulation, offers a highly effective strategy for improving chronic wound healing in diabetic patients. Statement of significanceInspired by photoautotrophic organisms, we combined microalgae with a conductive hydrogel and we demonstrated the synergistic promotion of chronic wound healing by electrical stimulation combined with microalgae oxygen-producing hydrogel. The approach of combining microalgae hydrogel patches with electrical stimulation demonstrates the feasibility of delivering oxygen to tissues while combining electrical stimulation for synergistic tissue repair. The hydrogel is easy to fabricate and handle, and may be suitable for a variety of treatments, such as myocardial infarction, lower limb ischemia, and drug delivery. The potential applicability of this hydrogel in a variety of treatments suggests that it has promising applications in regenerative medicine.

Accelerated Wound Healing of Tetrahedral-Framework Nucleic Acid Nanozymes with High Penetration and Antioxidant Capacity.

The wound repair process usually leads to a non-functioning mass of fibrotic tissue because of the oxidative imbalance of deep tissue layers. However, how to improve the penetration of active ingredients into deeper layers and regulate oxidative imbalances to create a regenerative microenvironment still remains a challenge. In this study, we designed a novel tetrahedral-framework nucleic acid (tFNA) nanozyme that could penetrate the skin/mucosa barrier as deep as 450 μm within 24 h. We also demonstrated the protective role of tFNAs on the mitochondrial structural and functional integrity and inhibition of reactive oxygen species production to repair oxidative imbalances through ERK1/2-Nrf2-HO-1 during repair processes. It was found that the proliferative state and the migration ability of postburn cells in vitro were accelerated, and the early closure of wounds in vivo was significantly promoted. This study therefore provides a promising strategy to efficiently regulate the oxidative imbalances in the deep layers of the skin during wound healing.

Safety and feasibility of transcatheter closure of atrial septal defects in small children weighing less than 10 kg.

When young patients with an oval fossa defect present early with symptoms of heart failure and pulmonary hypertension, surgical treatment is recommended in small bodyweight rather than transcatheter closure. Outcomes of device closure in consecutive symptomatic children weighing under 10 kg were compared with young children aged below 4 years but weighing above 10 kg. Transthoracic echocardiography under conscious sedation guided the procedure in all without need for balloon sizing, transesophageal echocardiogram, and intubation anaesthesia. Symptoms, anthropometry, shunt ratio, pulmonary pressures, defect and device size, percentage oversizing, device/body weight ratio, complications, and post-procedural growth spurt were compared. Ninety-six patients weighing under 10 kg were compared with 160 patients weighing above 10 kg. In total, 83.3% of patients in the study group and 25% of controls were severely malnourished. The median indexed defect size was 35.2 mm/sq.m and 27.4 mm/sq.m, and the device was oversized by 8.7% and 14.2% in the study group and controls, respectively. The device/body weight ratio was 1.93 in study group and 1.4 in controls. Procedure was successful in all except one patient weighing under 10 kg who had a device embolisation. Both groups showed significant growth spurts and proportion, with severe malnutrition reduced to 42% and 11% in the two groups. Device closure was feasible and safe in patients under 10 kg. Transthoracic echocardiographic imaging on conscious sedation provided adequate guidance. Symptoms and growth significantly improved after intervention. Despite a larger defect size, smaller patients had comparable outcomes. In symptomatic children under 10 kg needing early closure, transcatheter intervention should not be deferred.

Combined local flap placement and negative-pressure wound therapy for the management of critical peritracheostomal pharyngocutaneous fistula

ObjectivePeritracheostomal pharyngocutaneous fistula (PCF), a direct connection between the PCF and tracheal stoma due to a skin defect, is among the most problematic complications after total laryngectomy or pharyngolaryngectomy. Peritracheostomal PCFs can cause lethal complications, including severe pneumonia or carotid blowout, secondary to salivary leakage directly into the tracheal stoma, and their management is challenging without early invasive surgical closure. We aimed to evaluate the utility of our novel and minimally invasive combined local skin flap placement and negative-pressure wound therapy (NPWT) method for the management and conservative closure of peritracheostomal PCFs. MethodsWe retrospectively enrolled patients who developed a peritracheostomal PCF from July 2015 to September 2021 at our institution and affiliated hospitals. Postoperative PCFs were all initially managed with appropriate wound bed preparation. Subsequently, a small local flap of healthy, lower neck skin was elevated and transferred anterior to the PCF to replace the peritracheostomal skin defect. The flap served to provide a sufficient surface for film dressing attachment and facilitated airtight sealing during NPWT. We initiated NPWT after confirming the local skin flap was firmly sutured to the tracheal mucosa. A flexible hydrocolloid dressing was applied to the peritracheostomal skin flap, and a film dressing was placed on the flexible hydrocolloid dressing and surrounding cervical skin. We inserted the NPWT foam shallowly into the fistula tract and applied negative pressure (73.5–125 mmHg). NPWT was continued until the PCF was closed or became so small that salivary leakage was minimal and could be managed by conventional compression dressings. ResultsWe enrolled six patients [male, n = 6; mean age, 66.5 years (range, 57–80 years)]. NPWT was applied for an average of 18.2 days (range, 2–28 days). During NPWT, air leakage occurred once (2 cases), only a few times (2 cases), or not at all (2 cases). In all patients, complete fistula closure was achieved in an average of 28.2 days (range, 15–55 days) after the start of NPWT, and no patient required further surgical intervention. There were no lethal complications (e.g., severe pneumonia) during treatment. ConclusionOur method of combined local flap placement and NPWT enabled effective management of salivary aspiration and accelerated wound healing, which allowed conservative fistula closure in all patients. We believe combined local flap placement and NPWT should be considered a first-line treatment for intractable peritracheostomal PCF.

Timing of Stoma Closure in Neonates: the ToSCiN mixed-methods study.

Neonates undergoing emergency abdominal surgery frequently require a stoma; closing this stoma with a second operation is an essential part of recovery. Timing of closure varies. Optimal timing is unclear and would be best resolved through a randomised controlled trial; such a trial is likely to be challenging. To determine if it is feasible to conduct a clinical trial comparing 'early' versus 'late' stoma closure in neonates. Mixed methods comprising three parallel workstreams incorporating: a clinician survey, prospective observational cohort study, parent interviews, focus groups, database analyses and consensus meeting. Specialist neonatal surgical centres across the United Kingdom. Neonatologists, neonatal surgeons, neonatal dietitians and neonatal nurses who care for neonates with stomas. Neonates with recent stoma, their parents and the clinicians looking after them. Three existing, overlapping clinical databases. One hundred and sixty-six professionals from all 27 neonatal surgical centres completed the survey: 6 weeks was the most common target time for stoma closure across clinical scenarios, although there was wide variation. Timing of closure was influenced by nutrition, growth and stoma complications. The prospective cohort study enrolled 56 infants from 8 centres. Infants were mostly preterm with necrotising enterocolitis or intestinal perforation. Clinicians identified extreme preterm gestation and clinical conditions as reasons for not randomising babies into a hypothetical trial comparing early and late stoma closure. Parents and healthcare professionals identified that comparator arms needed more clinical flexibility in relation to timing of stoma closure. Analysis of existing databases revealed wide variation in current timing of stoma closure in neonates and identified approximately 300 eligible infants for a trial per annum in the United Kingdom. A trial of 'early' compared to 'late' stoma closure in neonates is feasible and is important to families and health professionals. The population of eligible babies in the United Kingdom is sufficient for such a trial. Challenges centre around lack of equipoise in certain scenarios, specifically: extremely preterm infants; infants waiting too long for stoma closure in the 'late' comparator; and logistical issues in closing a stoma at a trial-allocated time. These challenges are addressable by incorporating flexibility based on gestation at birth, communicating that both trial arms are standard practice and valid treatment options, and providing resources, for example, for operating lists. We recommend the following population, intervention, comparator and outcome as a starting point to inform future trial design. Population: neonates with stomas (excluding those with a fixed treatment pathway). Intervention: stoma closure at 6 weeks and after 32 weeks post conceptual age. Comparator: expectant management with stoma closure undertaken when the clinical team determines is best for the infant. Primary outcomes: weight gain/growth or length of hospital stay. This study is registered as IRAS Project ID 278331, REC Reference 20/LO/1227. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128617) and is published in full in Health Technology Assessment; Vol. 28, No. 71. See the NIHR Funding and Awards website for further award information.

Influence of procedural timing on the preventive yield of percutaneous patent foramen ovale closure

BackgroundThe benefit of patent foramen ovale closure (PFOC) ≤9 months after a cryptogenic stroke has been demonstrated in several randomised clinical trials. There is, however, insufficient data to support PFOC...

The Safety and Efficacy of Hypertonic Saline in Achieving Primary Fascial Closure Following Damage Control Laparotomy: A Systematic Review and Meta-Analysis.

Effective fluid management is critical in patients undergoing damage control laparotomy (DCL) for trauma and sepsis. Hypertonic saline (HTS) has been proposed as an alternative to isotonic fluids to enhance primary fascial closure rates and optimize fluid balance. This systematic review and meta-analysis aimsto evaluate the efficacy and safety of HTS compared to isotonic fluids in patients undergoing DCL. A comprehensive literature search was conducted across multiple databases up to the 14thof June 2024, identifying studies that compared HTS to isotonic fluids in adult patients undergoing DCL for trauma or sepsis. Eligible studies included randomized controlled trials and observational studies reporting outcomes such as early primary fascial closure (EPFC) rates, time to fascial closure, fluid requirements, electrolyte imbalances, renal function, and mortality. Data extraction and quality assessment were performed independently by two reviewers, and pooled analyses were conducted using fixed-effectmodels where appropriate. Four studies encompassing 375 patients met the inclusion criteria, with 100 patients receiving HTS and 275 receiving isotonic fluids. HTS administration was associated with a significantly higher EPFC rate compared to isotonic fluids (odds ratio (OR): 0.314; 95% confidence interval (CI): 0.142-0.696; p=0.004). The mean time to fascial closure was also significantly reduced in the HTS group by approximately eight hours (mean difference (MD): 8.007 hours; 95% CI: 5.558-10.596; p<0.001). Patients receiving HTS required significantly less total fluid over 48 hours (MD: 1.055 liters; 95% CI: 0.713-1.398; p<0.001). While HTS use led to higher peak sodium levels (MD: -4.318 mEq/L; 95% CI: -4.702 to -3.934; p<0.001), there were no significant differences in peak creatinine levels, need for inpatient renal replacement therapy, or 28-day mortality between the groups. HTS appears to be effective in improving EPFC rates and reducing both time to closure and overall fluid requirements in patients undergoing DCL for trauma and sepsis. Although associated with higher serum sodium levels, HTS did not increase the risk of renal dysfunction or mortality. These findings suggest that HTS is a safe and efficacious alternative to isotonic fluids in the management of critically ill patients requiring DCL. Further large-scale, randomized controlled trials are warranted to confirm these results and inform clinical guidelines.

Clinical and histological study of cold physical plasma jet in treatment of full thickness skin wounds of normal and diabetic dogs.

To study the effect of physical plasma jet in treating open wounds in diabetic and non-diabetic dogs. The experimental study was conducted at the College of Veterinary Medicine, University of Baghdad, Iraq, from 20 January, 2020 to 1st May 2020, according to (no. 1364/ P.G), and comprised adult male diabetic and nondiabetic dogs. They were divided into non-diabetic group N and diabetic group D. Each group was further divided into treatment subgroup T and control subgroup C. Each dog was subjected to 4 wounds 3×3cm in size. Homemade helium non-equilibrium atmospheric pressure plasma jet therapy was used for healing purposes. Clinical parameters were evaluated by observation, while histological images were scored based on the semi-quantitative evaluation of histological sections on days 3-, 7- and 21-days post-wound. Data was analysed using SPSS Version 26 with One-way ANOVA for statistical analysis between groups and sub-groups. Of the 24 dogs, 12(50%) were in each of the two groups, which were further divided into subgroups having 6(50%) dogs each. The therapy accelerated the process of wound healing in the NT and DT subgroups compared to NC and DC. Clinical observations revealed early and complete closure of plasma-treated wounds in NT and DT subgroups started at day 30 post-wounding, while in the NC subgroup it started at day 35, and in the DC subgroup, wounds failed to close even after 35 days post-wounding. Histological analysis suggested that a plasma jet supported epithelisation, angiogenesis, formation of new hair follicles and collagen fibres, while it also controlled inflammation. In addition, in NT and DT subgroups, it increased the proliferation of fibroblasts and deposition of collagen, and there is a very, highly significant difference between groups (P<0.001), and a significant difference between days (P<0.05). Home-made helium non-equilibrium atmospheric pressure plasma jet therapy improved the quality and pace of wound healing.

Enhancing early-stage healing responses through the modified "Poncho" technique in customized titanium mesh-mediated bone regeneration: A soft tissue management approach-case series.

Soft tissue management is critical in bone augmentation surgery to prevent wound dehiscence. Several strategies for passive tissue primary closure have been explored. This article introduces a flap design known as the modified "Poncho" technique (MPT), integrated with customized titanium mesh-mediated bone regeneration, and investigates the healing quality during the initial stages of an incision. The cohort consisted of 5 patients undergoing customized bone regeneration procedures, concerned primarily with the successful integration and healing of the augmented bone site without complications such as wound dehiscence or infection. All patients were diagnosed with insufficient bone volume requiring augmentation to support future dental implants, necessitating the use of customized titanium mesh for guided bone regeneration. The MPT was detailed and applied during the customized bone regeneration procedures. Postoperative evaluations included recording complications and using Landry's healing index at intervals of 3, 7, 14, and 30 days post-surgery to assess the technique's performance in early wound closure. The study found that 95.7% of surgery sites experienced uneventful soft tissue healing within the observation period. Only 1 of 23 sites exhibited partial wound dehiscence at postsurgical days 14 and 30, accompanied by mild inflammation. The Landry's healing index increased from 3 ± 0.47 to a final value of 4.69 ± 1.06, indicating substantial improvement in healing over time. The MPT shows promise as an innovative approach for promoting passive and predictable primary wound closure beneath a digitally customized titanium mesh for bone regeneration, demonstrating a high rate of successful healing and minimal complications during the early postoperative phase.

Evaluation of Full Thickness Wounds Following Application of a Visco-Liquid Hemostat in a Swine Model.

Wound healing is a complex dynamic biomechanical process as the body attempts to restore the integrity of traumatized or devitalized tissues. There are four stages of wound of healing that begins with hemostasis followed by inflammation, proliferation and finally weeks later wound remodeling. Full thickness wounds usually are covered with a dressing material after hemostasis, which allows for controlled hydration. We investigated the potential of a visco-liquid hemostat, polyhedral oligomeric silsesquioxane (POSS), for providing hemostasis and to maintain a microenvironment in the wound bed that would maintain moisture content and promote early re-epithelialization. We hypothesized that the hemostatic agent POSS if left in the wound bed would maintain a protective barrier and accelerate wound healing similar to using saline to irrigate the wound to keep the wound moist. We compared the early phase of wound repair (3-7 days) in a porcine full thickness wound model to evaluate the efficacy of the material. Biopsies were taken after 3 and 7 days to determine the acute response of the POSS hemostat or saline on inflammation, cell migration, concentrations of metalloproteinase (MMPs), and tissue inhibitors of metalloproteinase (TIMPs). Accelerated healing was observed in POSS treated wounds by changes in wound contraction, keratinocyte migration, and development of granulation tissue in comparison to saline treated wounds. Increased concentrations at day 3 of MMP-2, MMP-3, and in MMP-1 at day 7 in POSS treated wounds compared to saline coincide with keratinocyte migration observed in the tissue histology and changes in wound contraction. Tissue concentrations of TIMP-1 and TIMP-2 in POSS treated wounds appear to coordinate the sequence of MMP events in the healing tissue. Matrix metalloproteinase-13, a marker for tissue remodeling, was not upregulated in the early wound healing cascade in either POSS or saline treated wounds at 3 or 7 days. Overall, the data suggests POSS treatment contributed to enhanced early cell migration and wound closure compared to saline treatment.

Impact of Candidemia on Survival Rates in Major Burn Patients: A Retrospective Study from the South of Türkiye

Abstract Objective In severely burned patients, fungal infections are among the most devastating complications. Candidemia is an important cause of mortality with an increasing incidence despite advances in burn care management. Higher affected body surface area, long intensive care unit (ICU) stay, flame burn, third-degree burn, and previous bacterial infections were associated with the development of candidemia. Candidemia in patients with major burns admitted to an ICU of a tertiary burns center is investigated. Methods Patients hospitalized in the ICU of Adana City Training and Research Hospital from July 1, 2017, to November 10, 2020, were included. The demographic and clinical variables, the Candida species isolated from blood cultures and their antifungal susceptibilities, need for grafting, complications, and rate of mortality are evaluated retrospectively. Patients were grouped as “candidemia” or “noncandidemia” according to whether or not they experienced Candida bloodstream infection. Results A total of 371 patients were included; the mean age was 22.02 ± 20.9 years. Most patients were male (69.5%). The percentage of burned surface area was 25.93 ± 17.6. The mean ICU stay was 16.95 ± 16.3 days. There were 90 candidemia episodes in 69 patients. The most commonly isolated Candida species were C. parapsilosis, C. tropicalis, and C. albicans. The mortality rates in the candidemia and noncandidemia groups were 24.6 and 5.6%, respectively (p &lt; 0.001). Conclusion Adhering to isolation rules, early wound debridement and closure, avoidance of catheters where possible, and avoidance of the early use of broad-spectrum antibiotics are important measures in reducing candidemia in patients with major burns. Candidemia was associated with greater burn surface areas, duration of hospital stay, and larger numbers of interventional procedures. However, previous bacterial infection receiving prolonged antibiotic therapy was the greatest risk factor of candidemia. Culture results are important to select the antifungal agent with high susceptibility, but results are not rapidly available. There is need for early clinical prediction measures to inform early and effective antifungal treatment.

The Impact of the Chlorhexidine Gel (WISDOM®) on Postoperative Sequelae Associated with the Surgical Removal of Impacted Mandibular Third Molars: A Randomized Controlled Clinical Trial

Background: One of the most prevalent procedures in oral surgery is the removal of impacted mandibular third molars, typically accompanied by trismus, edema, and pain. Several methods and biomaterials were implemented to mitigate or avoid these surgical problems. Objectives: To evaluate the efficiency of chlorhexidine gel (WISDOM®) in minimizing postoperative sequelae associated with the impacted mandibular third molar that will be surgically extracted and its role in promoting early soft tissue closure of the surgical site. Methods: The study design was a double-masked and randomized, controlled clinical study that included healthy patients needing the removal of a mandibular third molar through surgery. The participants were randomly assigned to two groups. The extraction site of the study group was filled with a mixture of gel foam and WISDOM®. In contrast, we filled the extraction sites of the control group patients with gel foam and sutured the surgical sites for both groups. The patients were evaluated on the first, third, and seventh postoperative days for pain, swelling, trismus, and early soft tissue healing. Results: Sixty eligible patients were enrolled in this study. The study group exhibited a statistically significant decrease in pain, edema, trismus, and early soft tissue healing on the first, third, and seventh postoperative days compared to the control group. Conclusions: WISDOM® gel can effectively reduce postoperative pain, trismus, and swelling and promote early soft tissue healing after surgical removal of an impacted mandibular wisdom tooth.

Impact of injury mechanism on early wound closure in patients with acute conflict-related extremity wounds: A prospective cohort analysis from two civilian hospitals in Iraq and Jordan.

Gunshots and bomb blasts are important causes of extremity injuries in conflict zones, yet little research exists on the characteristics and outcomes of these injuries in civilian populations. We performed a prospective cohort analysis utilizing data from a randomized trial conducted at two civilian hospitals in Jordan and Iraq in 2015-2019. Adults who presented ≤72h of sustaining an extremity injury were included. We used mechanism of injury (gunshot/bomb blast) as the exposure and wound closure by day 5 as the primary outcome measure. The population predominantly comprised young men (n=163, 94% male, and median age 29years) injured by gunshots (61%) or bomb blasts (39%). Compared with the gunshot group, more participants in the bomb blast group had concomitant injuries (32/63 [51%] vs. 11/100 [11%], p<0.001) and vascular injuries (9/63 [14%] vs. 4/100 [4%], p=0.02). The wounds were larger in the bomb blast group compared with the gunshot group (median area 86cm2 [IQR 24-161] vs. 21cm2 [IQR 7-57], p<0.001). Compared with the bomb blast group, significantly more participants in the gunshot group achieved wound closure by day 5 (74/100 [74%] vs. 16/63 [25%], p<0.001). This difference remained after controlling for confounding factors (odds ratio 4.7, 95% confidence interval 1.6-13.7). In civilians with conflict-related extremity injuries, bomb blast wounds had a lower likelihood of achieving closure within 5days than gunshot wounds, independent of other factors, such as wound size and vascular injuries. ClinicalTrials.gov, NCT02444598. Registered 14-05-2015, https://classic. gov/ct2/show/NCT02444598.

Health screening clinic to reduce absenteeism and presenteeism among NHS Staff: eTHOS a pilot RCT.

Staff sickness absenteeism and presenteeism (attending work while unwell) incur high costs to the NHS, are associated with adverse patient outcomes and have been exacerbated by the COVID-19 pandemic. The main causes are mental and musculoskeletal ill health with cardiovascular risk factors common. To undertake a feasibility study to inform the design of a definitive randomised controlled trial of the effectiveness and cost effectiveness of a health screening clinic in reducing absenteeism and presenteeism amongst the National Health Service staff. Individually randomised controlled pilot trial of the staff health screening clinic compared with usual care, including qualitative process evaluation. Four United Kingdom National Health Service hospitals from two urban and one rural Trust. Hospital employees who had not previously attended a pilot health screening clinic at Queen Elizabeth Hospital Birmingham. Nurse-led staff health screening clinic with assessment for musculoskeletal health (STarT musculoskeletal; STarT Back), mental health (patient health questionnaire-9; generalised anxiety disorder questionnaire-7) and cardiovascular health (NHS health check if aged ≥ 40, lifestyle check if < 40 years). Screen positives were given advice and/or referral to services according to UK guidelines. The three coprimary outcomes were recruitment, referrals and attendance at referred services. These formed stop/go criteria when considered together. If any of these values fell into the 'amber' zone, then the trial would require modifications to proceed to full trial. If all were 'red', then the trial would be considered unfeasible. Secondary outcomes collected to inform the design of the definitive randomised controlled trial included: generalisability, screening results, individual referrals required/attended, health behaviours, acceptability/feasibility of processes, indication of contamination and costs. Outcomes related to the definitive trial included self-reported and employee records of absenteeism with reasons. Process evaluation included interviews with participants, intervention delivery staff and service providers. Descriptive statistics were presented and framework analysis conducted for qualitative data. Due to the COVID-19 pandemic, outcomes were captured up to 6 months only. Three hundred and fourteen participants were consented (236 randomised), the majority within 4 months. The recruitment rate of 314/3788 (8.3%) invited was lower than anticipated (meeting red for this criteria), but screening identified that 57/118 (48.3%) randomised were eligible for referral to either general practitioner (81%), mental health (18%) and/or physiotherapy services (30%) (green). Early trial closure precluded determination of attendance at referrals, but 31.6% of those eligible reported intending to attend (amber). Fifty-one of the 80 (63.75%) planned qualitative interviews were conducted. Quantitative and qualitative data from the process evaluation indicated that the electronic database-driven screening intervention and data collection were efficient, promoting good fidelity, although needing more personalisation at times. Recruitment and delivery of the full trial would benefit from a longer development period to better understand local context, develop effective strategies for engaging with underserved groups, provide longer training and better integration with referral services. Delivery of the pilot was limited by the impact of COVID-19 with staff redeployment, COVID-research prioritisation and reduced availability of community and in-house referral services. While recruitment was rapid, it did not fully represent ethnic minority groups and truncated follow-up due to funding limitations prevented full assessment of attendance at recommended services and secondary outcomes. There is both a clinical need (evidenced by 48% screened eligible for a referral) and perceived benefit (data from the qualitative interviews) for this National Health Service staff health screening clinic. The three stop/go criteria were red, green and amber; therefore, the Trial Oversight Committee recommended that a full-scale trial should proceed, but with modifications to adapt to local context and adopt processes to engage better with underserved communities. This trial is registered as ISRCTN10237475. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/42/42) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 23. See the NIHR Funding and Awards website for further award information.

Role of Vickers Ligament in the Pathogenesis of Madelung Deformity.

The Vickers ligament is thought to hinder the growth of palmar ulnar radius by tethering the lunate to the radius, leading to Madelung deformity. The purpose of this study was to clarify the nature of the Vickers ligament and investigate its pathogenesis in Madelung deformities based on our observation of the Vickers ligament. All 22 patients (33 wrists) with Madelung deformities treated surgically between 2018 and 2022 were included. The diagnosis was confirmed radiographically in all patients. The three-dimensional computed tomography (3D-CT) data of 16 patients (19 wrists) were available. Magnetic resonance imaging (MRI) data were available for 9 patients (14 wrists). Wrist arthroscopy was used in 4 patients. The Vickers ligament was resected and submitted for histopathological examination in 8 patients. Radiographic outcomes, 3D-CT, MRI, arthroscopy, surgical findings, and histopathology of the Vickers ligament were evaluated. The 3D-CT revealed that the Vickers ligament originated in the metaphysis and formed a metaphyseal defect at the palmar ulnar radius. In the sequential MR coronal images, the Vickers ligament could be divided into 3 branches, extending to the lunate, triquetrum and ulnar styloid. Arthroscopy and surgical findings revealed that the nature of the Vickers ligament was the stretched palmar ligament of the wrist. The histopathology results revealed ligamentous tissue and fibrocartilaginous metaplasia with a structure similar to that of the triangular fibrocartilage complex (TFCC). The Vickers ligament is not a separate aberrant ligament. The nature of the Vickers ligament is a combination of the stretched TFCC ligament (palmar radioulnar ligament, ulnotriquetral ligament and ulnolunate ligament) and radiolunate ligament. The possible pathogenesis of Madelung deformity might be focal early epiphyseal closure at the middle part of the sigmoid notch, which leads to focal growth retardation of the radius and pulls palmar ligaments proximally to form the Vickers ligament.

TAilored SToma policY after TME for rectal cancer: The TASTY approach.

Diverting stomas are routinely used in restorative surgery following total mesorectal exicision (TME) for rectal cancer to mitigate the clinical risks of anastomotic leakage (AL). However, routine diverting stomas are associated with their own complication profile and may not be required in all patients. A tailored approach based on personalized risk of AL and selective use of diverting stoma may be more appropriate. The aim of the TAilored SToma policY (TASTY) project was to design and pilot a standardized, tailored approach to diverting stoma in low rectal cancer. A mixed-methods approach was employed. Phase I externally validated the anastomotic failure observed risk score (AFORS). We compared the observed rate of AL in our cohort to the theoretical, predicted risk of the AFORS score. To identify the subset of patients who would benefit from early closure of the diverting stoma using C-reactive protein (CRP) we calculated the Youden index. Phase II designed the TASTY approach based on the results of Phase I. This was evaluated within a second prospective cohort study in patients undergoing TME for rectal cancer between April 2018 and April 2020. A total of 80 patients undergoing TME surgery for rectal cancer between 2016 and 2018 participated in the external validation of the AFORS score. The overall observed AL rate in this cohort of patients was 17.5% (n = 14). There was a positive correlation between the predicted and observed rates of AL using the AFORS score. Using ROC curves, we calculated a CRP cutoff value of 115 mg/L on postoperative day 2 for AL with a sensitivity of 86% and a negative predictive value of 96%. The TASTY approach was designed to allocate patients with a low risk AFORS score to primary anastomosis with no diverting stoma and high risk AFORS score patients to a diverting stoma, with early closure at 8-14 days, if CRP values and postoperative CT were satisfactory. The TASTY approach was piloted in 122 patients, 48 (39%) were identified as low risk (AFORS score 0-1) and 74 (61%) were considered as high risk (AFORS score 2-6). The AL rate was 10% in the low-risk cohort of patient compared to 23% in the high-risk cohort of patients, p = 0.078 The grade of Clavien-Dindo morbidity was equivalent. The incidence of major LARS was lowest in the no stoma cohort at 3 months (p = 0.014). This study demonstrates the feasibility and safety of employing a selective approach to diverting stoma in patients with a low anastomosis following TME surgery for rectal cancer.

Significance of the Paleocene olistostrome–turbidite belt (Abant Formation) along the Intra-Pontide Suture, northern Turkey

A belt of Paleocene turbidites with olistostromes, the Abant Formation, crops out for 350 km along the Intra-Pontide Suture in northern Turkey. The suture constitutes the contact between two major Pontide tectonic units, the Istanbul and Sakarya zones, and the Abant Formation was used as evidence for the Paleocene–early Eocene closure of the Intra-Pontide ocean. We mapped and studied the Abant Formation along the Intra-Pontide Suture. The Abant Formation consists of deformed Paleocene siliciclastic turbidites with mass flows. The blocks in the olistostromes are mainly Late Cretaceous pelagic limestones; there are also Late Jurassic–Early Cretaceous, Late Cretaceous and Paleocene shallow-marine limestone blocks. Other rare block types include late Neoproterozoic and Permian granites, basalt, chert and serpentinite. The ophiolitic blocks make up less than 5% of the Abant Formation. Most of the blocks were derived from the south, from the Sakarya Zone; detrital zircon ages from the turbidite sandstones also indicate a predominantly southern source. The Abant Formation was deposited in a foreland basin, which was formed during the Paleocene collision between the Pontides and the Anatolide–Tauride Block. The basin was preferentially located on the Intra-Pontide Suture because the suture constituted an old crustal lineament.