Aimun A. B. Jamjoom

Surgical trainee research collaboratives in the UK: an observational study of research activity and publication productivity

Objectives To analyse the research activity and publication output of surgical trainee research collaboratives in the UK. Setting Surgical trainee research collaboratives in the UK. Participants A total of 24 collaboratives were included in this study from 33 identified organisations. We excluded one group that focused purely on systematic review of the literature and eight groups for which we could not identify suitable data sources (website or trainee committee contact). Primary and secondary outcome Primary data-points were identified for each collaborative including surgical subspeciality, numbers and types of projects. For published articles, secondary outcomes including study population size, journal impact factor, number of citations and evidence level were collected. Results A total of 24 collaboratives met our inclusion criteria with a portfolio of 80 projects. The project types included audit (46%), randomised clinical trial (16%), surveys (16%), cohort studies (10%), systematic reviews (2.5%) and other or unidentifiable (9.5%). A total of 35 publications were identified of which just over half (54%) were original research articles. The median size of studied population was 540 patients with a range from 108 to 3138. The published works provided a varied compilation of evidence levels ranging from 1b (individual RCT) to 5 (expert opinion) with a median level of 2b (individual cohort study). The West Midlands Research Collaborative had the highest number of publications (13), citations (130) and h-index (5). Conclusions The experience of UK-based trainee research collaboratives provides useful insights for trainees and policymakers in global healthcare systems on the value and feasibility of trainee-driven high quality surgical research.

Safety and Efficacy of Early Pharmacological Thromboprophylaxis in Traumatic Brain Injury: Systematic Review and Meta-Analysis

Patients with traumatic brain injury (TBI) are at an increased risk of developing venous thromboembolic events (VTE). Pharmacological thromboprophylaxis (PTP) is routinely delayed because of concerns of exacerbating intracranial hemorrhage (ICH). The aim of this review is to examine the literature and assimilate suitable data to assess the safety and efficacy of PTP administered within 72 h in TBI patients. We systematically searched the literature for randomized controlled trials or cohort studies reporting on the timing of PTP in TBI. We dichotomized the timing of PTP to early and late at 72 h post-injury. The rates of VTE and ICH progression were our primary endpoints and were pooled using a fixed-effects model. A total of five retrospective cohort studies were included within the review including a total of 1624 patients, of which 713 received early PTP and 911 received late PTP. Within the early and late group there was a total of 43 and 106 VTE respectively, with a risk ratio of 0.52 (0.37, 0.73). Assessing safety, the relative risk of ICH progression in the early compared with the late PTP group was 0.64 (0.35, 1.14). Based on the available literature, we can tentatively conclude that early PTP (<72 h) reduces the risk of VTE without affecting progression of ICH. However, much work is yet to be done to better clarify ICH subtypes at risk of progression and the implementation of evidence-based guidelines backed up with randomized control trial level evidence.

Publication fate of abstracts presented at Society of British Neurological Surgeons meetings.

Abstract Introduction. Society of British Neurological Surgeons (SBNS) meetings are important national events which allow for the presentation of current academic work. The publication rate of presented abstracts is considered a proxy marker of the scientific strength of a conference. We aimed to determine the publication fate of presented abstracts at SBNS meetings over a 5-year period. Methods. A retrospective review of SBNS conference proceedings between 2001 and 2005 was performed. To ascertain whether an abstract resulted in peer-reviewed publication, a range of databases (PubMed, Google Scholar, Medline and Ovid) were interrogated. Abstracts published in full were subsequently assessed for journal impact factor (IF), time of publication and number of citations received (per Google Scholar). Results. A total of 494 abstracts were presented. Of these, 181 abstracts were subsequently published in full, giving the conference a publication rate of 36.6%. The mean time to publication from presentation was 22 months (range 35 months pre-presentation to 133 months afterwards). The top three journals for publication were the British Journal of Neurosurgery (23.2%), Neurosurgery (7.7%) and Journal of Neurosurgery (7.7%). The IF of journal destinations ranged from no IF to 38.28 (median = 1.97). Number of citations ranged from 0 to 963 (median = 22). Abstracts with positive results were significantly more likely to be published in full compared to those with negative results (p = 0.0001). Conclusions. SBNS conferences have a respectable publication rate. Those abstracts that are published in full have gone on to gain a considerable number of citations reflecting their scientific relevance. However, studies presented at SBNS are susceptible to positive outcome bias.

External ventricular drainage: Is it time to look at national practice?

Aimun A. B. Jamjoom 1 , Angelos G. Kolias 2 , Malik Zaben 3 , Aswin Chari 2 , John Kitchen 4 , Alexis Joannides 2 , Paul M. Brennan 1 , Jothy Kandasamy 1 , Silvia Gatscher 5 , William P. Gray 3 , Michael D. Jenkinson 4 , Diederik O. Bulters 6 , Conor L. Mallucci 7 , Helmut Schuster 8 , Peter J. Hutchinson 2 & Aminul I. Ahmed 6 ; UK Neurosurgical Research Network & British Neurosurgical Trainee Research Collaborative

The effect of trainee research collaboratives in the UK

Trainee-led networks have pioneered a novel collaborative approach to research in the UK. Established at a similar time to the UK National Institute for Health Research in 2006, collaborative groups have developed new pathways for doctors in full-time specialty training to design, disseminate, and deliver high-quality, multicentre research. In parallel, the National Institute for Health Research set up Clinical Research Networks (CRNs) to coordinate delivery of research across 30 clinical specialties and 15 English regional networks. Analogous networks have also been established by the devolved administrations in Scotland, Northen Ireland, and Wales. CRNs provide infrastructure to promote and coordinate research, including funding research support staff and providing research skills training. Using gastrointestinal surgery as an example, we sought to quantify trainee-led collaborative research network engagement and compare hospital participation with CRN studies. We only considered CRN and trainee-led collaborative studies involving ten or more hospitals with information available about participating sites. We searched the CRN portfolio for closed gastrointestinal and general surgery studies. We contacted trainee networks via a national mailing list to identify trainee studies. We derived denominators from the total number of hospitals offering emergency or major elective gastrointestinal surgery. Overall, 238 (99%) of 241 UK hospitals providing general surgery services participated in one or more trainee-led collaborative studies over the past decade compared with 191 (79%) of 241 for CRN studies. With the three trainee-led studies that had been adopted into the CRN portfolio excluded, participation in trainee-led research remained similar, at 236 (98%) of 241. Trainee groups delivered 15 studies overall: 12 observational studies and three randomised controlled trials (RCTs), coordinated by five regional and two national trainee networks (appendix). These numbers compared with three observational studies and eight RCTs coordinated by the CRN. We noted strong participation in trainee collaborative studies, even in regions with low CRN coverage, with the mean number of studies per hospital greater for collaboratives than for CRNs (appendix). Regions with a Royal College of Surgeons Surgical Trials Centre had greater participation in both trainee and CRN studies: the mean number of studies per hospital was 8·2 versus 6·0 in regions without. Trainee-led collaboratives have driven substantial additional research participation across the UK, on top of that achievable through CRNs alone, and have engaged additional gastrointestinal surgery units with little infrastructure or associated costs. This success is now being replicated in other specialties, with the British Neurosurgical Trainee Research Collaborative engaging 26 of 30 UK adult trauma-receiving neurosurgical units in the RESCUE-ASDH RCT. As the collaborative model is extended globally, it offers a powerful opportunity to promote a collaborative research culture and grow capacity with minimal investment. Synergy between trainee-led networks and CRNs could maximise delivery of high-quality research across the UK.

Attitudes Towards Informed Consent: A Comparison between Surgeons Working in Saudi Arabia and the United Kingdom

OBJECTIVES Changes in legal standing and new guidelines for consent have generated changes in medical culture that doctors must adhere to. This study aims to highlight the differences in the way the surgeons in the two cultures view the informed consent for surgery processes. METHODS The attitudes towards informed consent of a group of surgeons working in Saudi Arabia (KSA) were compared with those of a similar group working in the United Kingdom (UK), a country with a longer medical history and a more established medico-legal system. RESULTS The study shows that KSA surgeons tend to view informed consent not only as an ethical and legal obligation but also as a benefit to patients. In addition, KSA surgeons are more likely to adopt a paternalistic attitude during informed consent. They believe that information about harmful risks may dissuade their patients from undergoing the operation and they admit that the amount of information they provide to their patients is significantly influenced by a number of patient and non-patient related factors. CONCLUSION It is concluded that surgeons in KSA should be more aware of the informed consent guidelines and they should adhere to them. In addition, there is room for the introduction of formal training on informed consent in both countries and for making written information more widely available particularly in KSA.

Randomized controlled trials in neurosurgery: an observational analysis of trial discontinuation and publication outcome.

OBJECTIVE This study aimed to determine the trial discontinuation and publication rate of randomized controlled trials (RCTs) in neurosurgery. METHODS Trials registered from 2000 to 2012 were identified on the website clinicaltrials.gov using a range of key words related to neurosurgery. Any trials that were actively recruiting or had unknown status were excluded. Included trials were assessed for whether they were discontinued early on the clinicaltrials.gov database; this included trials identified as withdrawn, suspended, or terminated in the database. For included trials, a range of parameters was identified including the subspecialty, primary country, study start date, type of intervention, number of centers, and funding status. Subsequently, a systematic search for published peer-reviewed articles was undertaken. For trials that were discontinued early or were found to be unpublished, principal investigators were sent a querying email. RESULTS Sixty-four neurosurgical trials fulfilled our inclusion criteria. Of these 64, 26.6% were discontinued early, with slow or insufficient recruitment cited as the major reason (57%). Of the 47 completed trials, 14 (30%) remained unpublished. Discontinued trials showed a statistically significant higher chance of remaining unpublished (88%) compared with completed trials (p = 0.0002). Industry-funded trials had a higher discontinuation rate (31%) compared with non-industry-funded trials (23%), but this result did not reach significance (p = 0.57). Reporting of primary outcome measures was complete in 20 (61%) of 33 trials. For secondary outcome measures, complete reporting occurred in only 11 (33.3%) of 33. CONCLUSIONS More than a fifth (26.6%) of neurosurgical RCTs are discontinued early and almost a third of those that are completed remain unpublished. This result highlights significant waste of financial resources and clinical data.

Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland

Objectives External ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, we aimed to establish a national ERI rate in the UK and Ireland and determine key factors influencing the infection risk. Methods A prospective multicentre cohort study of EVD insertions in 21 neurosurgical units was performed over 6 months. The primary outcome measure was 30-day ERI. A Cox regression model was used for multivariate analysis to calculate HR. Results A total of 495 EVD catheters were inserted into 452 patients with EVDs remaining in situ for 4700 days (median 8 days; IQR 4–13). Of the catheters inserted, 188 (38%) were antibiotic-impregnated, 161 (32.5%) were plain and 146 (29.5%) were silver-bearing. A total of 46 ERIs occurred giving an infection risk of 9.3%. Cox regression analysis demonstrated that factors independently associated with increased infection risk included duration of EVD placement for ≥8 days (HR=2.47 (1.12–5.45); p=0.03), regular sampling (daily sampling (HR=4.73 (1.28–17.42), p=0.02) and alternate day sampling (HR=5.28 (2.25–12.38); p<0.01). There was no association between catheter type or tunnelling distance and ERI. Conclusions In the UK and Ireland, the ERI rate was 9.3% during the study period. The study demonstrated that EVDs left in situ for ≥8 days and those sampled more frequently were associated with a higher risk of infection. Importantly, the study showed no significant difference in ERI risk between different catheter types.

A national survey of thromboprophylaxis in traumatic brain injury in the United Kingdom.

Abstract Introduction: Patients with traumatic brain injury (TBI) are at increased risk of venous thromboembolic events (VTE). In this survey, we aimed to assess current practice in the United Kingdom and identify areas of variation for further investigation. Methods: We distributed a case-based survey to neurosurgical consultants and trainees via e-mail. The survey included four index TBI cases commonly seen: a surgically treated acute extradural haematoma, bilateral frontal contusions treated conservatively, diffuse axonal injury requiring critical care and a conservatively managed small acute subdural haematoma. Each case vignette included questions looking at a range of areas regarding thromboprophylaxis. Results: Sixty-two responses were collected among UK neurosurgeons with a good geographic distribution. In each case, over 90% of respondents would initiate mechanical prophylaxis (MTP) at admission. There was greater variation on the decision to commence pharmacological prophylaxis (PTP). Consultants showed a higher willing to commence PTP across all cases (84%) compared to trainees (77.4%). Low molecular weight heparin (LMWH) was the favoured PTP agent in over 90% of respondents. There was significant variability in the timing of initiation of PTP within and between cases. The median times to commence PTP across all four cases ranged from 1 to 7 days. Conclusion: This survey highlighted broad consensus on the use of MTP and choice of PTP agent, when used. However, the survey also demonstrated wide intra-case variation on whether to start PTP and particularly the timing of initiation. This discordance in practice shines light on the lack of evidence guiding thromboprophyalxis in TBI and adds weight to the need for prospective randomised trials to guide clinical management.

The British Neurosurgical Trainee Research Collaborative: Five Years On

Since its inception in 2012, the British Neurosurgical Trainee Research Collaborative (BNTRC) has established itself as a robust example of a trainee-led research collaborative. This article summarises the work of the collaborative over its first 5 years of existence, outlining the structure, its research projects, impact and future directions.