Mohammed Omer Anwar

Support for reporting guidelines in surgical journals needs improvement: A systematic review

INTRODUCTION Evidence-based medicine works best if the evidence is reported well. Past studies have shown reporting quality to be lacking in the field of surgery. Reporting guidelines are an important tool for authors to optimize the reporting of their research. The objective of this study was to analyse the frequency and strength of recommendation for such reporting guidelines within surgical journals. METHODS A systematic review of the 198 journals within the Journal Citation Report 2014 (surgery category) published by Thomson Reuters was undertaken. The online guide for authors for each journal was screened by two independent groups and results compared. Data regarding the presence and strength of recommendation to use reporting guidelines was extracted. RESULTS 193 journals were included (as five appeared twice having changed their name). These had a median impact factor of 1.526 (range 0.047-8.327), with a median of 145 articles published per journal (range 29-659), with 34,036 articles published in total over the two-year window 2012-2013. The majority (62%) of surgical journals made no mention of reporting guidelines within their guidelines for authors. Of the 73 (38%) that did mention them, only 14% (10/73) required the use of all relevant reporting guidelines. The most frequently mentioned reporting guideline was CONSORT (46 journals). CONCLUSIONS The mention of reporting guidelines within the guide for authors of surgical journals needs improvement. Authors, reviewers and editors should work to ensure that research is reported in line with the relevant reporting guidelines. Journals should consider hard-wiring adherence to them.

The First 500 Registrations to the Research Registry®: Advancing Registration of Under-Registered Study Types

Introduction The Declaration of Helsinki 2013 encourages the registration of all research studies involving human participants. However, emphasis has been placed on prospective clinical trials, and it is estimated that only 10% of observational studies are registered. In response, Research Registry®1 was launched in February 2015; a retrospectively curated registry that is free and easy to use. Research Registry® enables prospective or retrospective registration of studies, including those study types that cannot be registered on existing registries. In this study, we describe the first 500 registrations on Research Registry®. Methods Since the launch of Research Registry® in February 2015, data of registrations have been collected, including type of studies registered, country of origin, and data curation activity. Inappropriate registrations, such as duplicates, were identified by the data curation process. These were removed from the database or modified as required. A quality score was assigned for each registration, based on Sir Austin Bradford Hill’s criteria on what research studies should convey. Changes in quality scores over time were assessed. Results A total of 500 studies were registered on Research Registry® from February 2015 to October 2015, with a total of 1.7 million patients enrolled. The most common study types were retrospective cohort studies (37.2%), case series (14.8%), and first-in-man case reports (10.4%). Registrations were received from 57 different countries; the most submissions were received from Turkey, followed by China and the United Kingdom. Retrospective data curation identified 80 studies that were initially registered as the incorrect study type, and were subsequently correct. The Kruskal–Wallis test identified a significant improvement in quality scores for registrations from February 2015 to October 2015 (p < 0.0001). Conclusions Since its conception in February 2015, Research Registry® has established itself as a new registry that is free, easy to use, and enables the registration of various study types, including observational studies and first-in-man case reports. Going forward, our plan is to continue developing Research Registry® in line with user feedback and usability studies. We plan to further promote Research Registry® to advance the cause of registration of research, to increase compliance with the Declaration of Helsinki 2013.

Meckel's diverticulum with intussusception in a 5-year-old patient with Down's syndrome

Meckels diverticulum is understood to be the commonest congenital malformation within the gastrointestinal tract with a prevalence of 2%, as found on autopsy studies. Although many cases are asymptomatic, complications can occur including haemorrhage, diverticulitis, chronic ulceration and intestinal obstruction. Intussusception is also a complication, but extremely rare. We present a rare case of Meckels diverticulum causing intussusception, which was surgically resolved, in a 5-year-old girl. Our aim through this case report is to generate greater awareness of this complication and to provide some potential guidance towards its treatment.

Vasospastic myocardial infarction caused by a slimming agent—do not forget non-prescription drugs

Abstract A 41-year-old woman presented with central chest discomfort. She had been previously well, was an ex-smoker and reported no regular medication. The ECG developed T-wave changes inferiorly and anterolaterally and troponin I concentrations were elevated confirming non-ST elevation myocardial infarction. Cardiac catheterization showed severe spasm of the right and left anterior descending coronary arteries which resolved with intracoronary nitrates. She later volunteered that prior to presentation she had been taking non-prescription Acti-Phen a slimming agent containing phentermine. Acti-Phen had its licence withdrawn in 2001 because of cardiovascular side effects including coronary spasm. Accordingly, she was advised to avoid Acti-Phen in future. The case emphasizes the importance of obtaining a complete drug history, including non-prescription drugs, in patients presenting with acute coronary syndromes.

Does revascularisation for residual ischaemia in patients with ACS influence prognosis

Results The 598 patients (age 59 ± 12 years, 20% female underwent stress CMR a median of 93 days (IQR: 41, 224 days) after coronary stenting with follow-up for 1.4 years (IQR: 0.6-2.7). Inducible perfusion defects were identified in 294 (49%) patients of whom 18 (6%) died during follow-up compared with 6 (2.0%) patients with no perfusion defects (p = 0.01). Of the 294 patients with perfusion defects, 70 (24%) were revascularised (PCI 55, CABG 27) of whom 5 (7%) died during follow-up compared with 13 (6%) who were not revascularised(p = 0.68). K-M survival analysis confirmed that revascularisation was unassociated with survival benefit, regardless of the severity of ischaemia (Figure 1).

The significance of the pelvic collateral circulation in aorto‐iliac disease

We read with great interest the recent review article by Wooten et al. (2014), which highlighted the significance of sound anatomical knowledge in aortoiliac occlusive disease. The authors emphasise the importance of recognising collateral circulations to avoid serious postoperative complications. For instance, the “Winslow Pathway” is mentioned as an important systemic collateral network where arterial blood flows from the subclavian artery to the external iliac artery via the internal thoracic, superior epigastric, and inferior epigastric arteries. The authors are to be congratulated on their most comprehensive research. However, it is the opinion of these correspondents that the systemic pelvic collateral circulation should also be explored in detail, especially in relation to postoperative complications following open and endovascular aortic aneurysm repairs. Of these, the most sinister is undoubtedly spinal cord ischaemia, resulting in paraplegia. Although paraplegia is a rare complication following thoracoabdominal repairs, with an incidence below 1% (Connolly et al., 1996), there has been an increasing number of reports over the past few decades (Svensson et al., 1994; Etz et al., 2008; Takahashi et al., 2009; Richards et al., 2010; Martin Torrijos et al., 2013). An association has been made between possible interruption of the pelvic collateral circulation, during aortic crossclamping and subsequent aortobifemoral bypass, and spinal ischaemia, particularly of the conus medullaris and cauda equina (Lazorthes et al., 1958; Connolly et al., 1996). The iliolumbar and lateral sacral arteries are branches of the internal iliac artery and are both responsible for perfusion of the conus medullaris. The iliolumbar artery is divided into the lumbar and iliac branches. The lumbar branch anastomoses with the fifth lumbar artery to send a small spinal branch into the vertebral canal, which perfuses the conus medullaris and cauda equina. The lateral sacral arteries anastomose with branches of the median sacral artery to course through the first anterior sacral foramen and, ultimately, perfuse the conus medullaris at the “anastomotic ansa of the conus,” a basket-shaped arterial anastomotic structure (Lazorthes et al., 1958; Kiray et al., 2010). This collateral network is of particular importance in the early stages of aortoiliac disease, as it accommodates a 2– 3-fold increase in blood flow, depending upon the extent of occlusion (Takebe et al., 1994; Novosad Ie, 2003). During aortic surgery, prolonged cross-clamping may lead to hypoperfusion of the conus medullaris and cauda equina via the iliolumbar-lumbar artery anastomosis, as there is reduced blood flow to the lumbar arteries. An aortic-cross clamp time >40 min has been associated with increased risk of spinal cord injury (Svensson et al., 1993). Furthermore, during aortoibifemoral bypass, the majority of the blood will be diverted to the femoral artery and beyond, so an interruption to the pelvic collateral circulation may occur via internal iliac artery hypoperfusion. The function of the aortobifemoral bypass mechanism is to divert blood flow past the iliac arteries and perfuse the lower extremities. If there is still patent blood flow via the aortoiliac segment, the pelvic collateral circulation may be receiving adequate perfusion. The distribution of neurological deficit may correspond to the anatomical basis of arterial hypoperfusion of the distal spinal cord. For instance, the most commonly reported neurological presentation after surgery is paraplegia, which is defined as bilateral sensorimotor loss in the lower extremities. The incidence here ranges between 1 and 32% in open surgery and 1–19% with endovascular aneurysm repairs (Panthee and Ono, 2015). Paraplegia may occur by prolonged aortic cross-clamping leading to hypoperfusion of the lumbar arteries. At the same time, the pelvic collateral circulation may remain intact with adequate perfusion to the conus medullaris and cauda equina via the sacral arteries. Thus, paraplegia may be seen as a complication without associated neurogenic bladder dysfunction. This theory could also explain the discrepancy between the incidence of paraplegia (16%) and neurogenic bladder dysfunction (0.5%) in a retrospective cohort study of 1,509 patients who underwent thoracoabdominal surgery (Svensson et al., 1993). Conus medullaris syndrome and cauda equina syndromes are manifestations of distal spinal ischaemia. Conus medullaris syndrome can present with a mixed range of symptoms and signs including mild back pain, muscle weakness, diminished tendon reflexes or sensorimotor loss in the lower extremities (Choi, 2014). The symptoms of cauda equina syndrome tend to be more specific to a dermatomal distribution of S3–S5 causing “saddle perianal anaesthesia,” intense back pain, unilateral or bilateral sciatica and late-presenting urinary retention (Orendacova et al., 2001). However, it may be difficult to attribute the type of neurological deficit to an exact anatomical cause as there are often overlapping symptoms such as bilateral sensorimotor loss in conus medullaris