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Accurate preoperative staging of colorectal cancers is critical in selecting patients for neoadjuvant therapy prior to resection. Inaccurate staging, particularly understaging, may lead to involved resection margins and poor oncological outcomes. Our aim is to determine preoperative imaging accuracy of colorectal cancers compared to histopathology and define the effect of inaccurate staging on patient selection for neoadjuvant treatment(NT). Staging and treatment were determined for patients undergoing colorectal resections for adenocarcinomas in a single tertiary centre(2016–2020). Data were obtained for 948 patients. The staging was correct for both T and N stage in 19.68% of colon cancer patients. T stage was under-staged in 18.58%. At resection, 23 patients (3.36%) had involved pathological margins; only 7 of which had been predicted by pre-operative staging. However, the staging was correct for both T and N stage in 53.85% of rectal cancer patients. T stage was understaged in 26.89%. Thirteen patients had involved(R1)margins; T4 had been accurately predicted in all of these cases. There was a general trend in understaging both the tumor and lymphonodal involvement (T p p

Objective The coronavirus pandemic has significantly disrupted the way we deliver healthcare worldwide. We have been flexible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. In this paper, we describe the impact of coronavirus on our elective services and how we have implemented new patient pathways to allow us to continue providing patient care. Methodology Data on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. Data on the number of proctology cases and telemed appointments were collected from the hospital theatre information management system and electronic patient record system respectively. Results During the pandemic, there was a complete shift towards cancer cases, with benign services and proctology cases being placed on hold. Hospital length of stay was reduced. We implemented earlier hospital discharge and more intense telephone follow up after elective major surgery. This has not resulted in an increase in post‐operative complications, nor any increase in readmission into hospital. During the recovery phase, we have introduced a higher proportion of telemed consultations, including one‐stop telemed proctology clinics, resulting in straight to tests or investigations. Conclusions We have created a streamlined multi‐disciplinary pathway to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed. We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over.

Aim Cancer surgery in the COVID-19 pandemic presents many new challenges. For each patient, the risk of contracting COVID-19 during the perioperative period, with the potential for life-threatening sequelae (1), has to be weighed against the risk of delaying treatment. We assessed the response and short-term outcomes from elective colorectal cancer surgery during the pandemic at our institution. Method We report a prospective cohort study of all elective colorectal surgery cases performed at our Trust during the 11 weeks following the national UK lockdown on 23rd March 2020, compared with the same time period in 2019. Results Eighty-five colorectal operations were performed during the 2020 (COVID) time period, and 179 performed in the 2019 (non-COVID) time period. A significantly higher proportion of cases during the COVID period were cancer-related (66% vs 26%, p

Background Cancer diagnostics and surgery have been disrupted by the response of healthcare services to the COVID-19 pandemic. Progression of cancers during delay will impact on patient long-term survival. Methods We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of three months and six months and periods of disruption of one year and two years. Using healthcare resource costing, we contextualise attributable lives saved and life-years gained from cancer surgery to equivalent volumes of COVID-19 hospitalisations. Findings Per year, 94,912 resections for major cancers result in 80,406 long-term survivors and 1,717,051 life years gained. Per-patient delay of three/six months would cause attributable death of 4,755/10,760 of these individuals with loss of 92,214/208,275 life-years. For cancer surgery, average life-years gained (LYGs) per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of three/six months (an average loss of 0.97/2.19 LYG per patient). Taking into account units of healthcare resource (HCRU), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of three/six months. For 94,912 hospital COVID-19 admissions, there are 482,022 LYGs requiring of 1,052,949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs. Interpretation Modest delays in surgery for cancer incur significant impact on survival. Delay of three/six months in surgery for incident cancers would mitigate 19%/43% of life-years gained by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59% when considering resource-adjusted life-years gained. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued., Highlights • Lockdown and re-deployment due to the COVID-19 pandemic is causing significant disruption to cancer diagnosis and management. • 3-month delay to surgery across all Stage 1-3 cancers is estimated to cause >4,700 attributable deaths per year in England. • The impact on life years lost of 3-6 month to surgery for Stage 1-3 disease varies widely between tumour types. • Strategic prioritisation of patients for diagnostics and surgery has potential to mitigate deaths attributable to delays. • The resource-adjusted benefit in avoiding delay in cancer management compares favourably to admission for COVID-19 infection.

BackgroundThe coronavirus pandemic has significantly disrupted the way we deliver healthcare worldwide. We have been flexible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. In this paper, we describe the impact of coronavirus on our elective services and how we have implemented new patient pathways to allow us to continue providing patient care.MethodsData on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. Data on the number of proctology cases and telemed appointments were collected from the hospital theatre information management system and electronic patient record system respectively. ResultsDuring the pandemic, there was a complete shift towards cancer cases, with benign services and proctology cases being placed on hold. Hospital length of stay was reduced. We implemented earlier hospital discharge and more intense telephone follow up after elective major surgery. This has not resulted in an increase in post-operative complications, nor any increase in readmission into hospital. During the recovery phase, we have introduced a higher proportion of telemed consultations, including one-stop telemed proctology clinics, resulting in straight to tests or investigations.ConclusionsWe have created a streamlined multi-disciplinary pathway to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed. We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over.

ObjectiveTo evaluate the impact of faecal immunochemical testing (FIT) prioritisation to mitigate the impact of delays in the colorectal cancer (CRC) urgent diagnostic (2-week-wait (2WW)) pathway consequent from the COVID-19 pandemic.DesignWe modelled the reduction in CRC survival and life years lost resultant from per-patient delays of 2–6 months in the 2WW pathway. We stratified by age group, individual-level benefit in CRC survival versus age-specific nosocomial COVID-19–related fatality per referred patient undergoing colonoscopy. We modelled mitigation strategies using thresholds of FIT triage of 2, 10 and 150 µg Hb/g to prioritise 2WW referrals for colonoscopy. To construct the underlying models, we employed 10-year net CRC survival for England 2008–2017, 2WW pathway CRC case and referral volumes and per-day-delay HRs generated from observational studies of diagnosis-to-treatment interval.ResultsDelay of 2/4/6 months across all 11 266 patients with CRC diagnosed per typical year via the 2WW pathway were estimated to result in 653/1419/2250 attributable deaths and loss of 9214/20 315/32 799 life years. Risk–benefit from urgent investigatory referral is particularly sensitive to nosocomial COVID-19 rates for patients aged >60. Prioritisation out of delay for the 18% of symptomatic referrals with FIT >10 µg Hb/g would avoid 89% of these deaths attributable to presentational/diagnostic delay while reducing immediate requirement for colonoscopy by >80%.ConclusionsDelays in the pathway to CRC diagnosis and treatment have potential to cause significant mortality and loss of life years. FIT triage of symptomatic patients in primary care could streamline access to colonoscopy, reduce delays for true-positive CRC cases and reduce nosocomial COVID-19 mortality in older true-negative 2WW referrals. However, this strategy offers benefit only in short-term rationalisation of limited endoscopy services: the appreciable false-negative rate of FIT in symptomatic patients means most colonoscopies will still be required.

Summary Background During the COVID-19 lockdown, referrals via the 2-week-wait urgent pathway for suspected cancer in England, UK, are reported to have decreased by up to 84%. We aimed to examine the impact of different scenarios of lockdown-accumulated backlog in cancer referrals on cancer survival, and the impact on survival per referred patient due to delayed referral versus risk of death from nosocomial infection with severe acute respiratory syndrome coronavirus 2. Methods In this modelling study, we used age-stratified and stage-stratified 10-year cancer survival estimates for patients in England, UK, for 20 common tumour types diagnosed in 2008–17 at age 30 years and older from Public Health England. We also used data for cancer diagnoses made via the 2-week-wait referral pathway in 2013–16 from the Cancer Waiting Times system from NHS Digital. We applied per-day hazard ratios (HRs) for cancer progression that we generated from observational studies of delay to treatment. We quantified the annual numbers of cancers at stage I–III diagnosed via the 2-week-wait pathway using 2-week-wait age-specific and stage-specific breakdowns. From these numbers, we estimated the aggregate number of lives and life-years lost in England for per-patient delays of 1–6 months in presentation, diagnosis, or cancer treatment, or a combination of these. We assessed three scenarios of a 3-month period of lockdown during which 25%, 50%, and 75% of the normal monthly volumes of symptomatic patients delayed their presentation until after lockdown. Using referral-to-diagnosis conversion rates and COVID-19 case-fatality rates, we also estimated the survival increment per patient referred. Findings Across England in 2013–16, an average of 6281 patients with stage I–III cancer were diagnosed via the 2-week-wait pathway per month, of whom 1691 (27%) would be predicted to die within 10 years from their disease. Delays in presentation via the 2-week-wait pathway over a 3-month lockdown period (with an average presentational delay of 2 months per patient) would result in 181 additional lives and 3316 life-years lost as a result of a backlog of referrals of 25%, 361 additional lives and 6632 life-years lost for a 50% backlog of referrals, and 542 additional lives and 9948 life-years lost for a 75% backlog in referrals. Compared with all diagnostics for the backlog being done in month 1 after lockdown, additional capacity across months 1–3 would result in 90 additional lives and 1662 live-years lost due to diagnostic delays for the 25% backlog scenario, 183 additional lives and 3362 life-years lost under the 50% backlog scenario, and 276 additional lives and 5075 life-years lost under the 75% backlog scenario. However, a delay in additional diagnostic capacity with provision spread across months 3–8 after lockdown would result in 401 additional lives and 7332 life-years lost due to diagnostic delays under the 25% backlog scenario, 811 additional lives and 14 873 life-years lost under the 50% backlog scenario, and 1231 additional lives and 22 635 life-years lost under the 75% backlog scenario. A 2-month delay in 2-week-wait investigatory referrals results in an estimated loss of between 0·0 and 0·7 life-years per referred patient, depending on age and tumour type. Interpretation Prompt provision of additional capacity to address the backlog of diagnostics will minimise deaths as a result of diagnostic delays that could add to those predicted due to expected presentational delays. Prioritisation of patient groups for whom delay would result in most life-years lost warrants consideration as an option for mitigating the aggregate burden of mortality in patients with cancer. Funding None.

Team sport players have regular daily meals together when in competition. Meals are designed to provide a balanced nutritional diet to optimise recovery and performance. Time in camp can be long, and meal content is varied to prevent boredom and encourage consumption. An international female

Background: Cancer diagnostics and surgery have been disrupted by the response of healthcare services to the COVID-19 pandemic. Progression of cancers during delay will impact on patient long-term survival. Methods: We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of three months and six months and periods of disruption of one year and two years. Using healthcare resource costing, we contextualise attributable lives saved and life years gained from cancer surgery to equivalent volumes of COVID-19 hospitalisations. Findings: Per year, 94,912 resections for major cancers result in 80,406 long-term survivors and 1,717,051 life years gained. Per-patient delay of six months would cause attributable death of 10,555 of these individuals with loss of 205,024 life years. For cancer surgery, average life years gained (LYGs) per patient are 18·1 under standard conditions and 15·9 with a delay of six months (a loss of 2·3 LYG per patient). Taking into account units of healthcare resource (HCRU), surgery results on average per patient in 2·25 resource-adjusted life years gained (RALYGs) under standard conditions and 1·98 RALYGs following delay of six months. For 94,912 hospital COVID-19 admissions, there are 474,505 LYGs requiring of 1,097,937 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5·0 LYG and 0·43 RALYGs. Interpretation: Delay of six months in surgery for incident cancers would mitigate 43% of life years gained by hospitalisation of an equivalent volume of admissions for community acquired COVID-19. This rises to 62% when considering resource-adjusted life-years gained. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued. Funding Statement: MEJ additionally received funding from Breast Cancer Now.GL is supported by a Cancer Research UK Advanced Clinician Scientist Fellowship Award [C18081/A18180] and is Associate Director of the multi-institutional CanTest Collaborative funded by Cancer Research UK [C8640/A23385]. B.T and A.G. are supported by Cancer Research UK award C61296/A27223. R.S.H. is supported by Cancer Research UK (C1298/A8362) and Bobby Moore Fund for Cancer Research UK). A.S. is in receipt of an Academic Clinical Lectureship from National Institute for Health Research (NIHR) and Biomedical Research Centre (BRC) post-doctoral support. This is a summary of independent research supported by the NIHR BRC at the Royal Marsden NHS Foundation Trust and Institute of Cancer Research. Declaration of Interests: The authors declare no competing interests.

Background: The COVID-19 pandemic has caused disruption across cancer pathways for diagnosis and treatment. In England, 32% of colorectal cancer (CRC) is diagnosed via urgent symptomatic referral from primary care, the “2-week-wait” (2WW) pathway. Access to routine endoscopy is likely to be a critical bottleneck causing delays in CRC management due to chronic limitation in capacity, acute competition for physician time, and safety concerns. Methods: We used age-specific, stage-specific 10 year CRC survival for England 2007-2017 and 2WW CRC cases volumes. We used per-day hazard ratios of CRC survival generated from observational studies of CRC diagnosis-to-treatment interval to model the effect of different durations of per-patient delay. We utilised data from a large London observational study of faecal immunochemical testing (FIT) in symptomatic patients to model FIT-triage to mitigate delay to colonoscopy. Findings: Modest delays result in significant reduction in survival from CRC with a 4-month delay resulting across age groups in ≥20% reduction in survival in Stage 3 disease and in total over a year, 1,419 attributable deaths across the 11,266 CRC patients diagnosed via the 2WW pathway. FIT triage of >10 ug Hb/g would salvage 1,292/1,419 of the attributable deaths and reduce colonoscopy requirements by >80%. Diagnostic colonoscopy offers net survival in all age groups, providing nosocomial COVID-19 infection rates are kept low (

Anastomotic leak after colorectal surgery increases postoperative mortality, cancer recurrence, permanent stoma formation, and poor bowel function. Anastomosis between the colon and rectum is a particularly high risk. Traditional management mandates laparotomy, disassembly of the anastomosis, and formation of an often-permanent stoma. After laparoscopic colorectal surgery it may be possible to manage anastomotic failure with laparoscopy, thus avoiding laparotomy.The purpose of this study was to determine the feasibility of the laparoscopic management of failed low colorectal anastomoses.This was a single-institute case series.A total of 555 laparoscopic patients undergoing anterior resection with primary anastomosis within 10 cm of the anus in the period 2000-2012 were included.Anastomotic failure, defined as any clinical or radiological demonstrable defect in the anastomosis; complications using the Clavien-Dindo system; mortality within 30 days; and patient demographics and risk factors, as defined by the Charlson index, were measured.Leakage occurred in 44 (7.9%) of 555 patients, 16 patients with a diverting ileostomy and 28 with no diverting ileostomy. Leakage was more common in those with anastomoses5 cm form the anus, male patients, and those with a colonic J-pouch and rectal cancer. Diverting ileostomy was not protective of anastomotic leakage. In those patients with anastomotic leakage and a primary diverting ileostomy, recourse to the peritoneal cavity was required in 4 of 16 patients versus 24 of 28 without a diverting ileostomy (p = 0.0002). In 74% of those cases, access to the peritoneal cavity was achieved through laparoscopy. Permanent stoma rates were very low, including 14 (2.5%) of 555 total patients or 8 (18.0%) of 44 patients with anastomotic leakage. Thirty-day mortality was rare (0.6%).This study was limited by the lack of a cohort of open cases for comparison.Laparoscopic anterior resection is associated with low levels of complications, including anastomotic leak, postoperative mortality, and permanent stoma formation. Anastomotic leakage can be managed with laparoscopy in the majority of cases. See Video Abstract at http://links.lww.com/DCR/A353.

Physical activity levels have been decreasing significantly for at least 50 years as advances in technology have allowed our lives to become more sedentary. Physical inactivity is a known risk factor for many diseases and regular exercise is known to have significant benefits. Promotion of physical activity by doctors can be limited, often by time and lack of knowledge. Additionally, practitioners' own participation has a significant effect on both exercise promotion and ability to provide a credible role model.

Nutritional deficiencies occur after weight loss surgery. Despite knowledge of nutritional risk, there is little uniformity of postoperative vitamin and mineral supplementation. The objective of this study was to evaluate a composite supplement based on the clinical practice guidelines proposed in 2008 regarding vitamin and mineral supplementation after Roux-en-Y gastric bypass. The composite included iron (Fe) and calcium as well. A retrospective chart review of 309 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) was evaluated for the development of deficiencies in iron and vitamins A, B1, B12, and D. Patients were instructed to take a custom vitamin and mineral supplement that was based on society-approved guidelines. The clinical practice guidelines were modified to include 1600 international units (IU) of vitamin D3 instead of the recommended 800 IU. The compliant patients’ deficiency rates were significantly lower than those of the noncompliant patients for iron (p = 0.001), vitamin A (p = 0.01), vitamin B12 (p ≈ 0.02), and vitamin D (p

Background The Genghis Khan Ice Marathon took place in January 2016 in the mountains of the Terelj National Park, Mongolia in a temperature of minus 35 0C. Objective To assess the experience, preparation, race strategy and effect of exercise in a group of ultrarunners undertaking a marathon in extreme cold. Design Prospective observational study. Setting Extreme environment. Participants Multinational group of experienced ultrarunners (n=9, male 5, female 4, age range 25–53 years). Interventions Pre and post race questionnaires. Post-race email surveillance. Main Outcome Measurements Experience, preparation, clothing, equipment, nutritional strategies for race. Adverse effects encountered when competing in the marathon. Perceived effort of race on the Borg Scale. Two weeks post race illness or injury surveillance. Results All nine ultrarunners completed the questionnaires and follow up. Concerns about safety in a remote environment were universal. Consensus was present regarding clothing, equipment, hydration and nutrition. The race was completed in 3:05–5:50. No significant difficulties were encountered. The cold air caused freezing around the nostrils and irritated the airways. No-one experienced cold induced bronchospasm. Clothing froze due to sweat and expired air. There were no cases of hypothermia. There were two cases of frostbite; earlobe (moderate) and nose (mild). Borg scale of perceived exertion values ranged from 13–17 (mean 15). Two week follow up; two cases of viral URTI9s reported. No athlete reported DOMS in the post race period. Conclusions All athletes were experienced in ultrarunning. They shared concerns regarding competing in a remote, extreme cold environment. All were adequately prepared pre race in terms of clothing, equipment and race nutrition strategy. This level of experience contributed to the lack of complications during the race and in the post race period. No athletes experienced DOMS presumably related to lack of peripheral muscular perfusion during exercise in extreme cold.

Background The traditional sports medicine “backroom” team in elite women9s international soccer was comprised of a doctor and physiotherapist(s). Objective To introduce a multidisciplinary sports medicine performance model into elite women9s international soccer and assess its impact. Design Prospective observational study. Setting Scotland women9s soccer national squad. Participants Elite women international soccer players. Interventions Introducing a sports science physiologist and strength and conditioning coach into the sports medicine team. Main Outcome Measurements To monitor objective measurements and subjective health and wellbeing data on a daily basis at international squad gatherings. Results All players reported to a health and wellbeing assessment in the medical area each morning. The following data was collected: Illness and injury surveillance, Urine hydration status, Body weight, Resting heart rate, Menstrual cycle, Physical objective tests (Sit and reach distance, Knee to wall distance, Thomas test, Counter movement jump height), Health and Wellbeing data (Fatigue status, Stress, Sleep quality, Motivation). The performance indicators were discussed amongst the sports medicine team and concerns regarding a player9s health and fitness relayed to the coaching staff. Conclusions Changing a traditional approach to performance and incorporating other professionals skills by working in partnership in a new sports medicine performance model provided an efficient method of determining player9s health, wellbeing and fitness on a daily basis allowing discussion within the sports medicine team with any concerns relayed to the coaching staff over performance indicators.

We report the case of 65-year-old man who developed massive rectal bleeding associated with the use of a fecal collecting device: the Flexi-Seal Fecal Management System. A colonoscopy showed an acute laceration of the anterior rectal wall mucosa, 6 cm from the anal verge, with active bleeding. The tear was most likely the result of an acute event, such as sudden movement of the device within the rectum or trauma sustained during insertion. Massive transfusion was required, and surgical endoscopic treatment was necessary to ensure hemostasis. This is, to our knowledge, the first such case to be reported.

Background The Genghis Khan Ice Marathon took place in January 2016 in the mountains of the Terelj National Park, Mongolia at an altitude of 1800 metre. The route was a 26 mile marathon following the route of the frozen Tul Goll River. Conditions on race day were dry, sunny, light wind, with an air temperature of minus 35°C. Aim To assess the effect of competing in a marathon in an extreme cold environment in a group of experienced ultrarunners. Method A multinational group of experienced ultrarunners (n = 9, male 5, female 4, age range 25-53 years) completed a post race questionnaire detailing any adverse effects encountered when competing in the marathon. All athletes also rated the perceived effort of the race on the Borg Scale. Two weeks after the event all runners were contacted via email to determine if any illness or injury had occurred in the post race period. Results The race was completed in 3:05 – 5:50. One person did not finish the race due to a navigational error. All athletes completed the post race questionnaire and the two week follow up email survey. No significant difficulties were encountered during the race. The cold air caused freezing around the nostrils and irritated the airways but no one experienced any cold induced bronchopasm. Clothing froze due to sweat and expired air but there were no cases of hypothermia. There were two cases of frostbite; earlobe (moderate) and nose (mild). Borg scale of perceived exertion values ranged from 13 – 17 (mean 15). On two week follow up all athletes had been well with only two cases of viral URTI’s reported. No athlete reported any DOMS in the immediate post race period. Conclusion All the athletes were very experienced in ultrarunning having competed in mountain, desert or cold environments. This experience level possibly contributed to the lack of complications during the race and in the post race period. No athletes experienced any DOMS in the post race period which is unusual for this distance and presumably related to lack of peripheral muscular perfusion during exercise in extreme cold.

Background Education of soccer players is important in injury prevention and maintaining health throughout their career. Injury epidemiological studies have highlighted risk around knee and ankle. Aetiological factors include direct trauma, biomechanical imbalances, poor mobility, strength imbalances and training load. Objective To monitor individual player specific physical range of movement scores to inform and educate players around self-management, readiness to train and injury risk. Design Prospective observational study. Setting Scotland women9s soccer national squad. Participants Elite women international soccer players. Interventions (or Assessment of Risk Factors) Players were assessed each morning during international team camps for a range of objective physical markers. Main Outcome Measurements Sit and reach distance, Knee to wall distance, Thomas test hip range of movement. Average scores were used to educate players and individually tasked with completing specific self-management modalities to improve these scores before entering a risk environment. Results 28 players completed the self-directed objective tests. The physical markers were averaged out and players given individual red, amber and green scores. The markers were discussed amongst the sports medicine team and concerns regarding a player9s health and fitness relayed to the coaching staff. The player was tasked with completing self-directed individualised exercises to improve any flagged scores. They were also tasked with completing this in their club environment and improvement in physical markers scores was noted on subsequent camp entries. Conclusions Using specific physical markers individual to each player we were able to track and inform of any flagged scores during the health check. This enabled us to give a clear understanding of player readiness to train as well as informing and educating the player on how they could improve their scores through self-management modalities therefore decreasing injury risk. Initial findings through injury surveillance suggest a decrease in lower limb muscle related injuries.

Background In recent years mobile devices (smartphones) have been used to gather subjective and objective international athlete health and wellbeing data via athlete self-report measures (ASRM’s). Aim To implement a system of ASRM’s in elite women’s international soccer players. Method ASRM’s require players to rate their perceived level of fatigue, motivation, stress, sleep quality on a 10 point scale and objective data such as sleep hours, illness/injury and menstrual cycle. The Scotland women’s national soccer team were asked to provide this data on a daily basis via a hand held mobile device both during periods of international duty and when with their domestic clubs. Results 26 international soccer players compiled this data over a period of six months. The adherence rate overall was 48% (home based players 64%, exiles 38%). Strengths of this process include decreased administration time for support staff, quantification of athlete wellbeing providing the ability to analyse this longitudinally and decrease both observer and peer bias. Weaknesses of this form of data collection include poor compliance, unstandardised timing of completion and decreased face-to-face conversations leading to a reduction in the identification of changes to body language. Conclusion ASRM’s have proved an invaluable tool for the quantification of health and wellbeing within the Scottish women’s national soccer team. They have provided important initial ‘red flags’ for many illness and injury situations during international and club duty. However, they cannot remove face-to-face wellbeing conversations completely and require practitioners to communicate the results obtained from ASRMs for continued athlete buy-in.

Background The Genghis Khan Ice Marathon took place in January 2016 in the mountains of the Terelj National Park, Mongolia at an altitude of 1800 metre. The route was a 26 mile marathon following the route of the frozen Tul Goll River. Conditions on race day were dry, sunny, light wind, with an air temperature of minus 35°C. Aim To assess the experience, preparation and race strategy of a group of ultra-runners undertaking a marathon in extreme cold. Method A multinational group of experienced ultra-runners (n = 9, male 5, female 4, age range 25–53 years) completed a pre-race questionnaire detailing experience, preparation, clothing, equipment and nutritional strategies. They were also given the opportunity to raise any fears or concerns about competing in an extreme cold environment. Results All nine ultra-runners completed the questionnaire. The group was very experienced in running/ultra-running with most have completed other arduous events in mountain or desert environments. Three had competed previously at the North or South Pole. All athletes were concerned about safety in a remote environment, the physical effects of prolonged cold exposure and the ability to maintain adequate hydration and nutrition. With some individual variation in styles, consensus was present regarding several layers of clothing (upper and lower), full face cover, double gloving for hands and trainers a size to big (to allow for extra socks) with spikes or overlying chain links attached. Water would be provided by aid stations that would not be frozen to allow for adequate hydration. Most athletes opted for energy gels for nutrition stored inside their insulated gloves to prevent freezing. Conclusion Despite a high level of experience all ultra-runners shared similar concerns regarding competing in a remote, extreme cold environment. With slight individual variations this experience level led to all the ultra-runners being adequately prepared pre-race in terms of clothing, equipment and race nutrition strategy.

The use of cannabis in our society is a common problem and the subject of much medical and political debate. We present a case in which a 17-year-old male regular cannabis user developed a large swollen uvula (uvulitis) and partial upper airway obstruction after smoking cannabis. Symptoms resolved with the administration of corticosteroids and antihistamines.

A 16-year-old boy presented to the emergency department with sudden onset of bilateral hip pain while performing in a 100 m sprint race. Examination revealed diffuse swelling and tenderness at both anterior superior iliac spines (ASIS). Pelvic x ray revealed bilateral displaced avulsion fractures of the ASIS at the origin of the sartorius muscle. He was managed conservatively with analgesia and bed rest with both hips held partially flexed at approximately 60°. Further x rays showed good healing and no further displacement of the avulsed fragments. Following physiotherapy he had a full range of hip movements at 6 weeks post-injury. He was able to return to full activity by 18 weeks post-injury.

Laparoscopic gastric banding is an established and increasingly popular surgical treatment for morbid obesity. Iatrogenic diaphragmatic injury can complicate upper abdominal and esophageal surgery. We describe here the case of a patient who had undergone revisional surgery to replace a laparoscopic band, who presented acutely, years following surgery, with breathlessness and abdominal pain. CT of the chest and abdomen demonstrated small bowel loops in the left chest and significant mediastinal shift. The patient required an emergency laparotomy to reduce the small bowel contents from the chest and repair the hernial defect. The small bowel contained within the hernia was ischemic though did not require resection. The patient made a prompt recovery. Iatrogenic diaphragmatic injury is a rare, though potentially life-threatening, complication of laparoscopic gastric band placement.

A 29-year-old man presented to the accident and emergency department complaining of a sudden onset of chest and upper abdominal pain. He had a past history of intravenous drug abuse and a previous stab wound to the left hypochondrium that had required laparotomy. On arrival he was distressed with grunting respiration. Initial chest X-ray showed a pneumopericardium. Despite titrated doses of opiate analgesia he became increasingly distressed, agitated and dyspnoeic. Repeat chest X-ray demonstrated an increase in the volume of air present within the pericardial sac. His clinical condition improved rapidly after needle pericardiocentesis decompression. A water-soluble contrast swallow revealed a diaphragmatic hernia with a filling defect in the greater curve of the stomach and contrast medium entering the pericardial sac. A thoraco-abdominal laparotomy confirmed a pre-existing diaphragmatic defect from the previous stab wound, with surrounding adhesions. A small portion of the stomach had herniated through this defect with a perforated gastric ulcer communicating directly into the pericardial sac.

Parasite-specific plasma immunoglobulins have been used to indicate the presence of Giardia intestinalis infection in 60 infants living in a rural area of The Gambia. Infants were studied longitudinally between 2 and 8 mo of age. The median age for first exposure to G. intestinalis was between 3 and 4 mo, and by 8 mo all but 3 infants (95%) showed a positive titer on at least one occasion. Raised Giardia-specific IgM titers were associated with reduced weight gain in the 2 wk preceding a positive titer, but catch-up growth occurred in the following 2 wk. IgM antibody titers were also positively associated with intestinal permeability (lactulose/mannitol ratio), urinary lactose excretion, plasma concentrations of alpha1-antichymotrypsin and total IgM, IgA and IgG immunoglobulins. However, infant growth over the whole 6-mo period (i.e., between 2 and 8 mo of age) was not related to mean Giardia-specific antibody titers, nor the time of first exposure to the parasite. The data suggest that giardiasis in these very young breast-fed children occurs as a mild, acute disease, and its presence could not explain the marked, long-term growth faltering observed in many of the subjects.

Diversion of the faecal stream with the distal colon left in situ can occur following both elective and emergency surgery for colonic disease. Whether the excluded colon is subsequently removed or continuity restored is variable. In patients undergoing subtotal colectomy for colitis, the majority will undergo a further procedure, either a restorative ileroectal anastomosis or completion proctectomy, with or without an ileoanal pouch. Amongst those patients who undergo Hartmann’s procedure, the rates of reversal varies widely, but a significant proportion will not undergo further surgery and remain with a permanent colostomy and rectal stump. In patients undergoing elective anterior resection of the rectum for adenocarcinoma, a significant proportion of patients will have a permanent stoma with distal colon in situ. Both acute and chronic complications may result from the redundant distal colon. In the acute postoperative period, such complications include pelvic sepsis resulting from rectal stump dehiscence. Chronic complications, which are more common in those in whom the original surgery was for inflammatory bowel disease, include on-going disease activity in the rectum, and in the long term, dysplastic changes and carcinoma. Where the original pathology was not inflammatory, those with a rectal stump may develop non-specific inflammatory changes in the rectum, so-called diversion colitis, as a consequence of diversion of the faecal stream. Diversion colitis may present with abdominal pain, bleeding and discharge. Here, we describe the late presentation of inflammatory change within a rectal stump resulting in massive distension of the rectum and significant haemorrhage. The rectal distension caused bladder outflow obstruction, bilateral hydronephrosis and acute renal failure requiring bilateral nephrostomies. At the age of 29, a male patient underwent investigation for life-long constipation. A barium enema showed gross colonic distension. It was decided to proceed with a subtotal colectomy, and in light of the technical difficulties anticipated as a consequence of the gross colonic distension, this was planned as a two-stage procedure. He initially underwent a difficult subtotal colectomy with an end ileostomy, though when he was readmitted for planned reversal of his stoma and an ileorectal anastomosis, the rectum was, during laparotomy, found to be distended. It was, therefore, not felt safe to perform an anastomosis; the rectum was left in place, and the ileostomy was refashioned. The patient was content not to pursue any further surgical intervention. Fifteen years later, the patient presented as an emergency complaining of rectal bleeding and anal pain. On this occasion, his symptoms settled spontaneously, and outpatient flexible sigmoidoscopy of the rectum was planned. He was readmitted in the interim complaining of abdominal distension, difficulty passing urine and further rectal bleeding. On examination, he was normotensive and pyrexial with a temperature of 41°C. His abdomen was distended, with a palpable tender bladder. He was unable to tolerate rectal examination. His blood tests revealed acute renal impairment, with a creatinine of 220, a urea of 16.7, potassium of 5.6, WCC 12.9, and CRP 166. He was catheterised and drained 1,800 ml of urine; urinalysis was positive for blood and nitrates. He was started on broad spectrum intravenous antibiotics. An ultrasound of the renal tract demonstrated bilateral hydronephrosis. He went on to have bilateral nephrostomies, with a consequent improvement in his renal function. A CT of Int J Colorectal Dis (2008) 23:1143–1144 DOI 10.1007/s00384-008-0491-3

A 48-year-old woman presented to the emergency department complaining of wrist pain after a fall onto her outstretched hand. Examination revealed generalised carpal tenderness with a reduction in wrist movements. Following an x-ray she was diagnosed as having a carpal ligament sprain and …

Pharyngocutaneous fistulae occur in 15%-25% of patients after total laryngectomy. Factors that may predispose to fistulae formation include prior radiation, surgical technique, tumor size and location, and patient nutritional status. In addition, many surgeons believe that the timing of oral feeding after surgery contributes to fistula development. Thus, they advocate delaying feeding postoperatively, especially in high-risk patients. The traditional guideline has been to wait until the seventh postoperative day. The purpose of this study was to examine the relationship between the timing of postoperative oral feeding and the development of pharyngocytaneous fistulae after total laryngectomy with primary closure in patients with squamous cell carcinoma. A questionnaire was sent to 210 members of the American Society for Head and neck Surgery to determine practice patterns toward feeding after laryngectomy. We also reviewed the records of 137 patients who underwent total laryngectomy at the University of Colorado Health Sciences Center and the Denver VA Medical Center from January 1975 through December 1987. Of the surgeons polled, 84.5% waited at least 7 days after surgery to begin oral feeding. However, in reviewing 94 patients eligible for study, we found no difference in the rate of fistula formation between patients fed on or before the fifth postoperative day and those fed on or after the sixth postoperative day. In fact, most fistulae were evident before the patient started oral feeding. Pyriform sinus tumors were predisposed to fistulae but prior radiotherapy and neck dissection seemed to have no effect. Earlier oral feeding after total laryngectomy may improve patient comfort and shorten hospital stay without increasing the incidence of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the effect of retrolabyrinthine vestibular nerve section (RVNS) on hearing, vertigo, and associated symptoms, we reviewed our experience in 48 patients. Of the 48, 39 responded to a questionnaire. Although RVNS appeared to have little effect on hearing in Meniere's patients, 91% of non-Meniere's patients had significant and often delayed postoperative sensorineural hearing loss. Our results for vertigo control compared favorably to previous reports with 96% of Meniere's patients and 69% of non-Meniere's patients reporting improvement. Presently, we more frequently recommend RVNS as the primary procedure for the control of severe vertigo in Meniere's patients. Patients with vertigo from other causes must be carefully selected.

IN OUR search for a less time-consuming method for measuring anatomical components and spaces within samples of wood of varying ages and heights in trees, we have found that the use of an integrating stage attached to the stage of a microscope has proved satisfactory and reliable1. Accumulating knobs are provided to measure units in hundredths of millimetres for six different readings in one traverse, and obtaining percentage values for each component is a simple operation.