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Introduction The empty pelvis syndrome is a significant source of morbidity following pelvic exenteration surgery. It remains poorly defined with research in this field being heterogeneous and of low quality. Furthermore, there has been minimal engagement with patient representatives following pelvic exenteration with respect to the empty pelvic syndrome. ‘PelvEx—Beating the empty pelvis syndrome’ aims to engage both patient representatives and healthcare professionals to achieve an international consensus on a core outcome set, pathophysiology and mitigation of the empty pelvis syndrome.Methods and analysis A modified-Delphi approach will be followed with a three-stage study design. First, statements will be longlisted using a recent systematic review, healthcare professional event, patient and public engagement, and Delphi piloting. Second, statements will be shortlisted using up to three rounds of online modified Delphi. Third, statements will be confirmed and instruments for measurable statements selected using a virtual patient-representative consensus meeting, and finally a face-to-face healthcare professional consensus meeting.Ethics and dissemination The University of Southampton Faculty of Medicine ethics committee has approved this protocol, which is registered as a study with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of this study will increase the potential for comparative research to further understanding and prevent the empty pelvis syndrome.Trial registration number NCT05683795.

Background: Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed., Aims: To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services., Methods: We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary., Results: Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world., Conclusion: Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival., Methods: Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed., Results: The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients., Conclusion: The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Intraabdominal and retroperitoneal sarcomas (IaRS) are malignant connective tissue tumors. Surgical resection is often the only curative treatment. The primary objective was to report the mid-term outcomes following contemporary treatment protocols and identify prognostic factors., Methods: A retrospective review of consecutive patients (n = 107) with IaRS treated at single center from 2013 until 2018 was conducted. Histological diagnosis, tumor grade, perioperative complications, mortality, and long-time survival were registered and retrieved from patient records. Primary and recurrent tumors were analyzed separately., Results: A total of 107 patients were identified. Median follow-up time was 3.5 years. Thirty-day mortality was 3.4% and 90-day mortality was 5.6% for all tumors. The major complication rate was 18%. The 5-year estimated survival for primary and recurrent tumors was 55.4% and 48.4%, respectively. Multifocal disease was evident in 32% of the patient cohort, and 58% of patients in the recurrent group. Multivariate analysis for survival revealed a hazard ratio (HR) of 3.1 (95% CI 1.68-8.41) for multifocality, HR 2.9 (95% CI 1.28-6.98) for Clavien-Dindo grade, HR 2.3 (95% CI 1.21-4.31) for tumor grades 2 or 3, and HR 1.002 (95% CI 1.001-1.004) for surgical margins., Conclusions: Our study found overall acceptable morbidity and mortality, and identified prognostic markers for overall survival. Recurrent tumors were not associated with worse survival. Multifocality is associated with a worse overall survival. The prognostic factors identified were; tumor grade, multifocality, intralesional margins and postoperative complications., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort ( n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors ( p = 0.038). Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Oerskov, Bondeven, Laurberg, Hagemann-Madsen, Christensen, Lauridsen and Pedersen.)

Introduction: Nitrate-induced headache is common and may signify responsive cerebral vasculature. We assessed the relationship between nitrate headache and outcome in patients with acute stroke., Materials and Methods: Patients were those randomised to glyceryl trinitrate (GTN) versus no GTN in the efficacy of nitric oxide in stroke trial. Development of headache by end of treatment (day 7), and functional outcome (modified Rankin Scale, primary outcome) at day 90, were assessed. Analyses are adjusted for baseline prognostic factors and give OR and mean difference (MD) with 95% CI., Results: In 4011 patients, headache was more common in GTN than control (360, 18.0% vs 170, 8.5%; p<0.001). Nitrate-related headache was associated with: younger age, female sex, higher diastolic blood pressure, non-total anterior circulation syndrome, milder stroke and absence of dysphasia (p<0.05). Nitrate headache was not associated with improved functional outcome (OR 0.90, 95% CI 0.73 to 1.10, p=0.30) or death (day 90) (HR 0.64, 95% CI 0.40 to 1.02, p=0.062), but reduced death or deterioration (day 7) (OR 0.45, 95% CI 0.25 to 0.82), death in hospital (OR 0.44, 95% CI 0.22 to 0.88) and improved activities of daily living (Barthel index, MD 3.7, 95% CI 0.3 to 7.1) and cognition (telephone interview cognitive screen, MD 2.0, 95% CI 0.7 to 3.3) (day 90). Non-nitrate headache was not associated with death, disability or cognition., Discussion and Conclusion: Development of a nitrate headache by day 7 after stroke may be associated with improved activities of daily living and cognitive impairment at day 90, which was not seen with non-nitrate headache., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To evaluate benefits and harms for computer based cognitive rehabilitation (CBCR) on working memory impairment after stroke., Methods: PRISMA guidelines were followed. Four electronic databases were systematically searched: Embase, Pubmed/Medline, PsycInfo and Cochrane Library. Authors of relevant studies were contacted to detect unpublished data or articles not found by searching databases., Selection Criteria: Studies were eligible for inclusion in the systematic review if they 1) investigated the effects of CBCR on working memory after acquired brain injury in a patient sample which consisted of at least 50% stroke-patients, 2) it was possible to isolate the effects of CBCR-training by comparison to passive or active control groups, and 3) if the outcome assessment included a quantitative working memory outcome measure either isolated or as part of a general outcome measure. Included studies were further eligible for the meta-analysis if 1) they were conducted as a randomized controlled trial, 2) they included only stroke patients, and 3) the effects of CBCR on working memory could be isolated., Results: Literature is limited and reported effects of CBCR on working memory after stroke are very heterogeneous. A meta-analysis was not performed as all studies used different measures of working memory. An additional analysis was performed in order to cautiously estimate the difference between the control interventions (whether passive or active) and CBCR interventions. The analysis revealed no meaningful differences in increase of working memory measures between control conditions and intervention conditions. However, this additional analysis should be interpreted with caution as it does not take the heterogeneity of outcome measures or the differences in sample sizes between studies into account. No harms were observed., Conclusion: There is insufficient evidence to conclude if CBCR is beneficial for patients with working memory deficits after stroke., Systematic Review Number: This systematic review is registered in Prospero with registration ID: CRD42018087437., Competing Interests: Declarations of interest statement None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: As of October 2020, COVID-19 has caused 1,000,000 deaths worldwide. However, large-scale studies of COVID-19 mortality and new-onset comorbidity compared to individuals tested negative for COVID-19 and individuals tested for influenza A/B are lacking. We investigated COVID-19 30-day mortality and new-onset comorbidity compared to individuals with negative COVID-19 test results and individuals tested for influenza A/B. Methods and findings: This population-based cohort study utilized electronic health records covering roughly half ( n = 2,647,229) of Denmark's population, with nationwide linkage of microbiology test results and death records. All individuals ≥18 years tested for COVID-19 and individuals tested for influenza A/B were followed from 11/2017 to 06/2020. Main outcome was 30-day mortality after a test for either COVID-19 or influenza. Secondary outcomes were major comorbidity diagnoses 30-days after the test for either COVID-19 or influenza A/B. In total, 224,639 individuals were tested for COVID-19. To enhance comparability, we stratified the population for in- and outpatient status at the time of testing. Among inpatients positive for COVID-19, 356 of 1,657 (21%) died within 30 days, which was a 3.0 to 3.1-fold increased 30-day mortality rate, when compared to influenza and COVID-19-negative inpatients (all p < 0.001). For outpatients, 128 of 6,263 (2%) COVID-19-positive patients died within 30 days, which was a 5.5 to 6.9-fold increased mortality rate compared to individuals tested negative for COVID-19 or individuals tested positive or negative for influenza, respectively (all p < 0.001). Compared to hospitalized patients with influenza A/B, new-onset ischemic stroke, diabetes and nephropathy occurred more frequently in inpatients with COVID-19 (all p < 0.05). Conclusions: In this population-based study comparing COVID-19 positive with COVID-19 negative individuals and individuals tested for influenza, COVID-19 was associated with increased rates of major systemic and vascular comorbidity and substantially higher mortality. Results should be interpreted with caution because of differences in test strategies for COVID-19 and influenza, use of aggregated data, the limited 30-day follow-up and the possibility for changing mortality rates as the pandemic unfolds. However, the true COVID-19 mortality may even be higher than the stated 3.0 to 5.5-fold increase, owing to more extensive testing for COVID-19., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Nersesjan, Amiri, Christensen, Benros and Kondziella.)

Objective: To assess the association of baseline imaging markers of cerebral small vessel disease (SVD) and brain frailty with clinical outcome after acute stroke in the Efficacy of Nitric Oxide in Stroke (ENOS) trial., Methods: ENOS randomized 4,011 patients with acute stroke (<48 hours of onset) to transdermal glyceryl trinitrate (GTN) or no GTN for 7 days. The primary outcome was functional outcome (modified Rankin Scale [mRS] score) at day 90. Cognition was assessed via telephone at day 90. Stroke syndrome was classified with the Oxfordshire Community Stroke Project classification. Brain imaging was adjudicated masked to clinical information and treatment and assessed SVD (leukoaraiosis, old lacunar infarcts/lacunes, atrophy) and brain frailty (leukoaraiosis, atrophy, old vascular lesions/infarcts). Analyses used ordinal logistic regression adjusted for prognostic variables., Results: In all participants and those with lacunar syndrome (LACS; 1,397, 34.8%), baseline CT imaging features of SVD and brain frailty were common and independently associated with unfavorable shifts in mRS score at day 90 (all participants: SVD score odds ratio [OR] 1.15, 95% confidence interval [CI] 1.07-1.24; brain frailty score OR 1.25, 95% CI 1.17-1.34; those with LACS: SVD score OR 1.30, 95% CI 1.15-1.47, brain frailty score OR 1.28, 95% CI 1.14-1.44). Brain frailty was associated with worse cognitive scores at 90 days in all participants and in those with LACS., Conclusions: Baseline imaging features of SVD and brain frailty were common in lacunar stroke and all stroke, predicted worse prognosis after all acute stroke with a stronger effect in lacunar stroke, and may aid future clinical decision-making., Identifier: ISRCTN99414122., (Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Objectives: The purpose of this pilot study was to investigate the feasibility and effects of computer-based cognitive rehabilitation (CBCR) in patients with symptoms of visuospatial neglect or homonymous hemianopia in the subacute phase following stroke., Method: A randomized, controlled, unblinded cross-over design was completed with early versus late CBCR including 7 patients in the early intervention group (EI) and 7 patients in the late intervention group (LI). EI received CBCR training immediately after inclusion (m = 19 days after stroke onset) for 3 weeks and LI waited for 3 weeks after inclusion before receiving CBCR training for 3 weeks (m = 44 days after stroke onset)., Results: CBCR improved visuospatial symptoms after stroke significantly when administered early in the subacute phase after stroke. The same significant effect was not found when CBCR was administered later in the rehabilitation. The difference in the development of the EI and LI groups during the first 3 weeks was not significant, which could be due to a lack of statistical power. CBCR did not impact mental well-being negatively in any of the groups. In the LI group, the anticipation of CBCR seemed to have a positive impact of mental well-being., Conclusion: CBCR is feasible and has a positive effect on symptoms in patients with visuospatial symptoms in the subacute phase after stroke. The study was small and confirmation in larger samples with blinded outcome assessors is needed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: There is concern that blood pressure (BP) lowering in acute stroke may compromise cerebral perfusion and worsen outcome in the presence of carotid stenosis. We assessed the effect of glyceryl trinitrate (GTN) in patients with carotid stenosis using data from the Efficacy of Nitric Oxide in Stroke (ENOS) Trial., Methods: ENOS randomised 4011 patients with acute stroke and raised systolic BP (140-220 mm Hg) to transdermal GTN or no GTN within 48 hours of onset. Those on prestroke antihypertensives were also randomised to stop or continue their medication for 7 days. The primary outcome was the modified Rankin Scale (mRS) at day 90. Ipsilateral carotid stenosis was split: <30%; 30-<50%; 50-<70%; ≥70%. Data are ORs with 95% CIs adjusted for baseline prognostic factors., Results: 2023 (60.5%) ischaemic stroke participants had carotid imaging. As compared with <30%, ≥70% ipsilateral stenosis was associated with an unfavourable shift in mRS (worse outcome) at 90 days (OR 1.88, 95% CI 1.44 to 2.44, p<0.001). Those with ≥70% stenosis who received GTN versus no GTN had a favourable shift in mRS (OR 0.56, 95% CI 0.34 to 0.93, p=0.024). In those with 50-<70% stenosis, continuing versus stopping prestroke antihypertensives was associated with worse disability, mood, quality of life and cognition at 90 days. Clinical outcomes did not differ across bilateral stenosis groups., Conclusions: Following ischaemic stroke, severe ipsilateral carotid stenosis is associated with worse functional outcome at 90 days. GTN appears safe in ipsilateral or bilateral carotid stenosis, and might improve outcome in severe ipsilateral carotid stenosis., Competing Interests: Competing interests: PMB is Stroke Association Professor of Stroke Medicine, Chief Investigator of MRC ENOS, and a NIHR Senior Investigator. PMB reports grants from British Heart Foundation and the NIHR Health Technology Assessment Programme, during the conduct of the study; other from Platelet Solutions Ltd, personal fees from Diamedica, personal fees from Nestle, personal fees from Phagenesis Ltd, personal fees from ReNeuron, personal fees from Athersys, personal fees from Covidien, outside the submitted work.

Background and Purpose- Increased blood pressure (BP), heart rate, and their derivatives (variability, pulse pressure, rate-pressure product) are associated with poor clinical outcome in acute stroke. We assessed the effects of glyceryl trinitrate (GTN) on hemodynamic parameters and these on outcome in participants in the ENOS trial (Efficacy of Nitric Oxide in Stroke). Methods- Four thousand and eleven patients with acute stroke and raised BP were randomized within 48 hours of onset to transdermal GTN or no GTN for 7 days. Peripheral hemodynamics were measured at baseline (3 measures) and daily (2 measures) during treatment. Between-visit BP variability over days 1 to 7 (as SD) was assessed in quintiles. Functional outcome was assessed as modified Rankin Scale and cognition as telephone mini-mental state examination at day 90. Analyses were adjusted for baseline prognostic variables. Data are mean difference or odds ratios with 95% CI. Results- Increased baseline BP (diastolic, variability), heart rate, and rate-pressure product were each associated with unfavorable functional outcome at day 90. Increased between-visit systolic BP variability was associated with an unfavourable shift in modified Rankin Scale (highest quintile adjusted odds ratio, 1.65; 95% CI, 1.37-1.99), worse cognitive scores (telephone mini-mental state examination: highest quintile adjusted mean difference, -2.03; 95% CI, -2.84 to -1.22), and increased odds of death at day 90 (highest quintile adjusted odds ratio, 1.57; 95% CI, 1.12-2.19). GTN lowered BP and rate-pressure product and increased heart rate at day 1 and reduced between-visit systolic BP variability. Conclusions- Increased between-visit BP variability was associated with poor functional and cognitive outcomes and increased death 90 days after acute stroke. In addition to lowering BP and rate-pressure product, GTN reduced between-visit systolic BP variability. Agents that lower BP variability in acute stroke require further study.

Post-stroke dysphagia is common, associated with poor outcome and often requires non-oral feeding/fluids. The relationship between route of feeding and outcome, as well as treatment with glyceryl trinitrate (GTN), was studied prospectively. The Efficacy of Nitric Oxide in Stroke (ENOS) trial assessed transdermal GTN (5 mg versus none for 7 days) in 4011 patients with acute stroke and high blood pressure. Feeding route (oral = normal or soft diet; non-oral = nasogastric tube, percutaneous endoscopic gastrostomy tube, parenteral fluids, no fluids) was assessed at baseline and day 7. The primary outcome was the modified Rankin Scale (mRS) measured at day 90. At baseline, 1331 (33.2%) patients had non-oral feeding, were older, had more severe stroke and more were female, than 2680 (66.8%) patients with oral feeding. By day 7, 756 patients had improved from non-oral to oral feeding, and 119 had deteriorated. Non-oral feeding at baseline was associated with more impairment at day 7 (Scandinavian Stroke Scale 29.0 versus 43.7; 2p < 0.001), and worse mRS (4.0 versus 2.7; 2p < 0.001) and death (23.6 versus 6.8%; 2p = 0.014) at day 90. Although GTN did not modify route of feeding overall, randomisation ≤6 h of stroke was associated with a move to more oral feeding at day 7 (odds ratio = 0.61, 95% confidence intervals 0.38, 0.98; 2p = 0.040). As a proxy for dysphagia, non-oral feeding is present in 33% of patients with acute stroke and associated with more impairment, dependency and death. GTN moved feeding route towards oral intake if given very early after stroke. Clinical Trial Registration Clinical Trial Registration-URL: http://www.controlled-trials.com . Unique identifier: ISRCTN99414122.

Aim: Preventive home visits (PHVs) to frail elderly patients, provided by the GP, have been widely promoted in many health care systems, including the Danish system. This study investigates to what extent PHVs are provided to patients with characteristics of frailty., Methods: During a four-week period, GPs and their staff in three different parts of Denmark filled in a questionnaire for each patient aged 75 years or older who attended the clinic or received a home visit. The association between 20 different frailty characteristics and the receipt of a PHV was assessed through logistic regression., Results: A total of 73 GPs and 41 staff members sampled information about 3133 patients, of whom 332 patients (10.7%) had received a PHV within one year prior to their audit date. A PHV was closely associated with the patient's number of frailty characteristics. The adjusted odds ratios show that the receipt of a PHV was associated with a low walking distance 2.34 (1.65-3.31), dementia 3.35 (2.26-4.96), depression 2.24 (1.38-3.63) and a need for home care 3.40 (2.45-4.73), and increased with the GP's tendency to provide PHVs., Conclusion: Most PHV-receiving elderly patients have several characteristics of frailty, the most significant being impaired mobility, dementia, depression and a need for home care. PHVs are also more often provided to patients listed with a GP who has an overall high tendency to conduct these visits., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background Thrombolysis with intravenous recombinant tissue-type plasminogen activator improves functional outcome in acute ischemic stroke. Few studies have investigated the effects of thrombolysis in a real-world setting. We evaluated the impact of thrombolysis on long-term hospital bed day use and the risk of readmission due to stroke-related complications. Methods We conducted a register-based nationwide propensity score-matched follow-up study among ischemic stroke patients in Denmark (2004-2011). Thrombolysed patients were propensity-score matched with non-thrombolysed acute ischemic stroke patients admitted to stroke centers not yet offering thrombolysis in 2004-2006. The outcomes were length of the stroke admission, total all-cause hospital bed day use during the first year after the stroke, and the long-term risk of readmissions. Thrombolysed and non-thrombolysed patients were compared using multivariable log-linear regression and Cox regression. Results We identified 1095 thrombolysed and 1095 propensity score matched eligible but non-thrombolysed acute ischemic stroke patients. The median length of the stroke admission was 9 days in the thrombolysed group and 13 days in the non-thrombolysed group (adjusted geometric mean ratio, 0.88; 95% CI: 0.78-1.00). The median all-cause hospital bed day use within the first year was 12 days in the thrombolysed group and 19 days in the non-thrombolysed group (adjusted geometric mean ratio, 0.82; 95% CI: 0.73-0.92). There was no significant difference in the overall risk of readmission (adjusted hazard ratio, 0.91; 95% CI: 0.79-1.04); however, thrombolysis was associated with reduced risk of pneumonia (adjusted hazard ratio, 0.59; 95% CI: 0.35-0.97). Conclusions Thrombolysis in ischemic stroke was associated with lower long-term hospital bed day use and decreased risk of readmission due to pneumonia.

Residency training clearly impacts physicians' approach toward fellowship in Primary Care Sports Medicine. Although the Accreditation Council for Graduate Medical Education sets strict standards for all programs, family medicine and emergency medicine training differ a great deal in general and provide physicians from both backgrounds varied perspectives and skill sets. The family physician acquires a substantial amount of experience in continuity of care and integration of health care into a patient's everyday life. On the other hand, the emergency physician receives exceptional training in the management of acutely ill and injured patients and leadership of a large health care team. Furthermore, while the emergency physician may be skilled in procedures such as fracture reduction and diagnostic ultrasound, the family physician is proficient in developing patient rapport and compliance with a treatment plan. Although physicians from different backgrounds may start with many differences, fellowship training is essential in bridging those gaps.

Background: The use of the vertical rectus abdominis myocutaneous flap in reconstruction after abdominoperineal resection or pelvic exenteration for neoplasia is well documented. However, functional outcomes after vaginal reconstruction, including sexual function, are poorly described., Objective: This study aimed to examine sexual function in women following extensive pelvic surgery with colpectomy and vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap., Design: This study is a retrospective review of medical records in combination with patient questionnaires. Nonresponders were followed up with a second contact., Settings: This study was performed at a tertiary care university medical center (Colorectal Section, Department of Surgery P, Aarhus University Hospital, Denmark), Patients: All women undergoing pelvic surgery and simultaneous vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap between 2004 and 2010 at our department were identified from a patient database. Thirty women who were alive at the time of identification were included in the study., Main Outcome Measures: Sexual function before and after surgery was evaluated by the use of the Sexual function Vaginal changes Questionnaire. The main outcome end point was whether the patient was sexually active after vaginal reconstruction., Results: Twenty-six participants (87%) answered the questionnaire. Fifty percent of patients reported an active sex life before surgery. In general, patients reported an unchanged desire for both physical and sexual contact after surgery. However, only 2 patients (14%) reported being sexually active after surgery., Limitations: This was a retrospective study with a heterogeneous cohort involving several types of cancers and surgical procedures. Factors other than vertical rectus abdominis myocutaneous flap reconstruction itself may interfere with the sexual function., Conclusion: Extensive pelvic surgery with colpectomy leads to sexual dysfunction even when the vagina is reconstructed with a vertical rectus abdominis myocutaneous flap. This knowledge may improve the quality of information given to this group of patients before surgery.

Purpose: To retrospectively assess treatment outcome of image and laparoscopic guided interstitial pulsed dose rate brachytherapy (PDR-BT) for locally advanced gynaecological cancer using the adaptive GEC ESTRO target concept., Materials and Methods: Between June 2005 and December 2010, 28 consecutive patients were treated for locally advanced primary vaginal (nine), recurrent endometrial (12) or recurrent cervical cancer (seven) with combined external beam radiotherapy (EBRT) and interstitial PDR-BT. Treatment was initiated with whole pelvic EBRT to a median dose of 45 Gy followed by PDR-BT using the Martinez Universal Perineal Interstitial Template (MUPIT). All implants were virtually preplanned using MRI of the pelvis with a dummy MUPIT in situ. The GEC ESTRO high risk clinical target volume (HR CTV), intermediate risk clinical target volume (IR CTV) and the organs at risk (OAR) were contoured and a preplan for implantation was generated (BrachyVision, Varian). The subsequent implantation was performed under laparoscopic visualisation. Final contouring and treatment planning were done using a post-implant CT. Planning aim of PDR-BT was to deliver 30 Gy in 50 hourly pulses to HR CTV. Manual dose optimisation was performed with the aim of reaching a D90>80 Gy in the HR CTV calculated as the total biologically equivalent to 2 Gy fractions of EBRT and BT (EQD2). Dose to the OAR were evaluated using dose volume constraints for D(2cc) of 90 Gy for bladder and 70 Gy for rectum and sigmoid., Results: For HR CTV the median volume was 26 cm(3) (7-91 cm(3)). Coverage of the HR CTV was 97% (90-100%) and D90 was 82 Gy (77-88 Gy). The D(2cc) for bladder, rectum, and sigmoid were 65 Gy (47-81 Gy), 61 Gy (50-77 Gy), and 52 Gy (44-68 Gy), respectively. Median follow up was 18 months (6-61 months). The actuarial 2 years local control rate was 92% (SE 5), while disease-free survival and overall survival were 59% (SE 11) and 74%, respectively (SE 10). No complications to the laparoscopic guided implantation were encountered. Late grade 2 (CTC v 3.0) complications were recorded in nine (32%) patients. One patient had a grade 3 vaginal complication. No grade 4-5 complications have been recorded so far., Conclusion: Image and laparoscopic guided interstitial PDR-BT using the GEC ESTRO target concept is applicable for locally advanced primary vaginal or recurrent endometrial and cervical cancer resulting in an excellent local control rate and limited morbidity., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Extralevator abdominoperineal excision for low rectal cancer includes resection of the pelvic floor as a part of the operative technique to reduce the risk of tumor-involved section margins., Objective: This study aimed to compare perineal defect reconstruction with a fasciocutaneous gluteal flap vs biological mesh regarding healing and occurrence of perineal hernia., Design: Retrospective review of medical records comparing surgical methods during 2 consecutive periods., Settings: Tertiary care university medical center (Colorectal Section, Surgical Department P, Aarhus University Hospital, Denmark)., Patients: Patients with low rectal cancer who underwent extralevator abdominoperineal excision from December 2005 through October 2008 were included., Intervention: The perineum was reconstructed with a fasciocutaneous gluteal flap in the first period and with a biological mesh in the second period., Main Outcome Measures: We assessed rates of perineal wound infection requiring surgical intervention and perineal hernia diagnosed by clinical examination., Results: The study comprised 57 patients: 33 patients with gluteal flap and 24 with biological mesh reconstruction. Perineal hernia developed in 7 (21%) patients in the gluteal flap group and in none (0%) of the patients in the mesh group (P < .01). Median follow-up was 3.2 (1.7-4.3) years for gluteal flap and 1.7 (0.4-2.2) years for biologic mesh. All hernias occurred within the first postoperative year (median, 6 months; range, 1-12 months). Infectious complications were seen in 2 patients (6%) with a gluteal flap and in 4 patients (17%) with mesh repair (P = .26). After 3 months, all patients were completely healed except for 1 patient in each group with a persistent perineal sinus. The median (range) hospital stay was 14 (8-23) days in the flap group and 9 days (6-35) in the mesh group (P < .05)., Limitations: This was a nonrandomized retrospective observational study comparing 2 methods used in different time periods., Conclusion: We recommend biological mesh reconstruction of the pelvic floor after extralevator abdominoperineal resection because this method can achieve a high healing rate with an acceptable risk of infection, a low hernia rate, and a shorter hospital stay without donor-site morbidity.

The crucial aspect of open as well as laparoscopic rectal cancer surgery is to find the correct dissection plane to avoid damage of the nerves and to create a perfect specimen. By doing so, a "specimen oriented" resection will be achieved and the risk of a positive circumferential resection margin minimized. Currently, and for the foreseeable future, open surgery remains optimal for complex cases and in cases where a low difficult restorative resection is needed. Optimal surgery remains a crucial part in the curative treatment of this technically challenging cancer.

Purpose: The aim was to implement a fast-track model in a colorectal unit. We evaluated its effects on hospital stay and complication rate after elective open colonic surgery., Methods: A fast-track programme was fully implemented, with a dedicated staff and a schedule for all perioperative procedures which included provision of information to patients, surgical guidelines, mobilisation and postoperative care. All previously existing procedures were modified according to previously published guidelines. Criteria for success with regard to the length of hospital stay and rates and types of complications were defined. Fast-tracked patients were compared with patients not included in the programmes that were operated during the same period., Results: 131 fast-tracked patients were compared with 39 control patients. The fast track significantly reduced the median hospital stay from 7 to 3 days (p < 0.0001). There was no difference in complication rates between the two groups, and no major complications were observed after early discharge from the hospital. The readmission rate was 15% in the fast-track group and 16% with the control patients., Conclusion: Implementation of a fast track after open elective colonic surgery is safe and reduces the length of hospital stay., (Copyright © 2011 S. Karger AG, Basel.)

Introduction: Tobacco smoking is a well-known risk factor for stroke. The aim of this study was to assess whether smokers suffering ischaemic or haemorrhagic stroke differ from non-smokers in age, gender, socio-economic status, risk factors, pre-stroke level of function, and stroke severity., Materials and Methods: This work is based on 1,208 consecutive patients admitted to an acute stroke unit in a well-defined region of Copenhagen., Results: Haemorrhagic stroke was not correlated to smoking habits. In the patients with cerebral infarctions, we found no difference between smokers and non-smokers in stroke severity on admission or outcome at three months. The smokers were younger than the non-smokers. The mean age difference between smokers and non-smokers with ischemic cerebrovascular disease was nine years (95% CI 6.9-10.4), with the highest frequencies of smokers in male patients aged below 67 years and female patients aged below 74 years. The proportion of smokers in our stroke patients was larger than that in the general population. Lower socio-economic status was also related to a younger age at the onset of stroke., Discussion: This study demonstrates that stroke patients who smoke are on average nine years younger than non-smoking patients and thus emphasises the health hazards of smoking.

Forty-one patients with lymphomatoid papulosis have been followed from 1 to 22 years (mean 11.4 years, median 10 years). Six patients developed malignant lymphoma, 3 cutaneous T-cell lymphoma, 2 Ki-1 large cell lymphoma, and 1 Hodgkin's disease. A clinical malignant presentation combined with the finding of aneuploidy in skin lesions seem to be indications of a malignant potential. Treatment with methotrexate in low dosage is an efficient treatment of lymphomatoid papulosis and probably diminishes the risk of malignancy.

Five different bicarbonate-based continuous ambulatory peritoneal dialysis (CAPD) solutions (pH: 7.0-7.4; bicarbonate: 10-27 mM; lactate: 20.8-6.7 mM) were produced in order to examine the cytotoxic effects of the different compositions. The migratory capacity of normal human polymorphonuclear (PMN) granulocytes after exposure to the solutions was used as a cytotoxicity assay. All the tested solutions reduced cellular function compared to a standard cell culture medium, but considerable differences between the solutions were observed. The optimal conditions for the PMN migration were at a pH of 7.0 and at bicarbonate and lactate concentrations of 20 mM and 12.5 mM, respectively. Bicarbonate concentrations of more than 25 mM were associated with reduced cellular function as were lactate concentrations of more than 15 mM. The most advantageous CAPD solution regarding cytotoxicity towards normal human PMN's is a combination of a lactate and bicarbonate-based solution, which has a bicarbonate concentration of approximately 20 mM, a lactate concentration of 12.5 mM, and a pH of approximately 7.2.

Previous in vitro biocompatibility studies have shown bicarbonate-based continuous ambulatory peritoneal dialysis (CAPD) fluids to be superior to those based upon lactate/acetate. To evaluate these findings in vivo, 41 rabbits were subjected to CAPD for four weeks in a randomized prospective study using either Dianeal, a commercially available dialysis fluid containing lactate, or 87b, a bicarbonate-based CAPD fluid. Ten rabbits with CAPD catheters, which were flushed with a heparin solution every 36 hours, served as controls. None of the control rabbits showed clinical or histopathological signs of peritonitis, while 8 of 20 in the Dianeal group and 6 of 21 in the 87b group contracted peritonitis. Four rabbits in the Dianeal group had to be sacrificed early due to severe peritonitis. Post mortem examinations, including scanning and light microscopy, did not reveal any macroscopic or microscopic differences among the three groups of noninfected animals. No significant distinctions between the groups could be made for body temperature, weight gain, dialysate volume, dialysate differential leukocyte count, dialysate protein content, and food intake during the course of the study. In conclusion, the present animal model did not reveal any major difference in the biocompatibility between the lactate- and the bicarbonate-based CAPD fluids.

In a prospective, randomised, double blind controlled trial the adverse reactions, food consumption, changes in blood chemistry including acid-base balance, and anthropometry were studied during two consecutive dialysis periods of 3 months, using either acetate- or bicarbonate-based dialysis fluids. Sixteen chronic, stable patients were included. The dialysis fluid sodium content was fixed at 140 mmol/l during all treatments. Patient complaints and adverse reactions were identical using the two dialysis fluids. No differences were observed regarding blood chemistry except for a less pronounced metabolic acidosis present during bicarbonate dialysis compared to acetate dialysis. A slight but insignificant increment in food consumption and nutritional status was noticed during bicarbonate dialysis. In conclusion, the use of a bicarbonate-based haemodialysis fluid offered no significant advantages compared to an acetate-based one in the haemodialysis of chronic, stable patients.