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Surgery for patients with pancreatic cancer carries a high risk of major post-operative complications and only marginally improves overall survival. This review aims to assess the impact of surgical resection on health-related quality of life (HRQOL) of pancreatic cancer patients.A systematic review of the literature was performed according to the PRISMA guidelines. All studies assessing QOL using validated questionnaires in pancreatic cancer patients undergoing surgical resection were included.Twenty-two studies were assessed. Patients reported a decrease in physical, social and global scales within the first 3 months after surgery. These values showed improvement and were comparable to baseline values by 6 months. Recovery in emotional functioning towards baseline figures was demonstrated in the first 3 months post-operatively. Symptom scales including pain, fatigue and diarrhoea deteriorated after surgery, but reverted to baseline after 3-6 months.Surgical resection for pancreatic cancer has short-term negative impact on QOL. In the longer term, this will improve and eventually recover to baseline values after 6 months. Knowledge on the impact of surgery on QOL of pancreatic cancer patients is necessary to facilitate decision-making and tailoring of surgical techniques to the individual patient.

Summary Radiomics can interpret radiological images with more detail and in less time compared to the human eye. Some challenges in managing esophageal cancer can be addressed by incorporating radiomics into image interpretation, treatment planning, and predicting response and survival. This systematic review and meta-analysis provides a summary of the evidence of radiomics in esophageal cancer. The systematic review was carried out using Pubmed, MEDLINE, and Ovid EMBASE databases—articles describing radiomics in esophageal cancer were included. A meta-analysis was also performed; 50 studies were included. For the assessment of treatment response using 18F-FDG PET/computed tomography (CT) scans, seven studies (443 patients) were included in the meta-analysis. The pooled sensitivity and specificity were 86.5% (81.1–90.6) and 87.1% (78.0–92.8). For the assessment of treatment response using CT scans, five studies (625 patients) were included in the meta-analysis, with a pooled sensitivity and specificity of 86.7% (81.4–90.7) and 76.1% (69.9–81.4). The remaining 37 studies formed the qualitative review, discussing radiomics in diagnosis, radiotherapy planning, and survival prediction. This review explores the wide-ranging possibilities of radiomics in esophageal cancer management. The sensitivities of 18F-FDG PET/CT scans and CT scans are comparable, but 18F-FDG PET/CT scans have improved specificity for AI-based prediction of treatment response. Models integrating clinical and radiomic features facilitate diagnosis and survival prediction. More research is required into comparing models and conducting large-scale studies to build a robust evidence base.

BACKGROUND The ability to understand health information from electronic sources and apply this knowledge to address a health issue is termed digital health literacy (DHL). With the increasing use of digital technology such as smartphones, DHL has become important in the delivery of healthcare services. OBJECTIVE This study aimed to evaluate the mobile device proficiency and DHL amongst patients in a tertiary center, and identify possible social determinants that influence patients’ DHL. METHODS This is a cross-sectional study of 100 patients attending general surgery clinics from January-March 2022. All patients completed two questionnaires, namely the MDPQ-16 and the eHealth Literacy Scale (eHEALS) tools to quantify mobile phone proficiency and DHL, respectively. Data related to age, gender, educational status and income level was collected to establish relationships between these factors and scores on MDPQ-16 and eHEALS tools. RESULTS 52% of the 100 patients in our cohort were male. The median age was 62 (42-72) years. 85% owned a smartphone as opposed to a standard mobile device. Mobile phone ownership was lower in older patients and lower educational status (p CONCLUSIONS Individual socio-economic factors such as age, income level and educational status are important social determinants of digital health literacy regardless of the broader geographical setting. Further work should focus on understanding the challenges within specific factions of society, and how these can be overcome with the collaboration between service providers. CLINICALTRIAL N/A

Summary Large hiatus hernias with a significant paraesophageal component (types II–IV) have a range of insidious symptoms. Management of symptomatic hernias includes conservative treatment or surgery. Currently, there is no paraesophageal hernia disease-specific symptom questionnaire. As a result, many clinicians rely on the health-related quality of life questionnaires designed for gastro-esophageal reflux disease (GORD) to assess patients with hiatal hernias pre- and postoperatively. In view of this, a paraesophageal hernia symptom tool (POST) was designed. This POST questionnaire now requires validation and assessment of clinical utility. Twenty-one international sites will recruit patients with paraesophageal hernias to complete a series of questionnaires over a five-year period. There will be two cohorts of patients—patients with paraesophageal hernias undergoing surgery and patients managed conservatively. Patients are required to complete a validated GORD-HRQL, POST questionnaire, and satisfaction questionnaire preoperatively. Surgical cohorts will also complete questionnaires postoperatively at 4–6 weeks, 6 months, 12 months, and then annually for a total of 5 years. Conservatively managed patients will repeat questionnaires at 1 year. The first set of results will be released after 1 year with complete data published after a 5-year follow-up. The main results of the study will be patient’s acceptance of the POST tool, clinical utility of the tool, assessment of the threshold for surgery, and patient symptom response to surgery. The study will validate the POST questionnaire and identify the relevance of the questionnaire in routine management of paraesophageal hernias.

This meta-analysis aims to evaluate the long-term survival and prognostic factors in patients with metastatic small intestine neuroendocrine tumors (siNETs). Patients with siNETs usually present with advanced disease, limiting curative treatment options. The overall survival seems favorable compared to other cancers, but differences in terminology, lack of consistent coding, conflicting results from smaller cohorts, and recent developments of new treatment options make (reliable) survival data difficult to achieve. Nevertheless, accurate survival data are essential for many facets of health care. A systematic literature search was performed using MEDLINE®(PubMed), EMBASE®, Web of Science, and Cochrane Library up to June 30, 2021. Studies were included if the overall survival data in patients with metastatic siNETs were reported. The results were pooled in a random-effects meta-analysis and are reported as hazard ratios and 95% CIs. Subgroup analyses and meta-regression were performed to assess the observed heterogeneity and the impact of important prognostic factors. After screening 9065 abstracts, there were 23 studies, published between 1995 and 2021, that met the inclusion criteria, with a total of 8636 patients. The weighted 5- and 10-year overall survival was 67 and 37%, respectively. Meta-regression identified younger age and primary tumor resection to be associated with better prognosis. Subgroup analyses showed similar results. This study confirms that in an advanced, metastatic setting, the weighted 5- and 10-year overall survival reveal a favorable prognosis, improving over the last few decades. Meta-regression showed that age at diagnosis is an important prognostic factor.

BACKGROUND: There is currently a lack of evidence-based guidelines regarding surveillance for recurrence after esophageal and gastric (OG) cancer surgical resection, and which symptoms should prompt endoscopic or radiological investigations for recurrence. The aim of this study was to develop a core symptom set using a modified Delphi consensus process that should guide clinicians to carry out investigations to look for suspected recurrent OG cancer in previously asymptomatic patients. METHODS: A web-based survey of 42 questions was sent to surgeons performing OG cancer resections at high volume centers. The first section evaluated the structure of follow-up and the second, determinants of follow-up. Two rounds of a modified Delphi consensus process and a further consensus workshop were used to determine symptoms warranting further investigations. Symptoms with a 75% consensus agreement as suggestive of recurrent cancer were included in the core symptom set. RESULTS: 27 surgeons completed the questionnaires. A total of 70.3% of centers reported standardized surveillance protocols, whereas 3.7% of surgeons did not undertake any surveillance in asymptomatic patients after OG cancer resection. In asymptomatic patients, 40.1% and 25.9% of centers performed routine imaging and endoscopy, respectively. The core set that reached consensus, consisted of eight symptoms that warranted further investigations included; dysphagia to solid food, dysphagia to liquids, vomiting, abdominal pain, chest pain, regurgitation of foods, unexpected weight loss and progressive hoarseness of voice. CONCLUSION: There is global variation in monitoring patients after OG cancer resection. Eight symptoms were identified by the consensus process as important in prompting radiological or endoscopic investigation for suspected recurrent malignancy. Further randomized controlled trials are necessary to link surveillance strategies to survival outcomes and evaluate prognostic value. ispartof: DISEASES OF THE ESOPHAGUS vol:36 issue:1 ispartof: location:United States status: published

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer-related deaths. Of the various established risk factors for this aggressive condition, diet is a notable modifiable risk factor. This review aims to summarize the mounting evidence to suggest the role of diet, the microbiota and their cross-talk in modulating an individual's risk of developing CRC.Specifically, the metabolism of bile acids and its symbiosis with the microbiota has gained weight given its basis on a high meat, high fat, and low fibre diet that is present in populations with the highest risk of CRC. Bacteria modify bile acids that escape enterohepatic circulation to increase the diversity of the human bile acid pool. The production of microbial bile acids contributes to this as well. Epidemiological studies have shown that changing the diet results in different levels and composition of bile acids, which has in turn modified the risk of CRC at a population level. Evidence to identify underlying mechanisms have tied into the microbiota-led digestions of various foods into fatty acids that feedback into bile acid physiology as well as modulation of endogenous receptors for bile acids.There is adequate evidence to support the role of microbiota in in the metabolism of bile acids, and how this relates to colorectal cancer. Further work is necessary to identify specific bacteriome involved and their underlying mechanistic pathways.

Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. Objective The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy. Methods An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL). Results Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores. Conclusion This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Background Upper gastrointestinal cancers are aggressive malignancies with poor prognosis, even following multimodality therapy. As such, they require timely and accurate diagnostic and surveillance strategies; however, such radiological workflows necessitate considerable expertise and resource to maintain. In order to lessen the workload upon already stretched health systems, there has been increasing focus on the development and use of artificial intelligence (AI)-centred diagnostic systems. This systematic review summarizes the clinical applicability and diagnostic performance of AI-centred systems in the diagnosis and surveillance of esophagogastric cancers. Methods A systematic review was performed using the MEDLINE, EMBASE, Cochrane Review, and Scopus databases. Articles on the use of AI and radiomics for the diagnosis and surveillance of patients with esophageal cancer were evaluated, and quality assessment of studies was performed using the QUADAS-2 tool. A meta-analysis was performed to assess the diagnostic accuracy of sequencing methodologies. Results Thirty-six studies that described the use of AI were included in the qualitative synthesis and six studies involving 1352 patients were included in the quantitative analysis. Of these six studies, four studies assessed the utility of AI in gastric cancer diagnosis, one study assessed its utility for diagnosing esophageal cancer, and one study assessed its utility for surveillance. The pooled sensitivity and specificity were 73.4% (64.6–80.7) and 89.7% (82.7–94.1), respectively. Conclusions AI systems have shown promise in diagnosing and monitoring esophageal and gastric cancer, particularly when combined with existing diagnostic methods. Further work is needed to further develop systems of greater accuracy and greater consideration of the clinical workflows that they aim to integrate within.

Background Perforation of the oesophagus (OP) represent a potentially lethal yet poorly managed clinical condition due to its rarity, variation in clinical presentation and little consensus on the optimal management of these patients. Previous studies have shown that timely and appropriate treatment of OPs is the most important determinant of patient outcomes, and a delay in initiating the correct management within 24 hours increased the mortality rate from 10% to over 60%. Historically, patients have been managed based on the personal experience and preference of the surgeon, and accordingly most patients underwent surgical management based on data from small retrospective case series. Depending on the cause of injury, location of perforation and status of the patient, options include conservative management; endoscopy (stenting or clipping); and surgery (drainage, diversion, primary repair, or oesophagectomy). Currently, there are no recent large-scale studies investigating the outcomes in oesophageal perforation, leading to a paucity of high-grade evidence on the management of oesophageal injuries. This study aims to characterise the variation in the management of OPs, update its epidemiology in the UK; and evaluate the mortality and morbidity outcomes of surgical and non-surgical modalities in managing OP. Methods This was a multi-centred cohort study involving eligible centers from the Association of Upper Gastro-intestinal Surgeons for Great Britain and Ireland (AUGIS) research network. All adult patients who were admitted with a diagnosis of esophageal perforation (iatrogenic, spontaneous or traumatic causes) and managed as an inpatient for more than 24 hours were included in the study. Exclusion criteria were as follows: pediatric population; OP due to anastomotic leaks post-esophagectomy; and unavailability of data matching primary outcome measures. The time period for inclusion of patients was from January 2016 to December 2020. Investigators were asked to actively monitor patients and their electronic medical records to identify post-intervention complications up to 90 days from time of intervention if appropriate. The primary outcome was 90-day mortality. Other secondary outcomes included the incidence of complications secondary to OP or interventions; incidence of 30-day re-intervention; length of hospital stay (LOS) and intensive care unit (ICU) stay; readmission within 30 days; and recurrence. Results During the study period 369 patients with oesophageal perforation from eight centres and were included in the study. The mean age of the population was 63 (18) years, body mass index was 25 (9)kg/m2, 60% were male, 30% were ASA grade 3, and 41% ECOG performance status 0. The aetiology of OP was spontaneous in 57% and iatrogenic in 37%. The mean time from presentation to referral and intervention were 37 hours and 111 hours respectively. In patients transferred from a district general to a tertiary hospital the mean time from presentation to transfer was 100 hours. Surgery was used as the primary treatment approach in 31%, endoscopic intervention in 10% and conservative management in 56%. Thoractomy and laparotomy was used in 20% and 24% respectively, endosponge and endoscopic stent used in 11% and 7% respectively. 90-day mortality was 20% across the cohort, 30-day re-admission rate was 18%, mean ICU stay, and LOS were 10 days and 37 days respectively. 90-day mortality was significantly reduced in the surgery group (9%) when compared with endoscopic (24%) and conservative management groups (28%) (p Conclusions In a centralised oesophageal and gastric cancer service, the management of complex upper gastrointestinal conditions including oesophageal perforation is most commonly centralised to oesophageal and gastric cancer centres. This large multi-centre collaborative study provides robust data concerning modern practices of the management of oesophageal perforation in the UK. Through a detailed and highly granular dataset, we have examined factors associated with the patient pathway, presentation and treatment that are associated with mortality following oesophageal perforation.

Locally advanced esophageal adenocarcinomas (EACs) are treated with multimodal therapy, namely surgery, neoadjuvant chemotherapy (NAC) or chemoradiotherapy (CRT) depending on patient and tumor level factors. Yet, there is little consensus on choice of the optimum systemic therapy. To compare the pathological complete response (pCR) after FLOT, non-FLOT-based chemotherapy and chemoradiotherapy regimes in patients with EACs. A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. Studies were included if they had investigated the use of chemo(radio)therapy regimens in the neoadjuvant setting for EAC and reported the pCR rates. A meta-analysis of proportions was performed to compare the pooled pCR rates between FLOT, non-FLOT and CRT cohorts. We included 22 studies that described tumor regression post-NAC. Altogether, 1,056 patients had undergone FLOT or DCF regimes, while 1,610 patients had received ECF or ECX. The pCR rates ranged from 3.3% to 54% for FLOT regimes, while pCR ranged between 0% and 31% for ECF/ECX protocols. Pooled random-effects meta-meta-analysis of proportions showed a statistically significant higher incidence of pCR in FLOT-based chemotherapy at 0.148 (95%CI: 0.080, 0.259) compared with non-FLOT-based chemotherapy at 0.074 (95%CI: 0.042, 0.129). However, pCR rates were significantly highest at 0.250 (95%CI: 0.202, 0.306) for CRT. The use of enhanced FLOT-based regimens have improved the pCR rates for chemotherapeutic regimes but still falls short of pathological outcomes from CRT. Further work can characterize clinical responses to neoadjuvant therapy and determine whether an organ-preservation strategy is feasible.

Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent malignant pancreatic tumor. Few studies have shown how often PDACs arise from cystic precursor lesions. This special report aims to summarize the evidence on the progression of precancerous lesions to PDAC. A review of the literature found four studies that discussed pancreatic intraepithelial lesions (PanINs), three that discussed mucinous cystic neoplasms (MCN) and five that discussed intraductal papillary neoplasms (IPMNs). PanINs were the most common precursors lesion, with approximately 80% of PDACs originating from this lesion. The lack of evidence characterizing the features of PDAC precursor cystic lesions potentially leads to a subset of patients undergoing surgery unnecessarily. Advancements in molecular techniques could allow the study of cystic lesions at a genetic level, leading to more personalized management.Cancer arising from the ducts within the pancreas is the most common type of pancreatic cancer. Some cancers develop from precancerous changes, but these are not currently well described. Therefore, we have summarized the existing knowledge on the precancerous changes causing pancreatic cancer. We found three main precancerous changes: pancreatic intraepithelial lesions; mucinous cystic neoplasms; and intraductal papillary neoplasms. Pancreatic intraepithelial lesions were the most common pancreatic precancerous lesion, leading to 80% of cancers of the pancreatic ducts. A few studies indicate that patients would benefit from surgery to remove precancerous lesions. We believe that, due to advances in genetic studies, personalized strategies for treating pancreatic cancers will emerge in the future.

BACKGROUND Social media platforms such as YouTube are integral tools for disseminating information about health and wellness to the public. However, anecdotal reports have cited that the human gut microbiome has been a particular focus of dubious, misleading, and, on occasion, harmful media content. Despite these claims, there have been no published studies investigating this phenomenon within popular social media platforms. OBJECTIVE The aim of this study is to (1) evaluate the accuracy and reliability of the content in YouTube videos related to the human gut microbiome and (2) investigate the correlation between content engagement metrics and video quality, as defined by validated criteria. METHODS In this cross-sectional study, videos about the human gut microbiome were searched for on the United Kingdom version of YouTube on September 20, 2021. The 600 most-viewed videos were extracted and screened for relevance. The contents and characteristics of the videos were extracted and independently rated using the DISCERN quality criteria by 2 researchers. RESULTS Overall, 319 videos accounting for 62,354,628 views were included. Of the 319 videos, 73.4% (n=234) were produced in North America and 78.7% (n=251) were uploaded between 2019 and 2021. A total of 41.1% (131/319) of videos were produced by nonprofit organizations. Of the videos, 16.3% (52/319) included an advertisement for a product or promoted a health-related intervention for financial purposes. Videos by nonmedical education creators had the highest total and preferred viewership. Daily viewership was the highest for videos by internet media sources. The average DISCERN and Health on the Net Foundation Code of Conduct scores were 49.5 (SE 0.68) out of 80 and 5.05 (SE 2.52) out of 8, respectively. DISCERN scores for videos by medical professionals (mean 53.2, SE 0.17) were significantly higher than for videos by independent content creators (mean 39.1, SE 5.58; PP CONCLUSIONS The overall quality and reliability of information about the human gut microbiome on YouTube is generally poor. Moreover, there was no correlation between the quality of a video and the level of public engagement. The significant disconnect between reliable sources of information and the public suggests that there is an immediate need for cross-sector initiatives to safeguard vulnerable viewers from the potentially harmful effects of misinformation.

OBJECTIVE: The aim of the study was to provide a rapid synthesis of available data to identify the risk posed by utilizing surgical energy devices intraoperatively due to the generation of surgical smoke, an aerosol. Secondarily it aims to summarize methods to minimize potential risk to operating room staff. SUMMARY BACKGROUND DATA: Continuing operative practice during the coronavirus disease-19 (COVID-19) pandemic places the health of operating theatre staff at potential risk. SARS-CoV2 is transmitted through inhaled droplets and aerosol particles, thus posing an inhalation threat even at considerable distance. Surgical energy devices generate an aerosol of biological particular matter during use. The risk to healthcare staff through use of surgical energy devices is unknown. METHODS: This review was conducted utilizing a rapid review methodology to enable efficient generation and dissemination of information useful for concurrent clinical practice. RESULTS: There are conflicting stances on the use of energy devices and laparoscopy by different surgical governing bodies and societies. There is no definitive evidence that aerosol generated by energy devices may carry active SARS-CoV2 virus. However, investigations of other viruses have demonstrated aerosolization through energy devise use. Measures to reduce potential transmission include appropriate personal protective equipment, evacuation and filtration of surgical plume, limiting energy device use if appropriate, and adjusting endoscopic and laparoscopic practice (low CO2 pressures, evacuation through ultrafiltration systems). CONCLUSIONS: The risk of transmission of SARS-CoV2 through aerosolized surgical smoke associated with energy device use is not fully understood, however transmission is biologically plausible. Caution and appropriate measures to reduce risk to healthcare staff should be implemented when considering intraoperative use of energy devices.

Background Roux-en-Y gastric bypass (RYGB) is a gold-standard procedure for treatment of obesity and associated comorbidities. No consensus on the optimal design of this operation has been achieved, with various lengths of bypassed small bowel limb lengths being used by bariatric surgeons. This aim of this systematic review and meta-analysis was to determine whether biliopancreatic limb (BPL) length in RYGB affects postoperative outcomes including superior reduction in weight, body mass index (BMI), and resolution of metabolic comorbidities associated with obesity. Methods A systematic search of the literature was conducted up until 1st June 2021. Meta-analysis of primary outcomes was performed utilising a random-effects model. Statistical significance was determined by p value Results Ten randomised controlled trials were included in the final quantitative analysis. No difference in outcomes following short versus long BLP in RYGB was identified at 12–72 months post-operatively, namely in BMI reduction, remission or improvement of type 2 diabetes mellitus, hypertension, dyslipidaemia, and complications (p > 0.05). Even though results of four studies showed superior total body weight loss in the long BPL cohorts at 24 months post-operatively (pooled mean difference −6.92, 95% CI –12.37, −1.48, p = 0.01), this outcome was not observed at any other timepoint. Conclusion Based on the outcomes of the present study, there is no definitive evidence to suggest that alteration of the BPL affects the quantity of weight loss or resolution of co-existent metabolic comorbidities associated with obesity.

Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPC), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. This meta-analysis aims to assess the impact of physiotherapy regimens following esophagectomy or gastrectomy. Methods An electronic database search was performed in MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPC and postoperative morbidity, in-hospital mortality rate, the Length of Hospital Stay (LOS) and the Health-Related Quality of Life (HRQoL). Results Seven RCTs and 7 cohort studies assessing prehabilitation totalling 960 patients, and 5 RCTs and 5 cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien-Dindo score >II). No difference was observed in functional exercise capacity, and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, a shorter LOS and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue and pain scores. Conclusions Our meta-analysis shows that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative period. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which subgroup of patients will gain the most benefit.

Background Oesophago-gastric malignancies are associated with a high recurrence rate, yet there is a lack of evidence to inform guidelines for the standardisation and structure of post-operative surveillance after curatively intended treatment. This study aimed to capture the variation in post-operative surveillance strategies across the United Kingdom and Ireland, and enquire the opinions and beliefs around surveillance from practicing clinicians. Methods A web based survey consisting of forty questions was sent to surgeons or allied health professionals performing or involved in surgical care for oesophago-gastric cancers at high volume centers in the United Kingdom (UK). Respondents from each centre completed the survey on what best represented their centre. The first section of the survey evaluated the timing and components of follow-ups, and their variation between centres. The second section evaluated respondents perspective on how surveillance can be structured. Results Thirty five surgeons from 25 centers consisting 28 consultants, 6 senior trainees and 1 specialist nurse had completed the questionnaire. 45.7% of responders arranged clinical follow-up at 2-4 weeks. Twenty responders had a specific post-operative surveillance protocol for their patients. Of these, 31.4% had a standardised protocol for all patients, while 25.7% tailored it to patient needs. Patient preference, comorbidities and chance of recurrence were considered as major factors for necessitating more intense surveillance than currently practised. Conclusions There is a significant variation in how patients are monitored after surgery between centers in the UK. Randomised controlled trials are necessary to link surveillance strategies to both survival outcomes and quality of life of patients and to evaluate the prognostic value of different post-operative surveillance strategies.

PAST Despite advancements in surgical management, esophageal and gastric cancer surgery is still associated with a significant morbidity. Traditionally, esophagectomy and gastrectomy via an open surgical approach has been the treatment of choice for esophageal and gastric cancer, respectively.1,2 Enhanced recovery after surgery (ERAS) protocols commonly include physiotherapy regimens or early mobilization intervention. These programs are well-established in colorectal cancer surgery and have shown to reduce postoperative complication rates and shortened the length of hospital stay (LOS).3 Only a small number of studies have assessed the role of respiratory physiotherapy in gastrointestinal cancer surgery, while this patient group commonly present with pre-existing respiratory disease and is particularly at risk for malnutrition and loss of muscle mass.4 Although there is growing evidence of the benefits of physiotherapy implementation in decreasing the risk for postoperative morbidity, there is currently insufficient strong evidence for routine implementation of standardized respiratory physiotherapy in esophageal and gastric cancer surgery. PRESENT This is the first meta-analysis assessing the effect of prehabilitation and peri- or postoperative physiotherapy regimens on postoperative mortality and morbidity in esophageal and gastric cancer surgery.5 A lower incidence of pneumonia was observed following both prehabilitation and peri- or postoperative rehabilitation. Furthermore, a lower incidence of postoperative morbidity was seen in patients undergoing prehabilitation, while peri- or postoperative rehabilitation resulted in a shorter LOS and better health-related quality-of-life scores for dyspnea and physical functioning. These results suggest that implementation of a physiotherapy regimen in both the pre- and peri- or postoperative setting may be beneficial. This meta-analysis is however limited by the lack of a standardized physiotherapy protocol for patients undergoing esophagectomy or gastrectomy, and by the lack of functional data in long-term survivors. FUTURE Further research is required focusing on the mechanism in which surgery might contribute to the development of postoperative complications and what outcomes are most likely to be affected. This information may aid in identifying which components of physiotherapy regimens have the greatest impact on clinical outcomes. In the future, tailored physiotherapy regimens may be developed aimed at decreasing the risk for complications in the preoperative setting (prehabilitation) and improve clinical outcomes postoperatively (rehabilitation) in major gastrointestinal cancer surgery. Discloure Karina Tukanova, Swathikan Chidambaram, Nadia Guidozzi, George B. Hanna, Alison H. McGregor, and Sheraz R. Markar declared no conflicts of interest.

Summary Background There is no consensus or guidelines internationally to inform clinicians of how patients should be monitored for recurrence after esophagogastric resections. Aim This systematic review and meta-analysis summarizes the latest evidence investigating the usefulness of surveillance protocols in patients who underwent esophagectomy or gastrectomy. Methods A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. Articles were evaluated for the use of surveillance strategies including history-taking, physical examination, imaging modalities and endoscopy for monitoring patients post-gastrectomy or esophagectomy. Studies that compared surveillance strategies and reported detection of recurrence and post-recurrence survival were also included in the meta-analysis. Results Fifteen studies that described a surveillance protocol for post-operative patients were included in the review. Seven studies were used in the meta-analysis. Random-effects analysis demonstrated a statistically significant higher post-recurrence survival (standardized mean difference [SMD] 14.15, 95% CI 1.40–27.26, p = 0.03) with imaging-based planned surveillance post-esophagectomy. However, the detection of recurrence (OR 1.76, 95% CI 0.78–3.97, p = 0.17) for esophageal cancers as well as detection of recurrence (OR 0.73, 95% CI 0.11–5.12, p = 0.76) and post-recurrence survival (SMD 6.42, 95% CI –2.16–18.42, p = 0.14) for gastric cancers were not significantly different with planned surveillance. Conclusion There is no consensus on whether surveillance carries prognostic survival benefit or how surveillance should be carried out. Surveillance may carry prognostic benefit for patients who underwent surgery for esophageal cancer. Randomized controlled trials are required to evaluate the survival benefits of intensive surveillance strategies, determine the ideal surveillance protocol and tailor it to the appropriate population.

Our paper highlights the use of artificial intelligence (AI) in oesophageal and gastric malignancies with acceptable levels of accuracy for both diagnostic and surveillance purposes. Here, we comment on the past, present and future work necessary for incorporating AI into the clinical framework and practice.

SummaryEsophageal cancer is an aggressive malignancy with a relatively poor prognosis even after multimodality therapy. Currently, patients undergo a series of investigations that can be invasive and costly or pose secondary risks to their health. In other malignancies, liquid biopsies of circulating tumor DNA (ctDNA) are used in clinical practice for diagnostic and surveillance purposes. This systematic review summarizes the latest evidence for the clinical applicability of ctDNA technology in esophageal cancer. A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. Articles were evaluated for the use of ctDNA for diagnosis and monitoring of patients with esophageal cancer. Quality assessment of studies was performed using the QUADAS-2 tool. A meta-analysis was performed to assess the diagnostic accuracy of sequencing methodologies. We included 15 studies that described the use of ctDNA technology in the qualitative synthesis and eight studies involving 414 patients in the quantitative analysis. Of these, four studies assessed its utility in cancer diagnosis, while four studies evaluated its use for prognosis and monitoring. The pooled sensitivity and specificity for diagnostic studies were 71.0% (55.7–82.6%) and 98.6% (33.9–99.9%), while the pooled sensitivity and specificity for surveillance purposes were 48.9% (29.4–68.8%) and 95.5% (90.6–97.9%). ctDNA technology is an acceptable method for diagnosis and monitoring with a moderate sensitivity and high specificity that is enhanced in combination with current imaging methods. Further work should demonstrate the practical integration of ctDNA in the diagnostic and surveillance clinical pathway.

Esophago-gastric malignancies are associated with a high recurrence rate; yet there is a lack of evidence to inform guidelines for the standardization and structure of postoperative surveillance after curatively intended treatment. This study aimed to capture the variation in postoperative surveillance strategies across the UK and Ireland, and enquire the opinions and beliefs around surveillance from practicing clinicians. A web-based survey consisting of 40 questions was sent to surgeons or allied health professionals performing or involved in surgical care for esophago-gastric cancers at high-volume centers in the UK. Respondents from each center completed the survey on what best represented their center. The first section of the survey evaluated the timing and components of follow-ups, and their variation between centers. The second section evaluated respondents perspective on how surveillance can be structured. Thirty-five respondents from 27 centers consisting 28 consultants, 6 senior trainees and 1 specialist nurse had completed the questionnaire; 45.7% of responders arranged clinical follow-up at 2–4 weeks. Twenty responders had a specific postoperative surveillance protocol for their patients. Of these, 31.4% had a standardized protocol for all patients, while 25.7% tailored it to patient needs. Patient preference, comorbidities and chance of recurrence were considered as major factors for necessitating more intense surveillance than currently practiced. There is a significant variation in how patients are monitored after surgery between centers in the UK. Randomized controlled trials are necessary to link surveillance strategies to both survival outcomes and quality of life of patients and to evaluate the prognostic value of different postoperative surveillance strategies.

Background Bariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity. Objectives This study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m2. Setting National Health Service and private hospitals in the United Kingdom. Methods This cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m2 undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014. Results There were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m2 for AGB; 75 ± 5 kg/m2 for SG; 74 ± 5 kg/m2 for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m2 and 51 ± 11 kg/m2, respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery. Conclusion This study found that primary BMS in patients with a BMI >70kg/m2 has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.

Background Patients with small intestinal neuroendocrine tumours (siNETs) usually present with advanced disease. Primary tumour resection without curative intent is controversial in patients with metastatic siNETs. The aim of this meta-analysis was to investigate survival after primary tumour resection without curative intent compared with no resection in patients with metastatic siNETs. Methods A systematic literature search was performed, using MEDLINE® (PubMed), Embase®, Web of Science, and the Cochrane Library up to 25 February 2021. Studies were included if survival after primary tumour resection versus no resection in patients with metastatic siNETs was reported. Results were pooled in a random-effects meta-analysis, and are reported as hazard ratios (HRs) with 95 per cent confidence intervals. Sensitivity analyses were undertaken to enable comment on the impact of important confounders. Results After screening 3659 abstracts, 16 studies, published between 1992 and 2021, met the inclusion criteria, with a total of 9428 patients. Thirteen studies reported HRs adjusted for important confounders and were included in the meta-analysis. Median overall survival was 112 (i.q.r. 82–134) months in the primary tumour resection group compared with 60 (74–88) months in the group without resection. Five-year overall survival rates were 74 (i.q.r. 67–77) and 44 (34–45) per cent respectively. Primary tumour resection was associated with improved survival compared with no resection (HR 0.55, 95 per cent c.i. 0.47 to 0.66). This effect remained in sensitivity analyses. Conclusion Primary tumour resection is associated with increased survival in patients with advanced, metastatic siNETs, even after adjusting for important confounders.

Introduction Knee osteoarthritis is a major cause of pain and disability for which joint distraction is a potential treatment to delay the need for knee arthroplasty. This systematic review aims to assess the short- and long-term clinical and structural outcomes following knee joint distraction (KJD). Methods MEDLINE, EMBASE, Scopus, and Web of Science databases were searched from the date of inception to 26th June 2019. Clinical studies investigating joint distraction for knee osteoarthritis with outcomes including ∆WOMAC index, ∆VAS pain score, and ∆joint space width were included. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) - CRD42018087032. Results Nine studies comprising a total of 507 patients were included. There were four randomized controlled trials (RCTs), five open prospective cohort studies, and one case series. Overall, there were significant improvements in WOMAC index, VAS pain score and joint space width following KJD, which persisted up to 9 years. KJD also demonstrated comparable clinical outcomes with high tibial osteotomy and total knee arthroplasty. Conclusion There is moderate quality evidence supporting the beneficial outcomes of joint distraction for knee osteoarthritis. Larger RCTs with longer follow-up (>1 year) are necessary to establish the true effect size of this procedure.

Introduction Knee osteoarthritis is a major cause of pain and disability for which joint distraction is a potential treatment to delay the need for knee arthroplasty. This systematic review aims to assess the short- and long-term clinical and structural outcomes following knee joint distraction (KJD). Methods MEDLINE, EMBASE, Scopus, and Web of Science databases were searched from the date of inception to 26th June 2019. Clinical studies investigating joint distraction for knee osteoarthritis with outcomes including ∆WOMAC index, ∆VAS pain score, and ∆joint space width were included. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) – CRD42018087032. Results Nine studies comprising a total of 507 patients were included. There were four randomized controlled trials (RCTs), five open prospective cohort studies, and one case series. Overall, there were significant improvements in WOMAC index, VAS pain score and joint space width following KJD, which persisted up to 9 years. KJD also demonstrated comparable clinical outcomes with high tibial osteotomy and total knee arthroplasty. Conclusion There is moderate quality evidence supporting the beneficial outcomes of joint distraction for knee osteoarthritis. Larger RCTs with longer follow-up (>1 year) are necessary to establish the true effect size of this procedure.

Purpose The metabolic and circulatory disturbances in patients with septic shock results in a high mortality rate. There is a lack of high-level evidence on the optimal approach. We present a meta-analysis elucidating the outcomes of regimes with only noradrenaline versus a combination of noradrenaline and vasopressin in managing septic shock. Methods A literature search of studies comparing the use of noradrenaline and vasopressin in septic shock was conducted, using MEDLINE and EMBASE databases. The primary outcome evaluated was mortality rate. Subgroup analysis of secondary measures was also conducted using Review Manager 5.3 software. Results Four RCTs of 1039 patients were included. There is good evidence supporting a comparable mortality rate (RR: 0.92, 95% CI: 0.78, 1.08, p = .32, I2 = 0%), and moderate evidence supporting an equivalent length of ICU stay (MD: 0.14, 95% CI: -1.37, 1.65, p = .86, I2 = 46%) and occurrence of adverse events (RR: 1.19, 95% CI: 0.83, 1.70, p = .35, I2 = 13%) between the two cohorts. Conclusion The two regimes have equivalent outcomes, but vasopressin has a role in selected patients experiencing less severe septic shock beyond a 36-h period. Further work will make definitive clinical recommendations for optimal strategy of vasopressin or noradrenaline usage.

Context Preoperative localization studies are standard practice in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT). The most common modalities are neck ultrasound (US) and sestamibi scanning. However, the nature of pHPT is changing, with imaging increasingly yielding negative results. Numerous studies suggest unlocalized disease is associated with poor outcomes, calling into question whether such patients are best treated conservatively. Objective This study aims to correlate parathyroidectomy outcomes with preoperative imaging in a single, high-volume institution. Methods Data from a prospectively maintained departmental database of operations performed from 2017 to 2019 were analyzed. All patients undergoing first-time surgery for sporadic pHPT were included. Data collected included patient demographics, preoperative imaging, surgical strategy, and postoperative outcomes. Results A total of 609 consecutive parathyroidectomies were included, with a median age of 59 years (range 20-87 years). The all-comer cure rate was 97.5%; this was 97.9% in dual localized patients (those with positive US and sestamibi), compared to 95.8% in the dual unlocalized group (those with negative US and sestamibi) (P = 0.33). Unilateral neck exploration was the chosen approach in 59.9% of patients with double-positive imaging and 5.7% of patients with double-negative imaging (otherwise, bilateral parathyroid visualization was performed). There was no significant difference in postoperative complications between patients undergoing unilateral or bilateral neck exploration. Conclusions Patients with negative preoperative imaging who undergo parathyroidectomy are cured in almost 96% of cases, compared to 98% when the disease is localized. This difference does not reach statistical or clinical significance. These findings therefore support current recommendations that all patients with pHPT who are likely to benefit from operative intervention should be considered for parathyroidectomy, irrespective of preoperative imaging findings.

Bariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.This study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/mNational Health Service and private hospitals in the United Kingdom.This cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/mThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/mThis study found that primary BMS in patients with a BMI70kg/m

Simple Summary Esophageal squamous cell carcinoma (ESCC) is the sixth most common cause of death worldwide. Incidence rates vary internationally, with the highest rates found in Southern and Eastern Africa, and central Asia. Initial studies identified multiple factors associated with an increased risk of ESCC, with subsequent work then focused on developing plausible biological mechanistic associations. The aim of this review is to summarize the role of risk factors in the development of ESCC and propose future directions for further research. A systematic literature search was conducted to identify risk factors associated with the development of ESCC. Risk factors were divided into seven subcategories: genetic, dietary and nutrition, gastric atrophy, infection and microbiome, metabolic, epidemiological and environmental, and other risk factors. Risk factors from each subcategory were summarized and explored. This review highlights several current risk factors of ESCC. Further research to validate these results and their effects on tumor biology is necessary. Abstract Esophageal squamous cell carcinoma (ESCC) is the sixth most common cause of death worldwide. Incidence rates vary internationally, with the highest rates found in Southern and Eastern Africa, and central Asia. Initial observational studies identified multiple factors associated with an increased risk of ESCC, with subsequent work then focused on developing plausible biological mechanistic associations. The aim of this review is to summarize the role of risk factors in the development of ESCC and propose future directions for further research. A systematic search of the literature was conducted by screening EMBASE, MEDLINE/PubMed, and CENTRAL for relevant publications. In total, 73 studies were included that sought to identify risk factors associated with the development of esophageal squamous cell carcinoma. Risk factors were divided into seven subcategories: genetic, dietary and nutrition, gastric atrophy, infection and microbiome, metabolic, epidemiological and environmental and other risk factors. Risk factors from each subcategory were summarized and explored with mechanistic explanations for these associations. This review highlights several current risk factors of ESCC. These risk factors were explored, and explanations dissected. Most studies focused on investigating genetic and dietary and nutritional factors, whereas this review identified other potential risk factors that have yet to be fully explored. Furthermore, there is a lack of literature on the association of these risk factors with tumor factors and disease prognosis. Further research to validate these results and their effects on tumor biology is absolutely necessary.

Individuals who are overweight or suffering from obesity are in a chronic state of low-grade inflammation, making them particularly susceptible to developing severe forms of respiratory failure. Studies conducted in past pandemics link obesity with worse health outcomes. This population is thus of particular concern within the context of the COVID-19 pandemic, considering the cessation of obesity management services. This systematic review highlights [1] the reciprocal link between the obesity and COVID-19 pandemics, [2] obesity as a risk factor for more severe disease in past pandemics, [3] potential mechanisms that make individual’s suffering from obesity more susceptible to severe disease and higher viral load, and [4] the need to safely resume bariatric services as recommended by expert guidelines, in order to mitigate the health outcomes of an already vulnerable population.

Complex regional pain syndrome (CRPS) is a painful, debilitating, and disabling condition that can be categorized into three diagnostic subtypes, based on the clinical presentation. Diagnosing this condition remains a challenge, but has been aided by improvements in diagnostic criteria and availability of different investigation modalities. Surgery and fractures are common inciting events, although the underlying mechanisms by which these trigger and propagate CRPS are unclear. Various treatments have been implicated but the lack of good quality evidence available is an issue. Current recommendations advocate for conservative measures involving physiotherapy and pharmacological pain relief as first-line treatment. As our understanding continues to grow, so too will our ability to prevent, diagnose, and treat this condition. Given the complex nature of CRPS, it is likely that a combination of different treatment modalities will be required to successfully manage this condition.

Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK healthcare trust during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. SAQ scores of doctors and &ldquo, other clinical staff&rdquo, were relatively higher than the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40&ndash, 49 years, non-White ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (&minus, 0.13), non-disclosed ethnicity (&minus, 0.11), nursing role (&minus, 0.15), and support (0.29) persisted to a level of significance. A significant decrease (p &lt, 0.003) was seen in error reporting after the onset of the Covid-19 pandemic. This is the first study to investigate SAQ during Covid-19. Differences in SAQ scores were observed during Covid-19 between professional groups when compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.

Individuals who are overweight or obese are in a chronic state of low-grade inflammation, making them particularly susceptible to developing severe forms of respiratory failure. Studies conducted in past pandemics link obesity with worse health outcomes. This population is thus of particular concern within the context of the COVID-19 pandemic, considering the cessation of obesity management services. This systematic review highlights (1) the reciprocal link between the obesity and COVID-19 pandemics (2) obesity as a risk factor for more severe disease in past pandemics, (3) potential mechanisms that make obese individuals more susceptible to severe disease and higher viral load, (4) the need to safely resume bariatric services as recommended by expert guidelines, in order to mitigate the health outcomes of an already vulnerable population.

IntroductionCovid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and in turn patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture.MethodsThe Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK teaching hospital during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined.ResultsSignificant increased were seen in SAQ scores of doctors and ‘other clinical staff’, there was no change in the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-white ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (−0.13), non-disclosed ethnicity (−0.11), nursing role (−0.15), and support (0.29) persisted to significance. A significant decrease (pDiscussionThis is the first study to report SAQ during Covid-19 and compare with baseline. Differences in SAQ scores were observed during Covid-19 between professional groups and compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.WHAT IS ALREADY KNOWN ON THE SUBJECTSafety culture is associated with patient safety and outcomesThis is the first study to investigate safety culture during the Covid-19 pandemicThis study uses the Safety Attitudes Questionnaire (SAQ) and Datix incident reporting data to investigate determinants of safety climate during the Covid-19 pandemic.Safety climate is context specific, this study is strengthened by the availability of benchmarking data from before the onset of the Covid-19 pandemic.Significant differences in SAQ scores between professional groups were observed during Covid-19.Gender, ethnicity and job role were significant determinants of safety attitudes.Support during redeployment was associated with improved safety attitudes.The number of incidents that were reported reduced significantly during Covid-19, although the number of events leading to harm remained constant.

'Payment by results' (PbR) remuneration for healthcare services relies on the accurate conversion of diagnoses into Healthcare Resource Group (HRG) codes that are then reimbursed. Inconsistencies in documentation can result in inaccuracies in this process, with consequent implications for measuring activity, disease incidence and organisational performance. The aim of this study was to determine if clinician involvement increases accuracy in the coding of medical cases. Selected records of medical patients admitted to a London NHS trust between November and December 2016 were reviewed by a coding auditor and a clinician. Any changes to the codes and HRG tariff were noted. In total, 123 cases were considered. Changes in code were made on 68 instances, resulting in an overall increase in remuneration of £39,215; an average of £318 per patient. The primary HRG code was changed in 31 cases which accounted for £28,040 of the increase in tariff. In conclusion, clinician involvement can help with documentation ambiguities, thus improving the accuracy of the coding process in a medical setting. Although such collaborative working offers advantages for both the clinician and the coding team, further work is required to investigate the feasibility of this recommendation on a larger scale.