Manchester University

Abstract Aims Free tissue transfer is a common plastic surgical procedure with a wide array of applications. There is limited consensus on how free flap ischaemia time impacts flap survival. This systematic review aims to evaluate the association between free flap ischaemia time and acute flap failure rate. Methods A systematic review and meta-analysis in compliance with PRISMA statement standards was conducted following registration on the PROSPERO Register (CRD420251052841). A search strategy was developed and the search conducted in September 2024. Studies eligible for inclusion reported length of ischaemia time for free flap surgery and acute flap failure rate. 78 articles were eligible for inclusion and were published between 1997 and 2024. Study populations ranged from 7 to 3926 patients, with a pooled total of 26 374 free flaps in 23 615 patients. The meta-analysis showed overall risk of flap failure was 3.5% (95% c.i. 3%–4.1%). Meta-regression using ischaemia time as a continuous variable showed an increasing risk of acute flap failure from 3% (2.3%–3.9%) at 30 min ischaemia time to 7.5% (4.4%–12.5%) at 240 min. The variables study type, flap type, indication and risk of bias did not account for between study heterogeneity which was substantial. Conclusions This study has systematically assessed existing literature to show a significant association between prolonged ischaemia time and acute free flap loss. This association can guide microsurgical training as carrying out microsurgery in a time efficient manner has a positive impact on free flap survival.

Abstract Introduction Minimally invasive techniques have transformed early rectal cancer treatment; yet the optimal approach is unclear. ESD, EMR, and TAMIS are increasingly being used, however, most studies only compare two of these techniques. This meta-analysis directly compares all three in efficacy, safety, and oncological performance. Methods PubMed, Scopus, and Medline were searched to identify relevant studies as of September 2024. Criteria included studies in adults with early rectal cancer treated by ESD, EMR, or TAMIS, reporting at least one outcome and specifying treatment type and cancer stage. Comprehensive Meta-Analysis v4 was used for analysis with heterogeneity assessed via I². Results A total of 127 studies encompassing 8915 patients were included (EMR = 3979, ESD = 4470, and TAMIS = 466). Mean procedural times were: overall 8.3 min (7.7–8.8), I² = 99%; EMR 7.5 (6.9–8.1), I² = 98%; ESD 32.6 (29.3–36), I² = 99%; TAMIS 101.6 (83.9–119.9), I² = 95%. En bloc resection: overall 87.1% (85.6–88.5), I² = 81%; EMR 86.5% (84.4–88.4), I² = 82%; ESD 87.2% (84.4–89.5), I² = 80%; TAMIS 94.1% (88.9–97), I² = 0%. R0 resection: overall 79.7% (78.6–80.8), I² = 80%—EMR 79.9% (78.3–81.5), I² = 85%; ESD 78.7% (77.1–80.3), I² = 76%; TAMIS 87.1% (82.8–90.4), I² = 42%. Conclusions Although EMR appears efficient, it demonstrated less favourable outcomes regarding en bloc resection. ESD showed favourable oncological outcomes while maintaining moderate procedural time. TAMIS is most time-intensive but yields the highest resection quality.

Efficacious and well-tolerated systemic, oral treatments for psoriasis are needed. We report preclinical and phase 1c (NCT06808815) results for DC-806, a small molecule interleukin (IL)-17 inhibitor, for the treatment of mild-to-moderate psoriasis. Preclinical results demonstrated DC-806 targets IL-17AA and IL-17AF with secukinumab-like therapeutic efficacy. In the phase 1c trial, 32 patients consented to receive twice daily (BID) doses of placebo or DC-806 (200 mg or 800 mg) for 28 days. No serious adverse events (SAEs) or discontinuations due to treatment-related adverse events (TRAEs) occurred. In an exploratory analysis, adjusted mean percentage reductions from baseline in psoriasis area and severity indices (PASI) at Day 29 were 43.7%, 15.1%, and 13.3% for 800 mg BID, 200 mg BID, and placebo arms, respectively (800 mg BID vs placebo, P value = 0.0008). DC-806 was found to be well tolerated with an acceptable safety profile and preliminary signals of clinical efficacy in mild-to-moderate psoriasis. EudraCT Identifier: 2021-002888-21.

Objective Risankizumab is an interleukin-23 p19 subunit inhibitor which received approval for Crohn’s disease (CD) by UK licensing authorities in May 2023. Our aim was to evaluate the real-world outcomes of risankizumab in the UK. Design We conducted a retrospective, multicentre, cohort study of patients with CD treated with risankizumab across 25 health boards in the UK between 1 January 2021 and 1 November 2024. Our primary outcome was treatment persistence at 6 months. Our secondary endpoints were steroid-free clinical remission (Harvey-Bradshaw index <5), C-reactive protein (CRP) remission (CRP ≤5 mg) and faecal calprotectin (FCAL) remission (FCAL <250 µg/g). Results We included 763 patients with a median follow-up time of 27 weeks (IQR 18–41 weeks) with a total of 432 and 110 patients having 6-month and 12-month data available. The median number of advanced therapy exposures was 3 (2–4), with 92% (704/763) having failed anti-tumour necrosis factor therapy and 72% (548/763) having failed ustekinumab. Treatment persistence at 6 and 12 months was 95.4% and 89.2%, respectively. Unadjusted persistence rates for ustekinumab-naive versus ustekinumab-exposed patients were 92.7% vs 95.3% and 89.0% vs 74.2% at 6 and 12 months, respectively (p=0.62). Rates of clinical, CRP and FCAL remission were 52% (123/236), 53% (169/319) and 44% (69/156) at 6 months. Rates of clinical remission for ustekinumab naive versus exposed were 57% (29/51) vs 51% (94/185) (p=0.54) 6 months. Adverse events occurred in 17% (n=127) of the cohort, of which 12% (n=92) were serious. Conclusion Risankizumab was effective in a large, real-world, medically refractory CD cohort with excellent persistence and good clinical and biochemical remission rates.

First, HCI is described from a cognitive standpoint. Much of the user’s behaviour at the interface can be attributed to the cognitive or mental model that the user holds of the task and system. Consequently, the concept and characteristics of mental models are discussed, as well as some of the differences in terminology regarding mental and conceptual models. Following this, the use of metaphors to help users form their models of the task and system is considered.

BackgroundHip fractures are among the most common causes of hospital admission in elderly patients. National Institute for Health and Care Excellence (NICE) recommends surgery within 24-48 hours in such patients; however, pre-operative transthoracic echocardiography (TTE) is occasionally requested inappropriately, risking delays in surgery without improving outcomes. Delays to hip fracture surgery are associated with increased morbidity and mortality, with each 24-hour delay linked to worse clinical outcomes, underscoring the importance of timely operative intervention. This quality improvement project (QIP) evaluated the use of pre-operative echocardiograms in patients with neck of femur fractures, aiming to reduce unnecessary requests, prevent surgical delays, and ensure consistent acknowledgement of TTE results by anaesthetists at a district general hospital in the United Kingdom.Materials and methodsA two-cycle Plan-Do-Study-Act (PDSA) audit was conducted at a district general hospital. Multiple guidelines were studied, and local trust guidelines regarding the use of pre-operative echocardiograms were selected as a standard that defined appropriate TTE indications. In Cycle 1 (March-April 2024), baseline compliance with three standards was assessed, which included: avoidance of surgical delay, appropriateness of echocardiogram requests and anaesthetic acknowledgement of TTE reports. Interventions included teaching sessions, posters outlining guideline criteria, and dissemination of audit findings. Cycle 2 (July-October 2024) re-evaluated compliance following these measures.ResultsIn Cycle 1, 12 patients were identified using our inclusion criteria who underwent TTE. Surgery was not delayed in any case (12/12, 100%). Only 4/12 (33.3%) TTE requests met guideline criteria, and 10/12 (83.3%) reports were acknowledged by anaesthetists. In Cycle 2, following interventions, 17 patients were identified using our inclusion criteria who underwent TTE. Again, surgery was not delayed in any case (17/17, 100%). Guideline adherence improved markedly, with 16/17 (94.1%) appropriate requests, but acknowledgement of reports fell to 12/17 (70.6%). In 4/17 (23.5%) cases, TTE findings led to changes in anaesthetic management, including invasive monitoring and optimisation of cardiac status. The reduction in documented acknowledgement may reflect a higher threshold for what clinicians considered necessary to formally record following improved guideline adherence. Importantly, in 4/17 (23.5%) of cases, echocardiography directly influenced anaesthetic decision-making, supporting its role as a clinically valuable investigation when appropriately targeted.ConclusionTargeted educational interventions and dissemination of local guidelines reduced inappropriate echocardiogram requests in hip fracture patients without delaying surgery. However, inconsistent documentation of anaesthetic acknowledgement remains a concern. Ongoing interventions, including the implementation of mandatory electronic sign-off of echocardiogram reports within the patient record, are planned to sustain improvements and optimise perioperative communication.