This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

BACKGROUNDThis is a rare cause of an axillary artery aneurysm in a young patient and brings together dermatology, rheumatology and vascular surgery. CASE PRESENTATIONA man in his late 20s presented with a painless swelling in his left axilla. He also had a long history of nocturnal sweating with no history of weight loss or fatigue. On examination, there was a large, well circumscribed lump measuring 3 × 2.5 cm within the apex of the left axilla. The mass was pulsatile, fi rm and non-tender. General examination was otherwise unremarkable; in particular, there were neither skin lesions nor palpable lymphadenopathy. INVESTIGATIONSBiochemical and haematological investigations were normal apart from a mildly raised eosinophil count of 0.5 × 10 9 /l (upper limit of normal 0.4 × 10 9 /l).Doppler ultrasound confi rmed a 2.9 cm long × 1.8 cm wide aneurysm of the distal axillary artery with evidence of an irregular thrombus present within. DIFFERENTIAL DIAGNOSISAngiolymphoid hyperplasia with eosinophilia (ALHE) has been known by a variety of different names, such as epithelioid haemangioma, pseudopyogenic granuloma, infl ammatory angiomatous nodule, papular angioplasia, subcutaneous angioblastic lymphoid hyperplasia with eosinophilia and lymphofolliculosis, intravenous atypical vascular proliferation and histiocytoid haemangioma. 1 This extensive list of nomenclature refl ects the spectral variation in microscopic presentations of ALHE encountered by past investigators and, not least, the divided opinion as to whether the pathogenesis of the lesion is truly neoplastic or a reactive phenomenon.There has been controversy over the exact relationship between Kimura's disease (KD) and ALHE, where the two terms have been used interchangeably in many articles. KD was fi rst described by Chinese authors Kimm and Szeto 2 in 1937 and later made widely recognised by Kimura in 1947. KD is a chronic infl ammatory disease of unknown aetiology usually presenting as solitary or multiple subcutaneous nodules in the head and neck region, often involving the parotid or submandibular salivary glands. KD is associated with regional lymphadenopathy; this may become generalised in longstanding disease, 3 and systemic eosinophilia with raised IgE levels. It is most prevalent in Asians with 85% of cases occurring in males.Although KD has been thought to be integral to the spectrum of ALHE in the past, histological features show that these conditions represent two separate disease entities. 4 KD is characterised by lymphoid nodules with germinal centres which may extend from the dermis to the underlying fascia and muscles. Lesions show a distinct eosinophilic infi ltrate with microabscesses. Vascular proliferation is not always present; however, when seen, there are many canalised capillaries lined by fl at endothelial cells. Systemic eosinophilia is almost always present, seen in approximately 98% of cases in comparison to 20% in ALHE. 5 In contrast to KD, ALHE lesions are superfi cial containing blood vessels of varying luminal sizes, some of w...

Introduction The prevalence of diverticular disease has been increasing in the western world over the last few decades, causing a growing burden on health care systems. This study compared the uses of flexible sigmoidoscopy with colonoscopy as a follow-up investigation for patients diagnosed with acute left-sided diverticulitis and to evaluate the need for using either procedure. Materials and methods A retrospective study of 327 patients diagnosed with acute diverticulitis was carried out. Of this total, 240 patients with left-sided diverticulitis diagnosed via computed tomography were included. These patients were categorised into two equal groups: the first 120 patients underwent colonoscopy and the second 120 patients underwent flexible sigmoidoscopy. Results All colonoscopes and flexible sigmoidoscopes confirmed the computed tomography diagnosis of sigmoid diverticular disease with no major new findings. All colonoscopes and flexible sigmoidoscopes were reported as having no complications, with nine colonoscopes reported as being difficult compared with only three flexible sigmoidoscopes. All biopsies were reported as no malignancy. Full bowel preparation was required in all colonoscopes, compared with no preparation required for flexible sigmoidoscopes. Conclusions There is no evidence to support the routine use of endoscopic evaluation after an episode of left-sided diverticulitis diagnosed on computed tomography if no worrying radiological findings have been reported. This study supports similar findings from other studies and therefore we disagree with The Royal College of Surgeons of England (Association of Coloproctology of Great Britain and Ireland recommendations) commissioning guide, which advocates routine surveillance of the colon.

Background: Decreased genomic and increased gene-specific DNA methylation predispose to colorectal cancer. Dietary folate intake and the methylenetetrahydrofolate reductase polymorphism (MTHFR 677C>T) may influence risk by modifying DNA methylation.Objective: We investigated the associations between MTHFR 677C>T genotype, folate status, and DNA methylation in the colon.Design: We conducted a cross-sectional study of 336 men and women (age 19–92 y) in the United Kingdom without colorectal neoplasia. We obtained blood samples for measurement of serum and red blood cell folate, plasma homocysteine, and MTHFR 677C>T genotype and colonic tissue biopsies for measurement of colonic tissue folate and DNA methylation (genomic- and gene-specific, estrogen receptor 1, ESR1; myoblast determination protein 1, MYOD1; insulin-like growth factor II, IGF2; tumor suppressor candidate 33, N33; adenomatous polyposis coli, APC; mut-L homolog 1, MLH1; and O6-methylguanine-DNA methyltransferase, MGMT) by liquid chromatography/electrospray ionization mass spectrometry and pyrosequencing, respectively.Results: Of the 336 subjects recruited, 185 (55%) carried the CC, 119 (35%) the CT, and 32 (10%) the TT alleles. No significant differences in systemic markers of folate status and colonic tissue folate between genotypes were found. The MTHFR TT genotype was not associated with genomic or gene-specific DNA methylation. Biomarkers of folate status were not associated with genomic DNA methylation. Relations between biomarkers of folate status and gene-specific methylation were inconsistent. However, low serum folate was associated with high MGMT methylation (P = 0.001).Conclusion: MTHFR 677C>T genotype and folate status were generally not associated with DNA methylation in the colon of a folate-replete population without neoplasia. This trial was registered at clinicaltrials.gov as ISRCTN43577261.

Internal hernia is the protrusion of an abdominal viscus through the peritoneum or mesentery into a compartment within the abdominal cavity. We present a case of internal herniation through the foramen of Winslow that was identified by CT imaging. It was treated with reduction at laparotomy and subsequent right hemicolectomy.