What's known on the subject? and What does the study add? Very few comparative studies to date evaluate the results of treatment options for prostate cancer using the most sensitive measurement tools. PSA has been identified as the most sensitive tool for measuring treatment effectiveness. To date, comprehensive unbiased reviews of all the current literature are limited for prostate cancer. This is the first large scale comprehensive review of the literature comparing risk stratified patients by treatment option and with long‐term follow‐up. The results of the studies are weighted, respecting the impact of larger studies on overall results. The study identified a lack of uniformity in reporting results amongst institutions and centres. A large number of studies have been conducted on the primary therapy of prostate cancer but very few randomized controlled trials have been conducted. The comparison of outcomes from individual studies involving surgery (radical prostatectomy or robotic radical prostatectomy), external beam radiation (EBRT) (conformal, intensity modulated radiotherapy, protons), brachytherapy, cryotherapy or high intensity focused ultrasound remains problematic due to the non‐uniformity of reporting results and the use of varied disease outcome endpoints. Technical advances in these treatments have also made long‐term comparisons difficult. The Prostate Cancer Results Study Group was formed to evaluate the comparative effectiveness of prostate cancer treatments. This international group conducted a comprehensive literature review to identify all studies involving treatment of localized prostate cancer published during 2000–2010. Over 18 000 papers were identified and a further selection was made based on the following key criteria: minimum/median follow‐up of 5 years; stratification into low‐, intermediate‐ and high‐risk groups; clinical and pathological staging; accepted standard definitions for prostate‐specific antigen failure; minimum patient number of 100 in each risk group (50 for high‐risk group). A statistical analysis (standard deviational ellipse) of the study outcomes suggested that, in terms of biochemical‐free progression, brachytherapy provides superior outcome in patients with low‐risk disease. For intermediate‐risk disease, the combination of EBRT and brachytherapy appears equivalent to brachytherapy alone. For high‐risk patients, combination therapies involving EBRT and brachytherapy plus or minus androgen deprivation therapy appear superior to more localized treatments such as seed implant alone, surgery alone or EBRT. It is anticipated that the study will assist physicians and patients in selecting treatment for men with newly diagnosed prostate cancer.

Background: Cholangiocarcinoma (CC) is increasing in incidence, but its pathogenesis remains poorly understood. Chronic inflammation of the bile duct and cholestasis are major risk factors, but most cases in the West are sporadic. Genetic polymorphisms in biliary transporter proteins have been implicated in benign biliary disease and, in the case of progressive familial cholestasis, have been associated with childhood onset of CC. In the current study, five biologically plausible candidate genes were investigated: ABCB11 (BSEP), ABCB4 (MDR3), ABCC2 (MRP2), ATP8B1 (FIC1) and NR1H4 (FXR). Methods: DNA was collected from 172 Caucasian individuals with confirmed CC. A control cohort of healthy Caucasians was formed. Seventy-three SNPs were selected using the HapMap database to capture genetic variation around the five candidate loci. Genotyping was undertaken with a competitive PCR-based system. Confirmation of Hardy-Weinberg equilibrium and Cochran-Armitage trend testing were performed using PLINK. Haplotype frequencies were compared using haplo.stats. Results: All 73 SNPs were in Hardy-Weinberg equilibrium. Four SNPs in ABCB11 were associated with altered susceptibility to CC, including the V444A polymorphism, but these associations did not retain statistical significance after Bonferroni correction for multiple testing. Haplotype analysis of the genotyped SNPs in ATP8B1 identified significant differences in frequencies between cases and controls (global p value of 0.005). Conclusion: Haplotypes in ATP8B1 demonstrated a significant difference between CC and control groups. There was a trend towards significant association of V444A with CC. Given the biological plausibility of polymorphisms in ABCB11 and ATP8B1 as risk modifiers for CC, further study in a validation cohort is required.

Introduction Surgical site infections are associated with increased morbidity and mortality in patients. The Getting It Right First Time surgical site infection programme set up a national survey to review surgical site infection rates in surgical units in England. The objectives were for frontline clinicians to assess the rates of infection following selected procedures, to examine the risk of significant complications and to review current practice in the prevention of surgical site infection. Methods A national survey was launched in April 2017 to assess surgical site infections within 13 specialties: breast surgery, cardiothoracic surgery, cranial neurosurgery, ear, nose and throat surgery, general surgery, obstetrics and gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, paediatric surgery, spinal surgery, urology and vascular surgery. All participating trusts prospectively identified and collected supporting information on surgical site infections diagnosed within the six-month study period. Results Data were received from 95 NHS trusts. A total of 1807 surgical site infection cases were reported. There were variations in rates reported by trusts across specialties and procedures. Reoperations were reported in 36.2% of all identified cases, and surgical site infections are associated with a delayed discharge rate of 34.1% in our survey. Conclusion The Getting It Right First Time surgical site infection programme has introduced a different approach to infection surveillance in England. Results of the survey has demonstrated variation in surgical site infection rates among surgical units, raised the importance in addressing these issues for better patient outcomes and to reduce the financial burden on the NHS. Much work remains to be done to improve surgical site infection surveillance across surgical units and trusts in England.

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ObjectiveFirst MTP joint fusion is a reliable procedure for advanced arthritis for the first MTP joint. There are many techniques described. The purpose of our study is to report clinical, radiological, functional outcomes and complications of first metatarsophalangeal joint fusion with hand preparation of the joint and fixation with two orthogonal locking plates without a compression screw.Methods32 feet in 26 consecutive patients under went first metatarsophalangeal joint fusion with above technique. There were 23 women and 3 men. Mean age was 64 years and mean follow-up was 49 months. 21 patients had osteoarthritis, 10 had rheumatoid arthritis and one had psoriatic arthritis. Clinical, radiological, American Orthopaedic Foot and Ankle Score and Foot and Ankle Disability Index clinical rating scales were used for evaluation.ResultsFusion was achieved in 27 feet. The incidence of radiological non-union was 15.7%. Mean AOFAS score improved from 37.1 to 80.7 (p < 0.0001) and mean FADI score improved from 40.3 to 86.9 postoperatively (p < 0.0001). Two patients with osteoarthritis and three with Rheumatoid arthritis did not unite. Four of these patients were managing hence revision surgery was not carried out but had low AOFAS and FADI scores. One patient with symptomatic non-union declined further surgery. One patient needed plate removal for a low grade infection and reoperation rate was 3.1%.ConclusionsIn our experience, first metatarsophalangeal joint arthrodesis using two orthogonal two hole plates without a compression screw is associated with a higher non-union rate in our cohort hence we do not recommend this technique.Level of evidenceLevel IV, therapeutic study.

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Stress fractures are uncommon, and bilateral stress fractures are rare. The diagnosis of stress fracture can be difficult as conventional radiographs usually show evidence of the fracture repair instead of the fracture. A stress fracture must be differentiated from more serious processes, particularly osteomyelitis and bone malignancies. In young children there may be no obvious cause, and imaging can greatly facilitate the diagnosis. We present a case of a toddler referred for evaluation for a possible bone malignancy but who was diagnosed with bilateral fibular stress fractures. Only one case of bilateral fibular stress fracture has been described in a toddler. However, unlike this case, our patient lacked an apparent explanation for the injury.

3578 Background: The risk of second primary colorectal cancers among rectal cancer patients has been described, but little is known about the risk of non-colorectal malignancies that may occur in the field of radiation. We attempted to quantify the risk, using data from the large population-based California Cancer Registry (CCR). Methods: We analyzed the CCR data for surgically-treated locoregional rectal cancer cases, diagnosed during the period 1988–2009. We excluded cases with second primary tumor (SPT) diagnosed within 12 months of initial diagnosis . Radiation treatment used was external beam radiation therapy. Standardized incidence ratios (SIR) with 95% confidence intervals (CI) were calculated to evaluate risk as compared to the underlying population after matching for age, sex, ethnicity, and time. Results: Of the study cohort of 13,418 rectal cancer cases, 1572 cases of SPTs were observed . The SIR was increased for small intestine cancer among cases receiving radiation treatment (4 cases observed vs. 1.01 cases expected; SIR=3.94, 95% CI 1.07-10.10) but not among cases lacking radiation treatment (4 observed vs. 4.45 expected; SIR=0.90, 5% CI 0.24-2.30). Among females treated with radiation, the SIR was increased for uterine cancer (12 observed vs. 5.59 expected; SIR=2.15, 95% CI 1.11 to 3.75) but not among cases lacking radiation therapy (23 observed vs. 26.17 expected; SIR=0.88, 95% CI 0.56-1.32). Among males receiving radiation treatment, the SIR for prostate cancer was decreased (23 observed vs. 69.78 expected; SIR=0.33; 95% CI 0.21 to 0.49) but of borderline significance among males lacking radiation therapy (243 observed vs. 276.97 expected; SIR=0.88, 95% CI 0.77-0.99). No significant differences were observed for cancers of the vagina, cervix, ovary, kidney, bladder, penis, testes, or leukemia based on prior radiation treatment for rectal cancer. Conclusions: Patients receiving pelvic radiation for treatment of rectal cancer have a subsequently higher than expected incidence of small intestine and uterine cancer. The incidence of prostate cancer appears to fall after pelvic radiation. These unexpected findings suggest complex relationships associated with radiation treatment for rectal cancer and SPT risk.