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Background The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown.

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Zoo animal welfare is a high priority for many institutions worldwide, with modern zoos now ensuring that animals are housed and cared for to the highest standards. However, in countries where this knowledge is not as available or understood, standards may be lower. The aim of this research was to investigate if there were common zoo welfare concerns across developing country zoos. Wild Welfare is a charity working globally to improve welfare for zoo animals and has an independent welfare audit that is carried out before any intervention occurs. The Wild Welfare Audit, consisting of 110 questions, covering nine topics, was completed at 11 zoos in seven developing countries (Brazil, Egypt, Libya, Indonesia, Thailand, Malaysia and Vietnam) following a Likert scale score (1–3). A principal component analysis was also performed to evaluate the audit questions. The results suggest that common areas of concern were animal behaviour, positive animal mental states and human health and safety. These themes were likely due to the lack knowledge and understanding that may be linked to historical and cultural differences. This research has helped to revise the welfare audit as well as inform future intervention strategies for improving developing country zoo animal welfare.

Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien–Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

BackgroundStudies of several tumour types have shown that expression profiling of cellular protein extracted from surgical tissue specimens by direct mass spectrometry analysis can accurately discriminate tumour from normal tissue and in some cases can sub-classify disease. We have evaluated the potential value of this approach to classify various clinico-pathological features in colorectal cancer by employing matrix-assisted laser desorption ionisation time of-flight-mass spectrometry (MALDI-TOF MS).MethodsProtein extracts from 31 tumour and 33 normal mucosa specimens were purified, subjected to MALDI-Tof MS and then analysed using the 'GenePattern' suite of computational tools (Broad Institute, MIT, USA). Comparative Gene Marker Selection with either a t-test or a signal-to-noise ratio (SNR) test statistic was used to identify and rank differentially expressed marker peaks. The k-nearest neighbours algorithm was used to build classification models either using separate training and test datasets or else by using an iterative, 'leave-one-out' cross-validation method.Results73 protein peaks in the mass range 1800-16000Da were differentially expressed in tumour verses adjacent normal mucosa tissue (P ≤ 0.01, false discovery rate ≤ 0.05). Unsupervised hierarchical cluster analysis classified most tumour and normal mucosa into distinct cluster groups. Supervised prediction correctly classified the tumour/normal mucosa status of specimens in an independent test spectra dataset with 100% sensitivity and specificity (95% confidence interval: 67.9-99.2%). Supervised prediction using 'leave-one-out' cross validation algorithms for tumour spectra correctly classified 10/13 poorly differentiated and 16/18 well/moderately differentiated tumours (P = < 0.001; receiver-operator characteristics - ROC - error, 0.171); disease recurrence was correctly predicted in 5/6 cases and disease-free survival (median follow-up time, 25 months) was correctly predicted in 22/23 cases (P = < 0.001; ROC error, 0.105). A similar analysis of normal mucosa spectra correctly predicted 11/14 patients with, and 15/19 patients without lymph node involvement (P = 0.001; ROC error, 0.212).ConclusionsProtein expression profiling of surgically resected CRC tissue extracts by MALDI-TOF MS has potential value in studies aimed at improved molecular classification of this disease. Further studies, with longer follow-up times and larger patient cohorts, that would permit independent validation of supervised classification models, would be required to confirm the predictive value of tumour spectra for disease recurrence/patient survival.

The use of diathermy in circumcision is traditionally frowned upon. The risk of arterial damage caused by the passage of a current along the shaft of the penis with monopolar diathermy is considered too great to permit its routine use'. This objection is overcome with bipolar diathermy, in which there is very little collateral current spread and the risk of vascular damage is negligible. A retrospective review was undertaken to determine the complication rate of the diathermy technique compared to the standard procedure using ties. Patients and methodsThe notes of all patients undergoing circumcision between February 1991 and December 1993 were reviewed. One surgeon and his team used bipolar diathermy only for haemostasis in all patients and the remaining teams used ligation for haemostasis. ResultsCircumcision was performed using bipolar diathermy in 93 patients aged from 16 months to 77 years (median 11 years). Of these, 87 (94 per cent) were admitted as day cases, although six subsequently stayed overnight; six were inpatients. Two patients developed minor bleeding which required haemostatic sutures. In the same period, 355Paper accepted 15 August 1994 circumcisions were performed using ligation for haemostasis in patients aged from 7 months to 95 years (median 35 years). Of these, 216 (61 per cent) were admitted as day cases and seven patients ( 2 per cent) had minor bleeding. DiscussionThe theoretical risk of arterial damage when using monopolar diathermy1 is removed with bipolar diathermy. Frequent use of diathermy, as is required in circumcision, results in rapid crusting of the forceps, rendering them inefficient and necessitating frequent cleaning. This problem can be overcome by dipping the forceps regularly in an aqueous solution, so preventing crusting while producing a more satisfactory escar.The age range in this series was from 7 months to 95 years and raises the question of the indications for circumcision. The differing day case rates reflect the different practice of the consultant surgeons, and these aspects are now the subject of a prospective audit.Complications of circumcision are well described2, and in this series there were no additional complications associated with the use of bipolar diathermy. This method gives satisfactory haemostasis and does not leave subcutaneous nodules, which may occur with ties.The exclusive use of bipolar diathermy is as good as other methods of haemostasis during circumcision. The use of the 'dip' represents an improvement in the diathermy technique, and its routine use is recommended3. References1 Azmy A, Boddy SA, Ransley PG. Successful reconstruction following circumcision with diathermy.

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