bluuebunny/crossref_metadata_2025 huggingface dataset:
Offering Surgical Definitive Options For Sigmoid Volvulus: Lessons From WSES (World Society of Emergency Surgery) Consensus Guidelines
Authors: Mithany Reda
Published: December 2023

Aim

This study evaluates the quality of care provided to patients with sigmoid volvulus and assess compliance with the World Society of Emergency Surgery (WSES) Consensus Guidelines regarding offering definitive surgical intervention.

Methods

All emergency surgical admissions involving individuals aged 65 or older, diagnosed with sigmoid volvulus between 2021 and 2023, were retrospectively included. The evaluation was conducted in conjunction with five critical WSES recommendations, encompassing the assessment strategy and diagnostic imaging for sigmoid volvulus, initial flexible endoscopy, and the decision-making process for urgent or elective sigmoid resection in all initial presentations. Adherence to these standards was assessed in each domain and subsequently categorized as Red (Urgent Attention Needed), Amber (Room for Improvement), or Green (Satisfactory Compliance).

Results

The study included a total of 20 patients. Compliance with the recommendation to offer sigmoid colectomy for the prevention of recurrent volvulus after successful endoscopic decompression was found to be in the Red category, scoring at 25%. In contrast, the remaining recommendations demonstrated satisfactory levels of compliance.

Conclusion

25% of our patients have not been offered the option of definitive surgical resection, highlighting an area for urgent need of attention. Given that the recurrence rate of sigmoid volvulus after endoscopic detorsion and conservative management ranges from 45% to 71%, and offering sigmoid colectomy to prevent recurrent volvulus is crucial, even during the index admission. In cases where frailty is identified, there should be documented consideration of best interest during the planning of definitive care. We envisage a better compliance to WSES recommendations.
Lower GI bleed audit
Authors: Dasa Micheal , Peters Paul , Bose Sayantan , Adeboye Opeyemi
Published: December 2023

Introduction

In the UK, Lower GI Bleeding is common emergency presentation and accounts for 3% of emergency surgical referrals. The most common cause is Diverticular Bleeds. Other frequent causes are the benign anorectal conditions. 23% of patients admitted to Hospital with LGIB in the UK are discharged without diagnosis. Most LGIB resolves on its own but may require further interventions.

Aim

To describe current local practice of risk stratification with Shock Index and Oakland’s Score in comparison with existing national guidelines by the British Society of Gastroenterology (BSG).

Method

Retrospective Analysis of 36 patients who presented to the local A&E with lower GI bleed between Sept 2021 – Nov 2021.

Result

Male:Female 18:18. Median age 56 years (3months – 95years).

Haemorrhoids (9, 25%) accounted for most of the presentation.

1 patient (3%) had their shock index documented.

2 patients (6%) needed a CT angiogram.

16 patients (44%) were admitted under the EGS team. Out of these 16 patients, 7 (44%) needed inpatient endoscopy, while 3 (19%) required transfusion.

Discussion

There was a consistent finding of no documented shock index in the patients notes, likely because there is easy access to EWS that allow clinicians to interpret this in real time. The Oakland score was rarely used to determine if a patient could safely be discharged.

Other specialties, endoscopy/gastroenterology or the emergency department, likely have different guidelines for the assessment of lower GI bleed. This could account for poor uptake, locally, of risk stratification as proposed by the BSG.
Management of chest trauma in a District General Hospital - Audit of current practice
Authors: Willis Kelly , Fitz-Gerald Alice , Ali Saqib
Published: December 2023

Aim

Audit the management of chest trauma in a District General Hospital according to guidelines set by the regional major trauma centre (MTC).

Methods

Patients admitted with traumatic rib fractures over a six-month period were included. Clinical notes and imaging were reviewed. Primary outcomes were chest injury severity score (CISS), pain team review and referral to MTC. Secondary outcomes included 30-day readmission and mortality.

Results

37 patients were included and only 2 had a CISS calculated on admission. Scores were retrospectively calculated with 89.2% scoring over 11 – the threshold for admission and aggressive management. 28 (75.7%) of patients met the criteria for referral to the MTC for consideration of rib fixation but only 8 were referred. 27 (73.0%) were seen by the pain team and 16 patients received a nerve block. There were 5 patients (13.5%) readmitted within 30 days of discharge with complaints of pain or dyspnoea. 3 were discharged from the emergency department, 2 required an additional inpatient stay. There were 2 deaths (5.4%) within 30 days of discharge. Cause of death was only available for 1 patient who had died of pneumonia.

Conclusion

Chest trauma has a high morbidity and is often managed by emergency general surgeons in centres without cardiothoracic services. Clear management guidance is vital to improving outcomes. As a result of this audit the trust’s pathway for chest trauma has been updated and new tools developed on our electronic patient record system to facilitate calculation of the CISS and completing the necessary referrals.
Outcomes of Patients with Liver Metastases from Colorectal Cancer who mostly Presented as Emergencies (Obstruction and Perforation) in a District General Hospital from 2014 to 2021
Authors: Amankwah Dennis , Ezeoke Chidimma , Shamsu Zaman , Annan Pangeni , Chowdhury Ashim , Cooke Joanne
Published: December 2023

Background

In the UK, District General Hospitals (DGH) play a pivotal role as primary sites for CRC diagnosis and staging, as many patients initially present as emergencies. However, patients with CRC-related liver metastases often require specialized management at tertiary facilities.

Methods

This study conducted a retrospective data collection in 2023, analysing anonymized CRC patient records from 2014 to 2021. The findings shed light on various aspects of CRC with liver metastases.

Results

Notably, a significant gender-based difference emerged, with males comprising 62.5% of the diagnosed patient cohort and females making up the remaining 37.5%. Anatomically, 27.08% of cases were localized in the rectum, while the majority (72.91%) occurred in the colon.

A substantial proportion of patients were diagnosed at advanced T stages, with 81.25% categorized as stages 3 and 4, indicating locally advanced or metastatic disease. Conversely, 18.75% were identified at earlier T stages, stages 1 and 2.

Diverse biological marker profiles showed: 33.3% dual KRAS/BRAF, 22.9% KRAS-only, 17.9% no markers.

Patient management at tertiary care facilities encompassed diverse interventions, including surgical procedures (45.83%), chemotherapy (75%), and palliative care (25%).

Survival outcomes were varied, with 35.41% achieving a commendable 3-year survival rate, 31.25% attaining a commendable 5-year survival rate, and 27.08% exceeding the 5-year milestone. However, 6.25% experienced survival limited to a year or less.

Conclusion

This study provides comprehensive insights into CRC with liver metastases, emphasizing the importance of early detection and personalized care, with potential for improved survival rates while acknowledging the complexities of managing this disease.
A review of emergency general surgery (EGS) admissions via the direct access pathway (DAP) in a district general hospital
Authors: Pal Shreya , Bartolome Iesleen Abigaelle , Pangeni Anang , Nahid Md Abu Kamal , Shrestha Ashish
Published: December 2023

Aims

Patients presenting with emergency general surgical (EGS) conditions require urgent management - however, increased waiting time in A&E often leads to delayed diagnosis and subsequently delayed management.

Having a direct access pathway (DAP) to Surgical Emergency Assessment Unit (SEAU) helps minimize these delays - leading to better outcome in management of these patients.

Methods

A retrospective observational study of EGS admissions in May 2023 was performed. Structured DAP referral proforma was implemented for patients to be directly referred to SEAU from A&E triage. Factors taken into consideration were - initial presentation, source of referral, time of initial assessment and patient outcome.

Results

A total of 188 referrals were made to SEAU, of which 46 (24.5%) were DAP referrals. The average number was 18 over weekdays and 10 over weekends - of these, 97.8% of referrals were appropriate with correctly filled out proforma, whereas 2.2% were inappropriate referrals. 33% patients were discharged, 10% were admitted, and 10% were planned to return for investigations the following day. The median waiting time for initial assessment was 1.5hours. The most common presentations were RUQ Pain, subcutaneous abscess and RLQ pain which correlated with the final diagnosis. It was also noticed that when compared with May 2022 (176patients during the same 2-week period), there was 6.8% increased referral since commencement of DAP.

Conclusion

The DAP for EGS admissions has been seen to have improved patient outcome as a result of avoiding unnecessary steps and delays before being reviewed by the surgical team through A&E pathway.
Factors Affecting Length of Stay in Patients With Traumatic Rib Fractures in a District General Hospital.
Authors: Hodson Alex , Bradley Rebecca , Jarman Caroline , Harahwa Tinotenda
Published: December 2023

Objective

The objective of this study was to ascertain which patient factors, injury and treatment variables contributed to an increased length of stay (LOS).

Methods

Retrospective data collection from a prospectively updated dataset was conducted from 01.01.23 to 31.08.23. All adult patients admitted to the general surgical department were included. Transfers directly from ED to an MTC, and paediatric patients were excluded. Outcome parameters were: age, gender, clinical frailty score (CFS), preinjury antiplatelet/anticoagulant use, mechanism of injury, number of ribs fractured, battle score, presence of intrathoracic injury, presence of flail chest, chest drain insertion, performance of analgesic nerve block, discussion with local MTC, total LOS, and 30-day mortality. Statistical analysis was performed to ascertain which of these variables significantly affected patient LOS.

Results

92 patients were admitted to the DGH. Most were female (58.7%) and the median age was 73. Median LOS was 5.5 days. 7 patients died during admission, all with a CFS of 6 or over. Patients with a higher age, CFS, number of fractures, and battle score had a significantly longer LOS. Patients who underwent a nerve block also had a longer LOS than those who did not. Presence of intra-thoracic injury and placement of a surgical chest drain did not affect LOS.

Conclusions

LOS appears to be related to higher age, frailty, and battle score. To improve patient management at this DGH, it may be suggested that older patients with a high battle score be discussed with critical care and have early frailty team input.
The importance of weekly Radiology-General Surgery Multi-Disciplinary Meetings (MDMs) in the management of Emergency General Surgery (EGS) patients
Authors: Pal Shreya , Yi Zoengzhen , Bartolome Iesleen Abigaelle , Bareli Leonardo , Shrestha Anuj , Shrestha Ashish
Published: December 2023

Aims

Most patients in Emergency-General-Surgery (EGS) require radiological investigations as part of their management plan. However, unlike cancer services where structured multi-disciplinary-meetings (MDMs) form an integral part of patient management, MDMs are not commonly practised in EGS.

Having a weekly Radiology-General Surgery-MDM leads to better outcome in management of EGS-patients, & also improves learning of surgeons & junior-doctors.

Methods

A prospective study of weekly 1-hour Radiology-GeneralSurgery-MDMs over 10-weeks during May2023-September2023 was performed. These MDMs were led by a consultant radiologist who discussed the scans with consultant surgeons & other junior-doctors. Factors taken into consideration were clinical presentation, original scan report, any missed findings not mentioned in original scan report, any changes recommended in management plan that would lead to better patient outcome. The scans were also discussed with junior-doctors to improve their knowledge of interpretation of scans.

Results

A total of 70 cases were discussed during the study period, 25 (35.71%) initially reported by the out-of-hours reporting system. Few had missed findings that were noted as result of Radiology-GeneralSurgery-MDM, & 27(38.57%) had change in management plan.

The informal feedback collected after these MDMs noted over 85% junior-doctors agreed that these MDMs had significant impact on their understanding of interpretation of radiological-scans in EGS.

Conclusion

Weekly Radiology-GeneralSurgery-MDMs for EGS-admissions has been seen to improve patient outcome as a result of having an expert 2nd-opinion, & also recommending change in management plan in significant proportion of patients. It also had an impact on learning the clinical correlation of radiological-scans by junior-doctors who regularly attended these meetings.
Assessment of the quality of care in acute bowel obstruction patients at a tertiary care hospital with the NCEPOD guidelines
Authors: Siby Jayas , Singh Anurag , Marathe Kajol , Ellet Donna , Tonsi Alfredo
Published: December 2023

Background

Acute bowel obstruction (ABO) is a common cause of admission under the emergency general surgery services offered across the UK. The Aim of this quality improvement project (QIP) was to assess the quality of care for patients with ABO with the national and NCEPOD guidelines in a tertiary care hospital.

Method

Data was collected for two months in October and November 2022 from an electronic database in the trust and patient notes maintained throughout the admission.

Results

35 patients were included in the QIP (19 males and 16 females). Consultant review is recommended in < 14 hours after admission and national statistics show a delay in 15.9% of cases, in our hospital, it was 73.33% (22/30). Pain assessment on admission, the national average is 57% but, in this hospital, it was 42.86% (15/35). Similarly, guidelines recommend assessment of MUST score, hydration status and Rockwood score at admission, which was documented in 0/35, 1/35 and 15/35 cases in our hospital.

QIP was presented in the local clinical governance meeting followed by a teaching session to improve the patient care in ABO.

Conclusion

This QIP showed a lack of documentation in the pain score, hydration status, Rockwood score, MUST score and a delay in the consultant review for patients with ABO when compared with the guidelines of NCEPOD and national statistics. A repeat cycle of this QIP will be conducted in 6 months' time to analyse the effectiveness of the intervention on patient care outcomes.
A Global Survey of Precision Medicine in Emergency General Surgery
Authors: Ng Oon-Hui , O’Connell Elizabeth , Mukherjee Rajarshi
Published: December 2023

Background

Since first sequencing the human genome, precision medicine has become a modern-day reality. However, translation to all areas of medicine has not been equal. This study aimed to provide a ‘status update’ of precision medicine in EGS to guide future priority setting.

Methodology

An observational study was conducted utilising two curated global on-line databases: 1. Pubmed publications from 2001 & 2. Clinical trials registered on ClinicalTrials.gov. The top 10 presenting conditions in EGS, Oncology, and Acute Medicine were identified from literature review. Publications/trials in these areas were identified using associated keywords: precision, personalised, genomics, genome-wide association studies, exome studies, epigenetics, transcriptomics, proteomics, metabolomics, microbiomics, and pharmacogenomics. Duplicated publications/trials were removed prior to final analysis and only active, recruiting or completed trials were included. Temporal trends were compared and annual growth rates were calculated.

Results

There were 209,423 EGS publications, 1807 (0.9%) being precision-focused. Oncology had 1,137,396 publications, with 127,556 precision-focused (11.2%), and Acute Medicine had 1,647,046 publications, with 80,240 (4.9%) precision-focused. The rate of rise of annual publications since 2001 (human genome project publication) was significantly (p<0.05) lower for EGS (x2.9) versus oncology (x3.5) and medicine (x6.0). Only 7 precision-focused clinical trials were identified for EGS compared to 96 for Oncology and 39 for Medicine. x10 fewer precision-focused EGS publications and trials exist over 20 years, compared to covid-19 over 2 years.

Conclusion

Research and implementation of precision medicine in EGS remains inadequate. Increased investment and improved global implementation are warranted to address the widening gap in translation.
Rise of The Hot Clinic
Authors: Tamanna Rezuana , Pandey Vikas , Nayak Peramapally , Cheetham Drostan
Published: December 2023

Introduction

The surgical hot clinic was opened in December 2019 as part of our emergency surgical service. Despite initially poor uptake, the clinic has demonstrated its resilience through two national lockdowns and continuing pressures within the NHS. We report a two-month snapshot of activity in the unit.

Methods

Between June 1st and 1st August 2023, 299 patients were seen in the clinic. We analysed the data for patient demographics referral source and presenting complaint. Outcome measures included inpatient admission and patient discharge.

Results

299 patients attended the clinic during the study period. The number of patients seen each day varied between 4 and 12 (median 5). Of these, 147 (49.1%) were male and 152 (50.9%) were female. The referral source was primary care in 28%, Emergency Department in 37.2% and ward discharges accounted for 34.8%. Abdominal pain accounted for the majority of presentations (39.5%,), abscesses (22.4%), urological complaints (17%) complex wounds (5%), rectal bleeding (3.4%), hernial disease in 2%. Miscellaneous conditions accounted for the remainder (10.7%). 279 patients were discharged from the clinic, the admission rate from the clinic 6.7%

Conclusions

The surgical hot clinic has become an invaluable for patient assessment and emergency surgical care, remaining open even when other areas of the trust have been closed due to the pandemic or NHS pressures. We recommend an emergency surgical ‘hot clinic’ as part of the framework in the provision of emergency surgical services.
Local education measures are insufficient at ensuring timely imaging in acute pancreatitis
Authors: Bhanot Kunal , Mian Areeb , Mohamed Nusbya , Dawani Aruna
Published: December 2023

Aims

The Royal College of Radiologists (RCR) has outlined specific criteria for imaging in acute pancreatitis. The presence of pancreatic necrosis, free intraperitoneal fluid and extensive perihepatic fat stranding is associated with worse outcome. Timely computed tomography (CT) scanning 72 to 96 hours following onset of symptoms leads to more accurate diagnosis of pancreatic necrosis. Furthermore, ultrasound examination of the gallbladder is also recommended within 24 hours of admission to demarcate cause.

Methods

Two plan-do-study-act (PDSA) cycles were run between January to October 2022 and January to September 2023 in the surgical emergency unit. 50 patients were randomly selected amongst all pancreatitis admissions for each cycle. Outcome measures were percentage of CT scans adhering to optimal timing and percentage of ultrasound scans that were carried out within the first 24 hours. Cycle 1 findings were presented locally to staff as a teaching intervention.

Results

CT scans were performed in 60% and 66% of patients in cycle 1 and 2, respectively. Of these, 39% and 70% had optimal CT scan timing during cycle 1 and 2, respectively. Furthermore, only 33% of patients had US scans performed within 24 hours of admission during both cycles.

Conclusion

The above findings suggest that local teaching interventions are inadequate at meeting the recommended standard of 95% compliance defined by the RCR. This is likely due to rotating staff, lack of knowledge and incomplete prompting when ordering imaging. Further audit with an information technology based intervention is suggested to improve compliance.
Why aren't patients having emergency laparotomy when presenting with acute surgical pathology - a single site experience
Authors: Bakrania Shiv , Manor Kristin , Capozzi Patrizia
Published: December 2023

Aim

To establish the documented cause for not proceeding to emergency laparotomy for the acute general surgical patient

Methods

Retrospective single site review of all emergency patients admitted over three calendar months. Identification of and further collection of data for patients that did not proceed to Emergency Laparotomy despite indicative pathology.

Results

A total of 619 emergency general surgical patients were admitted from 1st January to 31st March 2023.

39 (6.3%) patients had an Emergency Laparotomy.

17 (2.7%) patients did not proceed to laparotomy despite pathology that could indicate the need for emergency laparotomy. 100% of these patients has CT imaging to diagnose the pathology.

Of the 17 patients without laparotomy median age of 86 years (range 42 – 91 years) and 12 were female.

Two patients made the decision that they did not want to proceed with emergency laparotomy, both male (75 and 88 years old) and both were reviewed by Care of the Elderly. Relatives were also involved with decision making. Both died in hospital.

Two were managed conservatively, the decision was made by the Consultant Surgeon, both patients were female (42 and 55 years old) and both survived to discharge and at 30 days.

All remaining 13 patients had documentation of frailty as being the cause for not proceeding. Although all >65 years, 4 did not see a Care of Elderly. 4 patients survived to 30 days.

Conclusion

Principles of futility in medical care are published in literature and surgeons should use these in documentation for clarification.
Outcome of emergency groin hernia repair in a district general hospital.
Authors: Hussain Muhammad Ibrar , Singh Gautam , Ghoneima Ahmed , Nasir Uzair , Prosser Mia , Peter Mark
Published: December 2023

Background

Tension free mesh repair is considered as gold standard technique for elective groin hernia repair. However, use of synthetic mesh remains controversial in the presence of gangrenous bowel, contaminated or infected surgical field.

Aims/ Objective

This study aimed to evaluate the outcome of emergency groin hernia repair, to assess the safety of mesh repair and explore risk factors of postoperative complications for adult patients with incarcerated groin hernia.

Methods

From April 2019 to August 2022, consecutive adult patients who underwent emergency repair for incarcerated groin hernia in our trust were retrospectively reviewed. Data was collected from electronic patient record, which includes patient demographics, type of hernia, repair (mesh/ non mesh), and the outcome in terms of early and late postoperative complications.

Results

153 patients underwent emergency groin hernia repair, of these 137 were primary and 15 recurrent. Median age was 75.5 (range 23 to 96), with male to female ratio 3:1.

80 percent cases were inguinal hernia and 20 percent femoral. 75 percent patients had mesh repair and remaining had suture repair done. Bowel resection was performed in 11 cases. Early complications were reported in 7 cases (hematoma 2, seroma 2, chronic pain 2 , recurrence 1 and infection 1) and late complications within 90 days were seen in 5 cases (recurrence, groin pain, adhesions).

Conclusions

Polypropylene mesh could be safely used in incarcerated groin hernia repair. However, suture repair is recommended when bowel resection is required. Delay in surgical repair, obesity and co-morbidities are risk factor of post-operative complications.
Referrals to a Surgical Emergency Clinic in a District General Hospital
Authors: Fitz-Gerald Alice , Pansell Karin
Published: December 2023

Aims

The referral pathway for the consultant-led Surgical Emergency Clinic (SEC) at our District General Hospital has no triage process. Anecdotally there are issues with inappropriate patients being booked for this clinic, taking up valuable slots and consultant time, and causing patient dissatisfaction. This was audited to see how the clinic is being utilised.

Methods

A retrospective case note review spanning 8 months looked at 250 patients seen in SEC. The origin of referrals, reason for referral, investigations, and clinic outcomes were recorded. Using this, patients were classified as ‘appropriate’ or ‘inappropriate’ for SEC.

Results

Referrals came from the following sources: 158 from general practice, 54 from the emergency department, and 38 directly from the surgical team. 58% were deemed to be appropriate referrals, while the remaining 42% were deemed inappropriate for SEC. 84 patients (33.6%) had imaging performed on the same day as their appointment, while 74 patients (30%) had investigations requested for a later date. 156 (62.4%) patients were discharged, 25 (10%) were redirected to a suitable surgical specialty outpatient clinic, and 16 (6.4%) were referred to other specialties. 10.4% had an acute surgical admission or same day CEPOD theatre, and 8.4% were listed for theatre on an elective/urgent basis.

Conclusion

This suggests SEC is not being used optimally and highlights a need to restructure the referral process. Physician Associates and Advanced Clinical Practitioners will be trained to assist consultants and triage referrals to improve patient flow, the efficiency of SEC, and hopefully the patient experience.
Pancreatitis survey of clinicians in the surgical department.
Authors: Gurung Ganga , Ali Mahmoud , Taha Ahmed , Begum Hosna , Oo Myo Kyaw , Rathore Munir
Published: December 2023

Pancreatitis is a common emergency presentation with acute abdomen.

A short 10 question snapshot survey about pancreatitis based on Nice guideline NG 104 and the (United Lincolnshire Hospitals NHS Trust) ULHT Trust guidelines was conducted among clinicians in the surgical department.

Survey answers were collected anonymously via google forms and paper forms. Data was analysed with Excel.

First cycle 17 responses. 2nd cycle 20 responses.

Teaching sessions were conducted; wall posters, notice letters were installed to improve the clinicians knowledge. A second cycle was conducted with the same set of questions.1st Cycle2nd CycleDefinition (88%)Definition (95%)Cause (88%)Cause (85%)Common Presentation (88%)Common Presentation (80%)Fluid management (88%)Fluid management (95%)Mortality rate (40%)Mortality rate (55%)Confirmatory test (64%)Confirmatory test (50%)Intervention (64%)Intervention (60%)Complication (70%)Complication (60%)Pain management (70%)Pain management (55%)

In conclusion, the basic idea about pancreatitis of the responders is already good which is found to be further improved even in a slightly larger sample size. The overall mortality of acute pancreatitis vs acute severe pancreatitis seems to be confused. More diverse opinions of the participants are obtained in the slightly controversial questions such as the pain management and the diagnosis.

Why the varied response? It must be acknowledged, the set of responders were a different subset as clinicians rotate in various departments. It highlights the necessity to promote education and awareness in a constant manner to provide best patient care, despite the constraints of time and workload.
A Rare Case of Fatal Necrotizing Fasciitis In An ASA Grade I Young Patient.
Authors: Mithany Reda
Published: December 2023

This case report presents a young adult who tragically died within 24 hours of his presentation due to severe necrotising fasciitis. The patient, initially healthy, sought medical advice from his GP for a sore throat and was prescribed amoxicillin. However, three days later, they ended up in the emergency department, critically unwell, with disseminated intravascular coagulopathy and painful left thigh with mild crepitus on examination.

A CT scan of the abdomen and pelvis with contrast revealed extensive necrotizing fasciitis in the left psoas muscle, left thigh, and left leg. Urgent surgical intervention, including left lower limb fasciotomy, laparotomy, and left above knee amputation, were performed in one session. The patient was then admitted to the intensive care unit, despite this immediate management, he succumbed to this rapidly progressive disease, experiencing sepsis and multiorgan failure.

This case highlights the importance of recognizing the symptoms of necrotising fasciitis early, even in young patients without comorbidities.
Healthcare provider cost of antimicrobial resistance in two teaching hospitals in Ghana
Authors: Otieku Evans , Kurtzhals Joergen Anders Lindholm , Fenny Ama Pokuaa , Ofori Alex Owusu , Labi Appiah-Korang , Enemark Ulrika
Published: December 2023

Understanding the healthcare provider costs of antimicrobial resistance (AMR) in lower-middle-income countries would motivate healthcare facilities to prioritize reducing the AMR burden. This study evaluates the extra length of stay and the associated healthcare provider costs due to AMR to estimate the potential economic benefits of AMR prevention strategies. We combined data from a parallel cohort study with administrative data from the participating hospitals. The parallel cohort study prospectively matched a cohort of patients with bloodstream infections caused by third-generation cephalosporin-resistant enterobacteria and methicillin-resistant Staphylococcus aureus (AMR cohort) with two control arms: patients infected with similar susceptible bacteria and a cohort of uninfected controls. Data collection took place from June to December 2021. We calculated the cost using aggregated micro-costing and step-down costing approaches and converted costs into purchasing power parity in international US dollars, adjusting for surviving patients, bacterial species and cost centres. We found that the AMR cohort spent a mean of 4.2 extra days (95% CI: 3.7–4.7) at Hospital 1 and 5.5 extra days (95% CI: 5.1–5.9) at Hospital 2 compared with the susceptible cohort. This corresponds to an estimated mean extra cost of $823 (95% CI: 812–863) and $946 (95% CI: US$929–US$964) per admission, respectively. For both hospitals, the estimated mean annual extra cost attributable to AMR was approximately US$650 000. The cost varies by organism and type of resistance expressed. The result calls for prioritization of interventions to mitigate the spread of AMR in Ghana.
What digital health technology types are used in mental health prevention and intervention? Review of systematic reviews for systematization of technologies
Authors: Tani Naomichi , Fujihara Hiroaki , Ishii Kenji , Kamakura Yoshiyuki , Tsunemi Mafu , Yamaguchi Chikae , Eguchi Hisashi , Imamura Kotaro , Kanamori Satoru , Kojimahara Noriko , Ebara Takeshi
Published: December 2023

Digital health technology has been widely applied to mental health interventions worldwide. Using digital phenotyping to identify an individual’s mental health status has become particularly important. However, many technologies other than digital phenotyping are expected to become more prevalent in the future. The systematization of these technologies is necessary to accurately identify trends in mental health interventions. However, no consensus on the technical classification of digital health technologies for mental health interventions has emerged. Thus, we conducted a review of systematic review articles on the application of digital health technologies in mental health while attempting to systematize the technology using the Delphi method. To identify technologies used in digital phenotyping and other digital technologies, we included 4 systematic review articles that met the inclusion criteria, and an additional 8 review articles, using a snowballing approach, were incorporated into the comprehensive review. Based on the review results, experts from various disciplines participated in the Delphi process and agreed on the following 11 technical categories for mental health interventions: heart rate estimation, exercise or physical activity, sleep estimation, contactless heart rate/pulse wave estimation, voice and emotion analysis, self-care/cognitive behavioral therapy/mindfulness, dietary management, psychological safety, communication robots, avatar/metaverse devices, and brain wave devices. The categories we defined intentionally included technologies that are expected to become widely used in the future. Therefore, we believe these 11 categories are socially implementable and useful for mental health interventions.
EU ETS and voluntary carbon markets: key features and current challenges
Authors: Koumpli Vassiliki
Published: December 2023

Carbon emissions trading constitutes an important instrument in reaching global climate goals and enhancing energy transition. This brief provides an illustration of the EU ETS and Voluntary Carbon Markets (VCMs), focusing on their main features and some of their current challenges from a regulatory point of view. Issues pertaining to systems’ linkage and carbon leakage in the framework of the EU ETS as well as ensuring the overall project quality in the framework of VCMs have to be successfully faced for such schemes to be effective. The special issues of the interaction between the EU ETS and VCM schemes and their impact on the energy sector are ultimately highlighted.
Alteration of circulating miRNAs during myocardial infarction and association with lipid levels
Authors: Ozuynuk-Ertugrul Aybike Sena , Ekici Berkay , Erkan Aycan Fahri , Coban Neslihan
Published: December 2023

Background

Increasing mortality and morbidity of coronary artery disease (CAD) highlight the emerging need for novel noninvasive markers such as circulating microRNAs (miRNAs).

Objective

To evaluate the circulating levels of miR-126-3p, miR-210-3p, let-7g-5p, and miR-326, and their associations with known contributors to CAD, in CAD subgroups.

Methods

We divided the cohort into 4 groups: non-CAD controls (≤30% stenosis; n = 55), and patients with stable angina pectoris (SAP; n = 48), unstable AP (UAP; n = 46), and myocardial infarction (MI; n = 36). The circulating levels of miR-126-3p, miR-210-3p, let-7g-5p, and miR-326 were determined using TaqMan Advanced miRNA Assays in serum specimens.

Results

Circulating miR-126-3p levels were lower in the MI and UAP groups, compared with the non-CAD group, whereas miR-210-3p circulating levels were lower in the MI group than others. The levels of circulating let-7g-5p were shown to be useful for distinguishing UAP from MI, and there were substantial differences in circulating let-7g-5p levels between the UAP and MI groups. Moreover, lipid levels and ratios were lower in individuals with high circulating miR-126-3p and miR-210-3p levels.

Conclusions

The study results suggest that circulating miR-126-3p, miR-210-3p, and let-7g-5p are differentiated between different clinical presentations of CAD and associated with lipid levels, which are important risk factors and determinants of CAD.
Measuring the initial-final mass relation using wide double white dwarf binaries from Gaia DR3
Authors: Hollands M A , Littlefair S P , Parsons S G
Published: December 2023

The initial-final mass relation (IFMR) maps the masses of main-sequence stars to their white dwarf descendants. The most common approach to measure the IFMR has been to use white dwarfs in clusters. However, it has been shown that wide double white dwarfs can also be used to measure the IFMR using a Bayesian approach. We have observed a large sample of 90 Gaia double white dwarfs using FORS2 on the VLT. Considering 52 DA + DA, DA + DC, and DC + DC pairs, we applied our extended Bayesian framework to probe the IFMR in exquisite detail. Our monotonic IFMR is well constrained by our observations for initial masses of 1–5 M⊙, with the range of 1–4 M⊙ mostly constrained to a precision of 0.03 M⊙ or better. We add an important extension to the framework, using a Bayesian mixture-model to determine the IFMR robustly in the presence of systems departing from single star evolution. We find a large but uncertain outlier fraction of 59 ± 21 per cent, with outlier systems requiring an additional $0.70_{-0.22}^{+0.40}$ Gyr uncertainty in their cooling age differences. However, we find that this fraction is dominated by a few systems with massive components near 0.9 M⊙, where we are most sensitive to outliers, but are also able to establish four systems as merger candidates.
PM2.5 Concentrations of Outdoor Tobacco Smoke at Different Distances From the Smoking Source: Is There an Optimal Distance for a Designated Smoking Area?
Authors: Kim Soomin , Lee Kiyoung
Published: December 2023

Introduction

Many countries have enacted indoor smoke-free policies, and some have established outdoor nonsmoking areas. However, no clear standard for determining the optimal distance for these outdoor nonsmoking zones remains. This study aimed to evaluate outdoor tobacco smoke (OTS) exposure up to a distance of 21 m and to identify factors influencing OTS levels.

Methods

To assess OTS levels, PM2.5 concentrations were measured at distances of 6, 12, 15, 18, and 21 m using real-time aerosol monitors. Between August and October 2022, a total of 164 measurements were undertaken. The background PM2.5 concentration was gauged for 5 minutes before smoking commenced and then re-measured 3 minutes during smoking. OTS levels were determined by calculating the difference between the average background PM2.5 and the average PM2.5 concentrations during smoking. A one-sample t test was employed to ascertain if the OTS levels at each distance were significantly elevated compared to 0 µg/m3. Furthermore, a multiple linear regression analysis was conducted to determine the factors influencing OTS levels.

Results

The mean OTS levels recorded at all specified distances significantly surpassed 0 µg/m3. The regression analysis revealed that the OTS levels correlated significantly with distance and wind speed. Specifically, OTS levels diminished as distance expanded and wind speed reduced.

Conclusions

OTS levels, even at 21 m, were significantly greater than 0 µg/m3. Our results provide robust evidence supporting the establishment of outdoor nonsmoking zone up to 21 m.

Implications

Outdoor tobacco smoke (OTS) level was determined by PM2.5 concentration. The OTS levels significantly exceeded 0 µg/m3 at every measured distance up to 21 m. In the regression model, OTS levels notably correlated with distance and wind speed. OTS levels diminished as distance expanded and wind speed reduced.
False and missed alarms in seasonal forecasts affect individual adaptation choices
Authors: Hembach-Stunden Katharina , Vorlaufer Tobias , Engel Stefanie
Published: December 2023

Facing climate change, seasonal forecasts, and weather warnings are increasingly important to warn the public of the risk of extreme climate conditions. However, being confronted with inaccurate forecast systems may undermine individuals’ responsiveness in the long run. Using an online experiment, we assess how false alarm and missed alarm-prone forecast systems influence individuals’ adaptation behaviour. We show that exposure to false alarm-prone forecasts decreases investments if a warning is issued (the ‘cry-wolf effect’). Exposure to missed alarm-prone forecasts increases adaptation investments if no warning, but also if a warning has been issued. Yet, individuals exposed to both false and missed alarm-prone forecasts still adjust their adaptation investments depending on the forecasted probability of extreme climate conditions. Individuals with missed alarm-prone forecasts are, however, less sensitive to the forecasted probability if a warning has been issued. In case of low probability warnings, overshooting investments in adaptation hence becomes more likely.
Serum calprotectin correlates stronger with inflammation and disease activity in ACPA positive than ACPA negative rheumatoid arthritis
Authors: Sejersen Kristina , Weitoft Tomas , Knight Ann , Lysholm Jörgen , Larsson Anders , Rönnelid Johan
Published: December 2023

Objectives

The aim of the present study was to evaluate the performance of serum and SF levels of the granulocyte protein calprotectin as an inflammatory biomarker in RA patients with knee synovitis.

Methods

Seventy-six RA patients with ongoing knee synovitis were included. Data on DAS with 28 joints and their subcomponents and radiological destruction of the affected knee were collected. White blood cell count, CRP, ACPA against cyclic citrullinated peptide version 2 (anti-CCP2), IgM RF and calprotectin were analysed in parallel in circulation and in SF. Counts of polynuclear and mononuclear cells were measured in SF.

Results

Serum (S)-calprotectin correlated more strongly than SF-calprotectin with inflammatory markers and disease activity. Instead, SF-calprotectin showed a strong correlation to SF counts of white blood cells, and especially to polymorphonuclear cell counts (Spearman’s ρ = 0.72, P < 0.001). S-calprotectin showed markedly stronger correlation with inflammatory markers and disease activity in ACPA positive as compared with ACPA negative RA patients; a similar difference was observed for patients with and without IgM RF.

Conclusion

The particularly strong association between circulating calprotectin and inflammation in ACPA positive RA is a new argument for a specific role for polymorphonuclear granulocytes/neutrophils in this RA subset. Measurement of calprotectin in SF does not convey any additional benefit compared with measurement in the circulation in RA patients with knee synovitis.
Lung ultrasound and high-resolution computed tomography quantitative variations during nintedanib treatment for systemic sclerosis-associated interstitial lung disease
Authors: Di Battista Marco , Delle Sedie Andrea , Romei Chiara , Tavanti Laura , Da Rio Mattia , Morganti Riccardo , Della Rossa Alessandra , Mosca Marta
Published: December 2023

Objectives

Lung ultrasound (LUS) and high-resolution CT (HRCT) are commonly used for the evaluation of interstitial lung disease (ILD). Nintedanib (NIN) is an antifibrotic therapy approved for systemic sclerosis-associated ILD (SSc-ILD). We assessed LUS and quantitative HRCT changes in SSc-ILD patients treated with NIN during a 1 year follow-up, evaluating relationships between imaging variations and functional or quality-of-life outcomes.

Methods

SSc-ILD patients who started NIN were enrolled and followed for 12 months. Pulmonary function tests and patient-reported outcome measures (PROMs) were assessed half-yearly and quarterly, respectively. LUS was performed quarterly evaluating the presence of B-lines (BL) and pleural line irregularities (PLI). HRCT was repeated after 1 year and quantitatively analysed with CALIPER software.

Results

Ten patients (70% female, mean age 62 years) were enrolled. The mean total number of both BL and PLI was constantly decreased during NIN treatment, being significantly reduced after 12 months (from 175.1 [66.7] to 120.8 [70.3] for BL, P = 0.005; and from 50.6 [32.5] to 37.2 [22.4] for PLI, P = 0.05). Male gender, smoking habit and baseline forced vital capacity <70% predicted were associated with worse LUS outcomes. A greater reduction in both BL and PLI was observed in those who improved in PROMs, especially modified Medical Research Council dyspnoea scale (P = 0.016 and P = 0.04, respectively) and Saint George's Respiratory Questionnaire (P = 0.006 and P = 0.026, respectively). No significant changes in the CALIPER percentages of normal parenchyma or ILD elements were observed after 12 months of NIN, thus paralleling the stabilization obtained at pulmonary function tests.

Conclusion

We present preliminary results on NIN effects on SSc-ILD as assessed by LUS, a useful method for frequently repeated monitoring, and CALIPER, a valid implementation whenever a HRCT is performed.
Estimating overdiagnosis in giant cell arteritis diagnostic pathways using genetic data: genetic association study
Authors: Chatzigeorgiou Charikleia , Barrett Jennifer H , Martin Javier , Morgan Ann W , Mackie Sarah L ,   UK GCA Consortium, Morgan Ann W , Mackie Sarah L , Sorensen Louise , Raashid Lubna Haroon , Martin Steve , Robinson James I , Mellen Sam , Hoggart Sarah , Barrett Jennifer H , Taylor John C , Pease Colin , Dasgupta Bhaskar , Watts Richard , Gough Andrew , Isaacs John D , Green Michael , McHugh Neil , Hordon Lesley , Kamath Sanjeet , Nisar Mohammed , Patel Yusuf , Yee Chee-Seng , Stevens Robert , Nandi Pradip , Nandagudi Anupama , Jarrett Stephen , Li Charles , Levy Sarah , Mollan Susan , Salih Abdel , Wordsworth Oliver , Gondo Prisca , Hollywood Jane , Peters Genessa , Routledge Christine , Gill Anne , Carr Lisa , Wood Rose , Williams Clare , Oakley Mandy , Sanders Emma , Mackenzie Felicity , Fong Rosanna , James Lynne , Spimpolo Jenny , Kempa Andy , Culfear Karen , Nugaliyadde Asanka , Roads Esme , Rowbotham Bridie , Masqood Zahira
Published: December 2023

Objectives

GCA can be confirmed by temporal artery biopsy (TAB) but false negatives can occur. GCA may be overdiagnosed in TAB-negative cases, or if neither TAB nor imaging is done. We used HLA genetic association of TAB-positive GCA as an ‘unbiased umpire’ test to estimate historic overdiagnosis of GCA.

Methods

Patients diagnosed with GCA between 1990 and 2014 were genotyped. During this era, vascular imaging alone was rarely used to diagnose GCA. HLA region variants were jointly imputed from genome-wide genotypic data of cases and controls. Per-allele frequencies across all HLA variants with P < 1.0 × 10−5 were compared with population control data to estimate overdiagnosis rates in cases without a positive TAB.

Results

Genetic data from 663 GCA patients were compared with data from 2619 population controls. TAB-negative GCA (n = 147) and GCA without TAB result (n = 160) had variant frequencies intermediate between TAB-positive GCA (n = 356) and population controls. For example, the allele frequency of HLA-DRB1*04 was 32% for TAB-positive GCA, 29% for GCA without TAB result, 27% for TAB-negative GCA and 20% in population controls. Making several strong assumptions, we estimated that around two-thirds of TAB-negative cases and one-third of cases without TAB result may have been overdiagnosed. From these data, TAB sensitivity is estimated as 88%.

Conclusions

Conservatively assuming 95% specificity, TAB has a negative likelihood ratio of around 0.12. Our method for utilizing standard genotyping data as an ‘unbiased umpire’ might be used as a way of comparing the accuracy of different diagnostic pathways.