bluuebunny/crossref_metadata_2025 huggingface dataset:
P77 Management of vitamin B12 deficiency in primary care during the COVID-19 pandemic: Do all patients need to come in?
Authors: Desai Chaitya , Machado Beno , Kumar Sanjay
Published: April 2021

Introduction

Not all causes of vitamin B12 deficiency require intramuscular hydroxocobalamin (IMH). NICE guidance states that diet-related deficiency can be treated orally, but pernicious anaemia must be excluded via anti-intrinsic factor antibodies (anti-IFAB). Our aim was to audit the management of B12 deficiency during the COVID-19 pandemic when reducing footfall is vital. Then, implement staff education strategies to improve adherence to guidance.

Methods

Data for patients who received IMH from March-June 2020 was retrospectively analysed for: full blood count (FBC), B12, folate and anti-IFAB levels. These patients were sent letters to have blood tests for the missing investigations. Results were presented at meetings and flowchart-posters were distributed. Audit was closed with prospective data for patients who requested IMH from September-October 2020.

Results

From 46 patients identified, 82.6% had B12 and folate checked prior to therapy commencement, but 23.7% had an untreated folate deficiency. 79.3% of patients receiving IMH had never been tested for anti-IFAB; none of those tested were positive. A lack of awareness of the NICE guidance was identified as a key cause for non-adherence. Following the intervention, all 34 patients were appropriately investigated. Out of these, 8.8% had positive anti-IFAB levels and following a review of their clinical histories, all patients were commenced on appropriate therapy.

Discussion

IMH can have great benefit; but it is invasive, has financial and nursing-time implications, and increases the risk of contagion via footfall in the practice. Thus, this multi-cycle audit shows that appropriate investigations prior to commencing therapy is key.
P83 Online Multidisciplinary Review of Point of Care Ultrasound Images During the COVID-19 Pandemic
Authors: Shuker B A , Perry J
Published: April 2021

Point-of-care-ultrasound (POCUS) is a valuable diagnostic tool in intensive care. Evaluation of POCUS images acquired in our intensive care unit (ICU) prior to the COVID-19 pandemic had typically been performed solely at the point of care. Where further evaluation was required, cross-sectional thoracic imaging or departmental echocardiography would be requested. Clinicians also had access to ICU ultrasound machines for review of images, or to repeat studies for clarification of findings. However, the nature of the pandemic limited access to ICU to minimise contact with COVID-19.

Objectives

We aimed to develop an online solution for review of POCUS images by the multidisciplinary team (MDT).

Methods

Microsoft Teams was utilised to create a dedicated channel for the MDT to review POCUS images. Images were exported from ultrasound machines used inside our ICU to portable USB drives in standard formats (DICOM or WMV). The portable USB drives were decontaminated prior to transfer outside of the ICU. Anonymised images were uploaded with relevant clinical details to the Teams platform for MDT review.

Results

The online platform provided rapid access to images for review by the MDT. POCUS images from ICU patients with and without COVID-19 were reviewed. MDT review frequently led to a change in patient management. Significant examples included identification of a missed inferior vena cava thrombus leading to initiation of anticoagulation therapy, and rapid expert input for a case of cardiac tamponade.

Conclusion

The use of an online platform allowed our intensive care unit to establish a reliable method for images acquired from point-of-care-ultrasound to be remotely reviewed by an expert multidisciplinary team, consequently improving patient care.
P84 Optimising hand trauma care at a Major Trauma Centre (MTC) during the COVID-19 pandemic
Authors: Khajuria Apoorva , Jones Matthew
Published: April 2021

Introduction

This study evaluates the management of hand injuries during COVID-19 following the prompt implementation of the BOA guidelines; reconfiguration of hand services and implementation of the ‘one-stop’ model.

Methods

285 cases OVER A 1-MONTH PERIOD were RETROSPECTIVELY reviewed to evaluate the effectiveness of managing patients using the ‘one-stop’ model and the new Urgent Treatment Centre (UTC).

Results

277 patients were included in the study. During Covid-19, operative cases fell by 62%. 86.3% (239/277) of cases were managed in the UTC; 54.4% (130/239) required conservative management and 45.6% (109/239) required minor procedures (in UTC). REMOVABLE SPLINT USE was optimized through design of ‘softcasts’ for non-operative management of distal radius fractures. A patient education video: ‘softcast removal at home’ was created and in cases requiring sutures, 95.1% (39/41) were absorbable, thereby avoiding COVID-19 exposure for follow-up. Only 50.5% (140/277) of patients had formal follow-up arranged and patient information follow-up cards were developed.

Conclusion

The one-stop model prevents delay in definitive treatment, allows effective initial treatment, and minimizes the need for face-to-face follow up. In light of a possible second wave of COVID-19 cases, this new model should be considered for implementation by all hand’s units for the foreseeable future.
P88 Paroxysmal sympathetic storm and the role of beta-blockers in traumatic brain injury: a scoping review protocol
Authors: Nguembu Stéphane , Meloni Marco , Endalle Geneviève , Dokponou Hugues , Dada Olaoluwa Ezekiel , Kanmounye Ulrick Sidney
Published: April 2021

Introduction

Most cases of paroxysmal sympathetic hyperactivity (PSH) result from traumatic brain injury (TBI). Little is known about its pathophysiology and treatment, and several neuroprotective drugs are used including beta-blockers. The aim of our study is to collate existing evidence of the role of beta-blockers in the treatment of PSH.

Method

We will search MEDLINE, Web of Science, EMBASE, Cochrane, and Google Scholar. The search terms used will cover the following terms: “paroxysmal sympathetic hyperactivity”, “traumatic brain injury” and “beta-blockers.”: No language or geographical restrictions will be applied. Two independent co-authors will screen the titles and abstracts of each article following predefined inclusion and exclusion criteria. If there is a conflict the two reviewers will find a consensus and if they cannot a third co-author will decide.

Using a pre-designed and pre-piloted data extraction form, data from each included citation will be collected (authors identification, study type, TBI severity, type of beta-blockers used, dosage of the drug, clinical signs of PSH, Glasgow Coma Scale, Glasgow Outcome Scale, mortality, morbidity and length of stay). Simple descriptive data analyses will be performed and the results will be presented both in a narrative and tabular form.

Results

The effectiveness of beta-blockers in post-TBI PHS will be evaluated through clinical signs of PHS(increased heart rate, respiratory rate, temperature, blood pressure, and sweating), Glasgow Coma Scale, and Glasgow Outcome Scale. mortality, morbidity and length of stay.

Conclusion

At the end of this scoping review we will design a systematic review with metaanalysis if there are a reasonable number of studies otherwise we will design a randomized controlled trial.
P92 Power dynamics in healthcare teams – a barrier to team effectiveness and patient safety: A systematic review
Authors: Kearns Emma , Khurshid Zuneera , Anjara Sabrina , De Brún Aoife , Rowan Brendan , McAuliffe Eilish
Published: April 2021

Introduction

Hierarchies in healthcare teams are pervasive and widely acknowledged as impacting on working cultures. This review explores the impact of power dynamics in multidisciplinary healthcare teams on patient safety and team effectiveness.

Methods

A systematic review was conducted using five academic databases (PubMed, CINAHL, PsycInfo, Cochrane Library, Embase) between January 2010-2020. Potentially relevant articles were selected based on title and abstract review, followed by full text review, data extraction and data appraisal. Consistent with PRISMA guidelines, two researchers independently carried out all stages, from data screening to quality appraisal. A narrative synthesis was conducted.

Results

The databases searches yielded a total of 869 studies. 28 studies met the eligibility criteria and were included in the synthesis. Of these, 20 articles associated power dynamics with team effectiveness and 19 linked power dynamics to patient safety outcomes. Hierarchical power dynamics inhibit team communication and speaking up behaviours, which impacts team effectiveness and patient safety. Barriers to speaking up include workplace policies; respect for seniors’ experience; time pressures; feelings of intimidation and powerlessness; fears of reprisal and repercussions; perceived poor self-efficacy; lack of confidence and role clarity.

Conclusion

Hierarchies and power dynamics have a profoundly negative effect on patient safety and team effectiveness through their negative impact on communication and speaking up behaviours. Whilst hierarchies cannot be abolished, to improve team communication and collaboration, healthcare organisations and training programmes should consider initiatives that break down silos and promote an inclusive approach to patient care. Initiatives that target the practice of collective leadership and an open and supportive work environment have been shown to improve communication and team effectiveness.

Theme: Cross-disciplinary research
P100 Recruitment barriers in multicentre collaborative studies as demonstrated by a single unit experience of the Management of Acutely Symptomatic Hernias (MASH) study
Authors: Wilkins A , Findlay A , Yau J , Ettles C
Published: April 2021

Introduction

MASH is a multi-centre prospective cohort study assessing the management of patients presenting with symptomatic abdominal wall hernia. Consenting patients are recruited during acute admission, with telephone follow up at day 30 and 90. We performed a retrospective review of all patients referred to a single general surgical unit with a symptomatic hernia to quantify recruitment rate and identify barriers to recruitment.

Methods

Patients meeting the inclusion criteria 1st August to 18th September were identified from prospective handover lists and electronic records and compared to the prospectively compiled screening log. Reason for not enrolment was coded according to protocol with an additional code added for patients not identified at time of admission.

Results

8/23 (35%) eligible patients were enrolled. 15/23 (65%) were not enrolled due to; Patient not identified at time of admission n = 9 (60%), declined n = 2 (13.3%), too unwell to consent n = 2 (13.3%), translational barrier n = 1 (6.6%) and lacking capacity n = 1 (6.6%). Patients not identified at time of admission included those seen by clinicians not involved in study (new starters and locums) and those discharged directly from A&E with insufficient time and resources to gain consent.

Conclusion

In our unit 65% of eligible patients were not recruited, the majority of whom were missed at time of presentation. This study will generate important information on management and outcomes of acute hernias however strategies are required to recognise and mitigate recruitment bias. Staff turnover may be a significant factor in prospective studies, particularly those prolonged during the COVID-19 pandemic.
P102 Reporting of innovations in surgery: a systematic review of robotic liver resections
Authors: Biggs Sarah , Lee Keng Siang , Shah Max , Brankin-Frisby Tom , Leow Tjun Wei , Torkington Amber , Scroggie Darren , Jones Conor , Pathak Samir , Blencowe Natalie S ,   on behalf of the RoboSurg Collaboration
Published: April 2021

Introduction

Liver resections are most commonly performed for either primary or secondary cancers. Consensus guidelines recommend that minor liver resections should be attempted laparoscopically, however this technique has limitations. These include difficulties with surgical access, ergonomics and visualization. Consequently, there has been increasing interest in innovative solutions such as robotic surgery. The IDEAL Collaboration has provided guidance for the reporting of surgical innovations, but it is not known how robotic liver resections have been reported. The aim of this study is to summarize technique descriptions and governance procedures, and understand which clinical outcomes have been reported.

Methods

A systematic review is being conducted in accordance with the PRISMA guideline. A search of Embase, Ovid Medline, the Cochrane Library and Web of Science was performed, using search concepts of “robotic” and “liver resection”. Articles will be screened to select primary research reporting outcomes of robotic liver resections. Data will be extracted on the reporting of study characteristics, governance and ethical arrangements, mitigations of harm, techniques and modifications, and outcomes. A descriptive summary of the data will be produced. The results will be critiqued in relation to guidance from the IDEAL Collaboration.

Results

The search returned 3063 articles, with 2385 remaining after de-duplication. An interim descriptive analysis of the data will be presented, summarizing how robotic liver resections have been reported. A critique of the available results in the context of IDEAL guidance will be provided.

Conclusion

This systematic review will describe how robotic liver resections have been reported as surgical innovations.
P105 Robosurgeons vs. robosceptics’: can we afford robotic technology or can we afford not to?
Authors: Sandhu Jasmesh
Published: April 2021

Aim

To investigate the cost-effectiveness of robotic technology in robotic-assisted radical prostatectomy in comparison with laparoscopic radical prostatectomy and open radical prostatectomy.

Methods

The British Association of Urology Surgeons database (2014–2016) and Cancer Research UK (2012–2014) were accessed in conjunction with media; keywords included: ‘Da Vinci’, ‘first robotic prostatectomy’, ‘hospital’ to estimate the cost-effectiveness of robotic-assisted radical prostatectomy in the National Health Service.

Results

Approximately 12/43 (27.9%) centres achieved 150 robotic-assisted radical prostatectomies per year while 26/43 (60.4%) centres have managed to meet 100 robotic-assisted radical prostatectomies per year in 2014–2016. A national mean of 120–130 robotic-assisted radical prostatectomies per year for 2014–2016 was estimated.

Conclusion

The cost of robotic-assisted radical prostatectomy is adequately justified if a high volume of surgeries (>150) are performed in high volume centres by high volume experienced surgeons per year. This can be achieved by subsidising the cost of robotic technology, centralisation and establishing robotic training centres.
P110 SMILE: Sustaining Medical Education In a Lockdown Environment. Facilitator perceptions of a free online access medical education platform as an adjunct to the traditional undergraduate curriculum during lockdown
Authors: Pascoe John , Foster Paul , Quddus Muntasha , Kosti Angeliki , Guest Francesca , Stevens Sian , Bamford Richard , Coulston James
Published: April 2021

Introduction

SMILE is a free online access medical education (FOAMed) platform created by UK surgical trainees and a medical student. During lockdown SMILE delivered 200 lectures with student attendance as high as 1400, from both UK and overseas medical schools. We report facilitator perceptions of delivering FOAMEd via SMILE.

Method

A questionnaire was sent to 77 facilitators covering preconceptions and post-session perceptions of FOAMed.

Results

61/77 responses were received from faculty of a range of medical and surgical specialties. Only 38% (23/61) had previously taught online.

Engaging a large audience virtually was a common concern and 17% purposely made sessions less interactive than they would have done for face-to-face teaching: 95% (58/61) felt the technology was adequate to deliver sessions.

100% of facilitators appreciated the use of SMILE moderators to help bridge the gap between themselves and the audience

24% (15/61) of facilitators used applications such as mentimeter that they perceived as increasing their connectivity with large audiences.

100% felt that FOAMed would play a central role beyond Covid.

Conclusions

In the times of Covid, where online medical education is becoming the new normal, we show facilitators feel comfortable with delivering FOAMed. We also discuss how facilitators maximized effectiveness in very large audiences.
P114 STING. Steroid Injections DurinG Covid-19. A cross speciality call
Authors: Hardman Lotte , Elamin Salma , Giddins Grey , Gardiner Matthew , Reay Emma
Published: April 2021

Introduction

An important clinical question during the Covid -19 pandemic is the safety of steroid use. Guidelines published by rheumatology, physiotherapy, orthopaedic and pain medicine societies have advised on the restricted use of corticosteroids for musculoskeletal and rheumatic conditions. For clinicians across the specialities there is a challenge to safely conducting best practice, yet ensuring patients have access to the significant functional benefits of steroid injections.

Methods

The STING prospective service evaluation will collect data on steroid injections undertaken during this part of the pandemic. Clinicians will be able to input information on patient demographics, background Covid risk and steroid injection specifics. At follow up at 4-6 weeks complications and Covid specific outcomes will be recorded, as well as patient perceived symptom improvement.

Each unit collecting data will have assigned collaborator(s), with a senior consultant validating the data.

Data will be collected and managed using Research Electronic Data Capture (REDCap). Data collection and management will adhere to Caldicott II principles and GDPR.

Results

Results will be analysed through RedCap and compared to national Covid incidence. Local complication and patient reported outcomes will be compared between specialities, environments and steroid specifics (volume, location etc.).

Conclusion

A pan-speciality look at steroid injection use during the pandemic will be useful primarily to contribute to understanding the safety of steroid use. Secondarily to look at cross speciality differences in administration, PROMs and to appreciate patient groups who may be excluded from steroid treatment.

Join the team! Head to RSTN to get involved.
P116 SURGE: Survey of Undergraduate Respondents on Global surgery Education
Authors:   InciSioN UK Collaborative
Published: April 2021

Introduction

It is estimated that over 10% of the global burden of disease can be treated with surgery, most of which is located in low and middle-income countries (LMICs), underpinning the importance of the topic of global surgery (GS). The multidisciplinary principles of GS are increasingly recognised as being key to modern practice and as such, must be fostered at early stages of medical training. However, it is unclear whether medical students are being exposed to GS. This study aimed to assess the importance of GS and its presence in medical curricula.

Methods

A novel, 22-item online questionnaire was developed and disseminated to medical students and faculty members using social media. Data collection was conducted by a collaboration of medical students, who acted as regional leads at their institutions.

Results

795 medical students and 141 faculty members representing 38/42 of UK medical schools (90.4%) completed the questionnaire. Only 84 students (10.6%) were previously exposed to GS. Most students (66.3%) and faculty (60.6%) agreed that GS should be an integral part of the curriculum. Only 20 students (2.5%) were or familiar with what a career in GS means.

Conclusion

Approximately 2/3 of students and faculty agree that global surgery should be an integral part of the mandatory curriculum. Findings of this study should underpin further incorporation of GS into curricula, as high-income countries can decisively contribute to achieving the global surgery 2030 targets, by training a new generation of clinicians who are ready for the challenges of the 21st century.
P122 The Diagnosis and Management of Appendicitis During the COVID-19 Pandemic: The Pennine Acute Trust Experience
Authors: Idama Daniel , Aldersley George , Connolly Meghan , O'Connor Alexander
Published: April 2021

Introduction

Appendicitis management has evolved recently with more reliance on Computed Topography (CT) and laparoscopic surgery being commonplace. In this project we looked at how the Coronavirus pandemic (COVID-19) had impacted the diagnosis, management and outcomes of patients with appendicitis in our unit.

Method

A retrospective review of patients diagnosed with appendicitis from 1st March – 30th April in 2019 and 2020. Data was collected on diagnosis, management and outcomes.

Results

In 2020, 91 patients were identified (mean 33, range 6-85, F:M 1:1.4). In 2019, 107 patients were identified (mean 32, range 7-69, M:F 1:1.1). There was no significant difference in patients’ symptom duration (p = 0.21), White Cell Count (p = 0.20) or C-Reactive Protein (p = 0.10). More CTs were performed in 2020 (56/91, 61.5%) than in 2019 (40/107, 37.4%). Less patients underwent appendicectomy in 2020 (75/91, 82.4%) than in 2019 (104/107, 97.2%). Open appendicectomies were performed in 64% (48/75) of those operated in 2020 compared with 12.2% (13/104) in 2019. There was no difference in hospital length of stay or re-admissions rates.

Conclusion

The diagnosis and management of appendicitis changed considerably at our trust during COVID-19 with more reliance on CT diagnosis and less use of laparoscopy. Despite this, outcomes remained unchanged.
P125 The effect of wellbeing mobile-applications on the Mental and Physical Health of Healthcare workers: A Systematic Review
Authors: Alford Natasha , Okocha Michael , Jones Conor
Published: April 2021

Introduction

The growing pressure on Healthcare workers (HCWs) can lead to worsening physical and mental wellbeing. Use of traditional support systems is limited and whilst there are a significant number of mental health platforms, few are targeted towards HCWs.

Objective

This review aimed to assess the available literature and platforms focused on supporting HCWs mental health and wellbeing.

Methods

A systematic search, following PRISMA guidelines was conducted. Abstracts were included if they targeted HCWs and used smartphone apps to support wellbeing. A further comprehensive application search of IOS and Android stores was performed to identify HCW wellbeing applications.

Results

In total 725 abstracts were identified. 10 publications, with a total of 683 participants, relating to wellbeing applications in HCWs met the inclusion criteria. 87% of the HCWs included in the studies were female. The majority (9/10) of the studies reported improved wellbeing of HCWs following the use of app-based interventions. A total of 1656 mobile applications were identified and met the inclusion criteria if they focused on HCWs wellbeing. The majority of the studies and apps focused on increasing mindfulness practices and yielded statistically significant results compared to traditional interventions.

Conclusion

Wellbeing programmes delivered through an app provide convenience and can improve the mental and physical wellbeing HCW’s. This is particularly key during challenging times. Given the limited number of published studies on smartphone apps and the limited number of apps for HCWs, it is clear that there is a deficit that requires urgent addressing despite two promising candidates.
P129 The utility of routine operative swab culture in uncomplicated peri-anal abscesses
Authors: Khajuria Apoorva , Rahim Tuba , Baig Mariam , Leong Kai
Published: April 2021

Introduction

Despite perianal abscess being a common presentation, certain aspects of its management remain controversial, especially the routine use of intra-operative swab cultures.

Methods

A retrospective review of patients that underwent incision and drainage procedures for a perianal abscess over a six-month period was undertaken.

Results

Over 6 months, 50 patients were identified. The male to female ratio was 3:1 and median ASA score was 1. Only 6/50 patients presented with recurrent abscess and 1 patient had history of inflammatory bowel disease. On the basis of operative findings, 39 patients (78%) had uncomplicated abscess (not associated with cellulitis, sinus or fistula); swab cultures were performed in 26 (67%) of these patients. All patients were discharged on the same day; microbiology reports did not impact the treatment and no patients were followed up in clinic post-operatively or presented with recurrence. The number of unnecessary microbiology swabs undertaken in this cohort equates to approximately 52 unnecessary swabs a year. The cost of one swab is £10.10p, which means £520 could potentially be saved annually.

Conclusion

Routine intra-operative swab cultures do not impact management decisions, add to unnecessary costs and therefore should not be undertaken in uncomplicated or first presentation of peri-anal abscesses.
P132 TRAVERSING: Transfer of thoracic Aortic Vascular Emergencies to Regional Specialist Institutes Group
Authors: Qureshi M I , Lee K S , Bevis P , Twine C P , Brooks M J , Hinchliffe R J
Published: April 2021

Introduction

The incidence of Acute Aortic Syndrome (AAS) is rising. The Department of Health is considering a supra regional tier of centralisation for complex aortic care. No standardised pathway exists to guide the transfer of patients with AAS, despite increasing evidence from coroners and the Healthcare Safety Investigation Board of delayed transfers and miscommunication costing lives. This study aims to deliver a pathway for the safe transfer of patients with suspected AAS to a specialist aortic centre through multidisciplinary Delphi consensus.

Methods

The researchers will create an interdisciplinary Steering Group to oversee the study, which will identify appropriate stakeholders for inclusion in the Delphi process. A systematic review will be performed to summarise existing evidence and highlight gaps in knowledge where consensus is required. The Steering Group will create, circulate and interpret the Delphi questionnaire. The outcomes will also enable determination of criteria for audit that should become the standard for ensuring a safe and efficient process for patient transfer to a complex aortic centre.

Results

Results will provide inter-disciplinary guidance to healthcare professionals for early management and transfer of patients with suspected AAS, and prevent unnecessary transfer, thereby improving outcomes, ensuring equity of access to specialist aortic care for patients. Results will also provide audit standards through which future improvements can be realised.

Conclusion

This study is reliant upon collaboration between multidisciplinary healthcare providers, qualitative researchers and patients. Its success will streamline emergency pathways in the management of AAS, saving lives and resources, with inbuilt mechanisms for continuous review and improvement.
P133 Types and timing Of venous thromboembolism Prophylaxis for Traumatic Brain Injury (TOP TBI) Study
Authors: Bandyopadhyay Soham , Borchert Robin , Kolias Angelos G , Chari Aswin , Fountain Daniel M , Layard Hugo H , Lawrence Tim P , Hutchinson Peter J
Published: April 2021

Background

Patients with traumatic brain injury are at significant risk for both developing venous thromboembolisms and haemorrhagic progression. Pharmacological thromboprophylaxis and mechanical thromboprophylaxis may be able to minimise the incidence of venous thromboembolisms. Problematically, pharmacological thromboprophylaxis also has the potential to augment clinically significant intracranial haemorrhage expansion. Compounding this issue is that the evidence for mechanical thromboprophylaxis is not based on neurotrauma populations, and there is insufficient evidence to guide clinicians on the optimum agent, dose, and timing of pharmacological thromboprophylaxis. Based on the need for high quality evidence, we propose the Types and timing Of venous thromboembolism Prophylaxis for Traumatic Brain Injury (TOP TBI) Study.

Aim

To collect high quality and relevant data regarding thromboprophylaxis practice and associated outcomes - including rates of venous thromboembolisms, intracranial haemorrhage expansion and mortality – for TBI patients in the UK and Ireland in order to optimise management for these patients.

Methods

We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units: in the UK and Ireland will be eligible to participate. Patient eligibility will be determined according to pre-specified criteria. Eligible cases will be prospectively recruited over two months and followed-up in 6 months. Based on epidemiological investigations and data from the Trauma Audit and Research Network, we expect to recruit between 1000 to 2000 patients. Anonymised data will be collected locally and submitted to a secure web-based central database.

Outcome measures

These include all-cause mortality, venous thromboembolism events, haemorrhagic progression, re-admission, surgical intervention, length of stay in admitting unit, neurological status, and Extended Glasgow Outcome Scale during follow-up.

Conclusion

TOP TBI is an important step in the ongoing efforts to optimise the outcomes of patients who have suffered a traumatic brain injury. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and inform future studies.
O1 Admission avoidance in tonsillitis and peritonsillar abscess: a prospective national audit during the initial peak of the COVID-19 pandemic
Authors:   Integrate UK ENT Trainee Research Network, Rocke John
Published: April 2021

Introduction

During the COVID-19 outbreak, the collaborative network for ENT trainees in the UK (INTEGRATE), conducted a multi-centre prospective audit on the management of Tonsillitis and Quinsy. This was in response to the implementation of new COVID-19 specific guidelines released by ENT UK and to explore factors relating to unscheduled re-presentations discharges direct from the Emergency Department (ED).

Methods

Consecutive patients with suspected tonsillitis or quinsy, aged 18 or over, and referred to ENT in secondary care were eligible for inclusion. Data was collected, using a standardised electronic case report form, relating to patient demographics, COVID-19 status, clinicians’ grade, assessment and interventions. Each case was followed-up for 10 days to assess predictors of unscheduled re-presentation after discharge direct from the ED.

Results

83 centres submitted 765 tonsillitis and 416 quinsy cases. 54.4% of tonsillitis cases and 45.3% of quinsy were discharged directly from the ED. 9.6% of tonsillitis and 10.3% of quinsy discharges re-presented within 10 days, compared to 9.7% and 10.6% for those initially admitted.

IV steroids were given to 67.0% of tonsillitis patients and 73.6% of quinsy.

77.2% of quinsy patients underwent drainage during their initial presentation, but there was no significant difference in re-presentation rate in those drained vs not-drained (p = 0.85).

Univariable logistic regression showed no significant predictors of re-presentation within 10 days.

Conclusion

Management of tonsillitis and quinsy was affected during the initial peak of the pandemic, with a shift towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.
V3 Is re-introducing major open and minimally invasive surgery during COVID-19 safe for patients and healthcare workers? An international, multi-centre cohort study in the field of oesophago-gastric surgery
Authors: Alasmar Mohamed , Kausar Afsana , Borgstein Alexander , Moons Johnny , Doran Sophie , de Pascale Stefano , Restrepo Rafael , Verrengia Apollonia , Alloggio Mariella , Delgado Ana Moro , del Val Ismael Díez , Kumar Sacheen , Giocapuzzi Simone , Baiocchi Gian Luca , de Vega Irañeta Marta , Salcedo Gabriel , Vorwald Peter , Romario Uberto Fumagalli , Nafteux Philippe , Gisbertz Suzanne , Chaudry Asif , Alkhaffaf Bilal
Published: April 2021

Introduction

The Covid-19 pandemic has resulted in unprecedented and challenging changes to surgical practice, especially with the suspension of cancer surgery. There have been concerns regarding Covid-19 risk and infection to patients and healthcare workers, during major complex open surgical intervention, especially with minimally invasive surgery. This study examines the COVID-19 related risks to patients and healthcare workers following the re-introduction of major oesophago-gastric (OG) surgery.

Methods

This was an international, multi-centre, cohort study of open and minimally invasive oesophagectomy and gastrectomy procedures in specialist Upper GI centres, over a consecutive period of two months. Patients were recruited from nine European centres serving regions with a high population incidence of COVID-19 infections. 30-day operative morbidity and mortality data was collected for patients. All staff involved in the operative care of patients, were invited to complete a health-related survey.

Results

A total of 158 patients were included in the study (71 oesophagectomy, 82 gastrectomy), of which 87 patients (57%) underwent minimally invasive surgery (59 esophagectomy, 28 gastrectomy). A total of 403 staff were eligible for inclusion of which 313 (78%) completed the health survey. Non- standardised precautions to minimise against the risks of COVID for patients and staff were implemented at the centres. There were no cases of Covid-19 among patients in the post-operative period, however, two healthcare workers developed self-limiting COVID infection.

Conclusion

Precautions to minimise COVID-19 infection risk to healthcare staff and patients, have allowed the safe and successful reintroduction of major open and minimally invasive OG surgery.
V9 Risk of death following pulmonary complications after surgery with and without SARS-CoV-2 infection: a pooled analysis of individual patient data from pre-pandemic and pandemic international cohort studies
Authors:   COVIDSurg Collaborative,   STARSurg Collaborative, Gujjuri Rohan
Published: April 2021

Introduction

Whilst the severe consequences of COVID-19 around the time of surgery are well described, no comparison has been made to pulmonary complications in the absence of infection. This study aimed to compare postoperative death in patients with and without SARS-CoV-2 infection.

Methods

A patient-level comparative analysis of two international prospective cohort studies; one conducted before (January to October 2019) and one during the SARS-CoV-2 pandemic (from local emergence of COVID-19 to April 2020). Patients undergoing elective resection of an intra-abdominal cancer with curative intent were included in a multilevel logistic regression. The primary outcome was 30-day postoperative mortality.

Results

Of 7402 patients included, 3031 underwent surgery before and 4371 during the pandemic. Overall, 6.5% (n = 484) patients suffered a pulmonary complication, 5.1% had a SARS-CoV-2 infection diagnosed, and 1.4% patients (n = 107) died. Compared to patients without pulmonary complications, those with SARS-CoV-2 pulmonary complications had a higher adjusted odds of death (OR: 54.14, 95%CI: 23.46 to 124.91, p < 0.001) than those with non-SARS-CoV-2 pulmonary complications (OR: 7.20, 95%CI: 3.85 to 13.45, p < 0.001).

Conclusion

Postoperative pulmonary complications were associated with increased 30-day mortality. SARS-CoV-2 associated pulmonary complications were associated with a far higher mortality than a non-SAR-CoV-2 pulmonary complication.
Social Work and Policy Practice: Understanding the Role of Social Workers
Authors: Saxena Ankur , Chandrapal Sneha
Published: April 2021

The social work profession is a practice-based profession that promotes social justice and advocacy for marginalised individuals. In spite of the fact that the policy practice is considered as crucial component of social work practice, the real participation of social workers in policy practice seems very less. It has a potentially significant influence on social work profession, both as a field of study and an area of practice. History is filled with an evidence showing that the policy practice paved the way for the development of social work profession as people used different social work skills to campaign for the formalisation of the social work profession. Social workers have been held up as exercising substantial power to influence policy being policy implementers (Schorr, A. L. (1985) ‘Professional practice as policy’, Social Service Review, 59(2), pp. 178–96; Scott, W. R. and Davis, G. F. (2007) Organisations and Organising: Rational, Natural, and Open System Perspectives, Upper Saddle River, Pearson Prentice Hall). Social workers having practice experience make them excellent advocates because they understand clearly the challenges confronted by their clients, including clients’ presenting problems, holistic environmental factors, and client strengths that can be drawn on so as to assist them. This article throws light on linkages between social work and social policy, policy practice in social work and role of social worker as a change agent in policy practice.
Supportive Social Work Supervision as an Act of Care: A Conceptual Model
Authors: Newcomb Michelle
Published: April 2021

Supportive supervision is an important but often over-looked practice in contemporary social work, often assisting in maintaining practitioner well-being. The following research explores how eleven social workers in Australia experience supportive supervision and its impact on their well-being and job satisfaction. The research used interpretative phenomenological analysis to reveal the complex and important role supportive supervision has for social workers, working within risk-adverse, managerialist settings. Participants revealed how supportive supervision allowed them to feel cared for and valued within their work environment. This was contrasted with their experience of the tokenistic supervision they received in many agencies leading to feelings of emotional unsafety in the workplace. Whilst social work is inherently an emotionally driven profession, this study revealed how supervisory practices that focus on risk and surveillance place supportive supervision as an afterthought. This research highlights the importance of supportive supervision in ‘caring for the carers’ in front line social work positions.
Measurement of Immature Reticulocytes in Dried Blood Spots by Mass Spectrometry
Authors: Cox Holly D , Miller Geoffrey D , Manandhar Abhilasha , Husk Jacob D , Jia Xuan , Marvin James , Ward Diane M , Phillips John , Eichner Daniel
Published: April 2021

Background

Immature reticulocytes (IRC) are the first cells to respond to changes in erythropoiesis. For antidoping applications, measurement of IRC may improve detection of blood doping practices. Unfortunately, this small cell population has limited stability in liquid blood samples and is difficult to measure with optimal precision. We developed a method to measure 3 IRC membrane proteins in dried blood spots (DBS) to monitor changes in erythropoiesis.

Methods

DBS spots were washed with buffers to remove soluble proteins, membrane proteins remaining in the spot were digested with trypsin, and one peptide for each protein was measured by LC-MS/MS. IRC protein concentration was determined using a DBS single point calibrator.

Results

Intraassay precision for IRC proteins was between 5%–15%. IRC proteins were stable in DBS for 29 days at room temperature. In a longitudinal study of 25 volunteers, the mean intraindividual variation for 3 IRC proteins was 17%, 20%, and 24% from capillary blood DBS. In comparison, the mean longitudinal variation for IRC counts measured on an automated hematology analyzer was 38%. IRC protein concentration from capillary blood DBS correlated well with venous blood DBS protein concentrations.

Conclusions

Measurement of IRC proteins in DBS samples provides a method to measure changes in erythropoiesis with improved analytical sensitivity, stability, and precision. When combined with the inherent advantages of capillary blood collection in the field, this method may substantially improve the detection of blood doping practices.
Dose optimisation for Loss of Response to Vedolizumab— Pharmacokinetics and Immune Mechanisms
Authors: Ungar Bella , Malickova Karin , Hanžel Jurij , Abu Arisha Muhammad , Paul Stephane , Rocha Catia , Ben Shatach Zohar , Abitbol Chaya Mushka , Haj Natour Ola , Selinger Limor , Yavzori Miri , Fudim Ella , Picard Orit , Shoval Irit , Eliakim Rami , Kopylov Uri , Magro Fernando , Roblin Xavier , Chowers Yehuda , Drobne David , Lukas Milan , Ben Horin Shomron
Published: April 2021

Background

Real life data regarding pharmacokinetics of vedolizumab in patients needing dose optimisation are scarce. We set to examine whether pre-optimisation vedolizumab levels associate with therapy outcomes and which mechanisms explain the associations.

Methods

A multicentre observational study assessed the outcome of dose increase in association with pre-escalation levels in vedolizumab-treated patients. SubsequentIy, α4β7 occupancy on peripheral blood [PB] and intestinal lamina propria [LP] tissues was investigated on various cellular subsets in patients undergoing lower endoscopy on infusion day. Cellular localisation of vedolizumab-bound α4β7 and effects on M1 and M2 macrophages were also explored.

Results

A total of 161 inflammatory bowel disease [IBD] patients were included. Among 129/161 patients intensified during maintenance [Week 14 onward], pre-intensification trough levels were comparable or higher among those subsequently attaining post-optimisation clinical, biomarker, and endoscopic remission, compared with non-remitting patients [p = 0.09, 0.25, 0.04, respectively]. Similar results were demonstrated for those dose-optimised during induction [Week 6, n = 32]. In the immune sub-study [n = 43], free α4β7 receptors at trough were similarly low among patients with/without mucosal healing, on PB T cells [p = 0.15], LP T cells [p = 0.88], and on PB eosinophils [p = 0.08]. Integrin receptors on M1 and M2 macrophages were also saturated by low levels of vedolizumab and anti-inflammatory cytokine secretion was not increased. Co-localisation and dissociation experiments demonstrated membranal α4β7 receptors of two origins: non-internalised and newly generated α4β7, but re-binding was still complete at very low concentrations.

Conclusions

These results do not support pharmacokinetics as the mechanism responsible for loss of response to vedolizumab, nor do they support a need for higher drug concentration to enhance vedolizumab’s immune effects. Higher pre-escalation levels may indicate less clearance [less severe disease] and higher likelihood of subsequent re-gained response, regardless of therapy escalation.
Four-dimensional flow analysis reveals mechanism and impact of turbulent flow in the dissected aorta
Authors: Takahashi Kenichiro , Sekine Tetsuro , Miyagi Yasuo , Shirai Sayaka , Otsuka Toshiaki , Kumita Shinichiro , Ishii Yosuke
Published: April 2021

OBJECTIVES

This study aimed to explore the flow dynamics factors affecting turbulence formation in the false lumen (FL) of aortic dissection using four-dimensional flow magnetic resonance imaging (4D flow MRI). This study also aimed to uncover risk factors affecting late complications of aortic dissection.

METHODS

Thirty-three aortic dissection patients were examined using 4D flow MRI for quantitative flow dynamics (gross flow, velocity and regurgitant fraction) and turbulence visualization (helix and vortex with three-point visual grading) in the FL. The incidence of late complications (rupture or prophylactic intervention) was also obtained prospectively.

RESULTS

The helix grade was correlated with FL gross flow (rS = 0.55, P < 0.001) and FL velocity (rS = 0.45, P = 0.008). The vortex grade was also correlated with FL gross flow (rS = 0.70, P < 0.001) and FL velocity (rS = 0.67, P < 0.001). Comparative analysis of patients with complications and stable patients revealed that patients with complications exhibited higher FL gross flow [41.7 (interquartile range, IQR 29.1–59.7) vs 17.7 (IQR 9.0–42.0) ml/s; P = 0.01], higher helix grade [2 (IQR 1.25–2) vs 0 (IQR 0–1); P = 0.001] and higher vortex grade [2 (IQR 1–2) vs 0 (IQR 0–2); P = 0.01].

CONCLUSIONS

Using 4D flow MRI analysis, we showed that turbulence formation depends on flow volume and velocity in the FL. Patients with high-volume turbulent flow in their FL are at higher risk of late complications; therefore, close follow-up and aggressive prophylactic intervention may improve their survival.

Clinical trial registration number

Nippon Medical School Hospital Institutional Review Board approved this observational study in September 2018 (No. 30-08-986).
GENETIC REGULATION OF MUP PRODUCTION IN RECOMBINANT INBRED MICE
Authors: Szoka P R , Paigen K
Published: April 2021

Inbred strains of mice excrete all three major urinary proteins (mups) when induced by testosterone, but differ as to the relative proportions and total levels of each mup present. We have now determined the urinary mup pheno-types before and after testosterone treatment of seven recombinant inbred strains derived from progenitor strains exhibiting different mup phenotypes. The results codirm previous observations indicating that total control of mup protein production is a multigenic process. One locus, Mup-a on chromosome 4, determines the relative mup protein proportions after induction by testoster- one. Mup-a, together with other genetic sites, determines the basal mup proportions. Genes other than Mup-a determine the kinetics of mup induction and total mup excretion.
Constitutional pluralism and loyal opposition
Authors: Flynn Tom
Published: April 2021

Constitutional pluralism has long been controversial, but has recently come under renewed attack. Critics allege that by justifying departure by national courts from the Court of Justice of the European Union’s (CJEU) orthodoxy on the primacy of EU law, constitutional pluralism is (at best) susceptible to abuse by autocratic member state governments, or is (at worst) a favored tool of Europe’s new authoritarians. This article is a defense of heterodoxy in European constitutional thought, and of constitutional pluralism in particular. It uses the concept of “loyal opposition” as a framing discourse, allowing us to see that heterodox approaches to EU constitutionalism and opposition to the received and dominant interpretation of the primacy of EU law are not necessarily any less “loyal” to the principles and values of European integration than agreement with the CJEU. A “legitimacy test” is proposed, by which we can determine whether a given instance of national judicial disagreement with the CJEU is loyal, principled opposition, or disloyal, abusive opposition.
Limited democracy and great distrust: John Hart Ely in Bolivia and Chile
Authors: Verdugo Sergio
Published: April 2021

This article shows that John Hart Ely’s defense of judicial review, as elaborated in his book Democracy and Distrust, has had little influence in Bolivia and Chile. However, that observation does not mean that a theory justifying judicial review when a political market failure is identified is useless for examining both countries’ judicial decisions. The author argues that an Ely-an procedural approach to judicial review can help justify or reject Chilean and Bolivian rulings—or judicial inactions—if certain conditions are taken into account to adapt Ely’s theory to both jurisdictions.