bluuebunny/crossref_metadata_2025 huggingface dataset:
TP8.2.30 Bleep paralysis: preventing inefficiency on the general surgical on-call
Authors: Whitmore Helen , Salem Rola , Bowling Kirk , Clamp Holly , Chandra Rosaline , Jaralla Nasir
Published: October 2021

Aims

The demand on surgical services is increasing. In our Trust, all surgical referrals and queries are directed through the Senior House Officer (SHO) on-call. This leads to inefficiency, with many hours spent on the telephone and away from clinical duties. Such constant intensity can cause increased stress and anxiety amongst those involved. Junior doctor burnout and stress-related sickness are increasing concerns amongst the current surgical workforce. In an attempt to alleviate these factors, we instigated an intervention to evenly distribute workload during surgical on-calls.

Method

The number of bleeps through the surgical SHO on-call were audited for four consecutive thirteen hour shifts. Each call was estimated to take an average of five minutes to resolve. A separate GP referral phone was introduced to reduce the volume of traffic through the SHO bleep. The number of calls through the SHO and referral phone were re-audited following this intervention.

Results

Before introduction of a referral phone, the mean length of time spent by the SHO per shift answering calls was 232.5 minutes, with a maximum of 330 minutes. Post intervention, the SHO spent an average of 92.5 minutes per shift answering calls and referrals through the GP phone averaged 43.75 minutes.

Conclusion

The introduction of a single point GP referral system has significantly reduced the volume of calls through the SHO, thus has also minimised time spent away from on-call duties. Not only does this improve efficiency within the on-call team, but also reduces risk of burnout amongst trainees.
TP9.1.2We must do better - An audit assessing local compliance with NICE Guidelines (2014) on giving patient discharge advice regarding driving following traumatic brain injury
Authors: Chouari Tarak , Khan Hamza , Wali Umar , Shanmuganandan Arun
Published: October 2021

Introduction

Driving is a complex activity involving the coordination of a number of cognitive and physical skills, which may be impaired after head injury. It is a legal requirement that patients’ inform the licensing authority when they have sustained a head injury. Failure to do so results in possible fines, invalid insurance and prosecution. NICE recommends printed patient advice about driving once discharged following a head injury.

Methods

A retrospective analysis of all traumatic brain injury admissions under the surgical team over a 6 months was performed. The aim was to identify current practice regarding assisting patients to return to safe driving after head injury. Information related to patient demographics, documented driving status and advice (verbal and written) related to driving, was sought. Descriptive statistics were used to portray the results.

Results

56 patients were admitted following a traumatic head injury. The average age was 77 (range of 24 to 94) Patients spent on average 4 days in hospital. Only 2 patients had their driving status documented. These two patients also had a documented occupation dependent on driving. No patients received advice specific to DVLA guidelines.

Conclusion

This study demonstrates that there is poor compliance with NICE guidelines. Indeed, there is a need for change in our practice. We have a duty of care for our patients and in ensuring the safety of the general public. The main limitation of this study relates to the adequacy of documentation. We provide solutions in order to tackle the findings of this audit.
TP9.2.5Routine ultrasound in paediatric appendicitis is highly accurate and substantially reduces negative appendicectomy rate
Authors: Darbyshire Alexander , Towers Ashley , Toh Simon , Mercer Stuart
Published: October 2021

Aims

Our centre routinely uses ultrasound in adults to confirm diagnosis of appendicitis. This study investigated its use in the diagnosis of suspected appendicitis in children and its impact on management.

Methods

Retrospective cohort study of children (5-16 years) managed by general surgeons with suspected appendicitis during 2019. Primary outcomes were ultrasound use. Secondary outcomes were diagnosis, length of stay, complications and negative appendicectomy rate.

Results

A total of 193 children were admitted with suspected appendicitis. The majority underwent an ultrasound scan (169/193 [88%]) which identified an inflammed appendix or secondary-inflammation in nearly all cases of appendicitis (65/71 [91%] and 5/71 [7%] respectively). A normal appendix was identified in more than half of children not diagnosed with appendicitis (53/95 [56%]), with the rest showing an ovarian pathology (3/95 [3%]) or normal scan (39/95 [41%]). Ultrasound had high sensitivity (92% [CI 83-97%]) and specificity (100% [CI 96-100%]) for appendicitis.

The majority of children diagnosed with appendicitis were treated with laparoscopic appendicectomy (75/85 [88%]) and a minority medically-managed (10/75 [12%]). One appendix mass was medically-managed, and two Meckels Diverticulitis underwent a laparoscopic small bowel resection. Negative appendicectomy rate was extremely low (2/77 [2.5%]). Post-operative complication rate was low (6%). Median length of stay was short for appendicitis and all other diagnoses (2days [IQR 2.2] and 1day [IQR 0] respectively).

Discussion

The majority of children with suspected appendicitis underwent pre-operative ultrasound, which was highly sensitive and specific for appendicitis. Negative appendicectomy rate was extremely low, and likely related to routine pre-operative imaging.
TP9.2.6An update of the surgical management of truncal cutaneous abscesses: A systematic scoping review of current practice in 2021
Authors: Bennet Melissa-rose , Hartrick Olivia , Eason Russell , Rajaretnam Niroshini
Published: October 2021

Introduction

NHS England has shown efficiency in patient flow and reduction of length of stay resulting in cost savings. There’s considerable variability in local and national guidelines for Incision and drainage (I&D) of cutaneous truncal abscesses which can financially impact NHS expenditure.

This Systematic Scoping Review (SSR) aims to explore current management recommendations for I&D of cutaneous truncal abscesses in both adult and paediatric populations; and assess the quality of this research.

Method

SSR search strategy employed the PICO framework. Cochrane Library, NICE Evidence, Pubmed, OVID medicine, CINAHL and EBSCO databases were searched using search syntax ((“abscess*”OR“perianal abscess*”) AND (“incision and drainage”OR“I&D”) AND (“Equipment*”OR”instrument*”OR“Kit*”OR“theatre staff*”OR“team*”)). Full texts were systematically assessed. Final review performed in accordance with Joanna-Briggs-Institute protocol.

Results

131 articles were identified. No limit was placed on publication date. After removal of duplicates and abstract screening, 10 full text articles were assessed. Research suggests day-case emergency surgery pathways to manage I&D of abscesses are efficient and sustainable. Antibiotic use after I&D is weakly recommended and there is low quality evidence for using internal packing for healing perianal abscess cavities, and yet, this is established, common practice.

Conclusion

There’s variable quality evidence reviewing the surgical pathways for I&D and the post-operative management of cutaneous truncal abscesses. Overall, the findings are limited and further work is required to establish national guidelines.
TP9.2.7Acute Surgical Admissions at the End of Life: an Analysis of Deaths in Non-operatively Managed Patients
Authors: Clements Hollie , Boghdady Michael El , Alijani Afshin
Published: October 2021

Aims

Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission.

Methods

This single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis.

Results

72 patients were included. 68.1% of patients died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p < 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death.

Conclusion

Frailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.
TP9.2.8Conservative versus surgical management of complicated diverticulitis - a retrospective study of long-term outcomes
Authors: Durrity Emily , Elliott Grace , Gana Tabitha
Published: October 2021

Introduction

The management of complicated diverticulitis has evolved over the years, with a shift towards a conservative approach. The aim of this study was to evaluate the feasibility and long-term outcomes of conservative management of an episode of complicated diverticulitis.

Method

We retrospectively evaluated patients presenting with perforated colonic diverticulitis between 2013 and 2017. Demographic, presentation and management data was recorded. CT grading system and Clavien-Dindo classification of complications was used.

Results

Ninety-two patients were included, with a male-to-female ratio of 1:2. Forty patients had a Hartmann’s procedure on the first admission (Group A), the remaining 52 patients were managed conservatively with antibiotics +/- radiological drainage (Group B). Mean follow-up was 64.9 months (range 3-7 years).

CT Grade 3 and 4 disease was observed in 65% of Group A and in 40.4% of Group B patients. 14 (26.9%) patients re-presented with recurrent diverticulitis in Group B, 12 (23.1%) of whom required surgical resection in the course of follow-up.

Group A had significantly increased morbidity and poorer outcomes compared to Group B with a longer median length of stay (23.5 vs 10.2 days). Post-operative complications affected 72.5% (29 patients), with 40% being grade III or higher. Stoma reversal was performed in 10 (25.8%).

Conclusion

In carefully selected cases, complicated diverticulitis including CT grade 3 and 4, can be managed conservatively with acceptable rates of recurrence. Better overall outcomes were observed compared to surgical intervention, which is associated with high rates of post-operative complications (72.5%) and low stoma reversal rates 25.8%.
TP9.2.17Developing Novel Referral Pathways in Emergency Surgery
Authors: Morrison-Jones Victoria , Pearson Katherine , Bailey Ian , Trompetas Vasileios , Berry David
Published: October 2021

Introduction

In line with the principles of GIRFT and recognising the demand on the Emergency Department (ED) the Acute Surgical Unit (ASU) developed a direct admission pathway entitled ‘ASU Direct’ (ASUD). Nurse led ED triage with adherence to a referral proforma allows direct admission of suitable surgical patients eliminating medical ED review or discussion with the on-call Registrar.

Aim

Investigate the usefulness of the ASUD pathway and adherence to admission criteria.

Method

Two retrospective audits of ASUD referrals were completed and compared with concurrent traditional registrar referrals. Inter-departmental discussions occurred between audit cycles.

Results

Audit 1: 13 days, 150 cases (8 excluded). 75 (53%) referred via ASUD, 67 (47%) via surgical registrar. Sixteen ASUD cases (22%) breached pathway protocols including 3 young women referred without pregnancy tests. Seventeen (25%) cases referred via the Registrar fulfilled ASUD criteria. Documentation complete in 56% of ASUD cases.

Audit 2: (3 weeks after feedback) - 10 days, 120 patients (25 excluded). Fifty one ASUD cases (54%) and 44 (46%) registrar referrals. 24% cases breached ASUD criteria, 7 registrar referrals (15%) appropriate for ASUD. ASUD documentation completed in 60% with 100% pregnancy status recorded.

Conclusions

Proportion of ASUD / registrar referrals remained constant but there were fewer missed opportunities for ASUD. Inappropriate ASUD admissions remained similar. While ASUD worked well for visible pathology, less-so for protocol-driven abdominal pain.

Senior ‘front-door’ triage in ED might improve protocol compliance, helping to develop such pathways, observing GIRFT and avoid unnecessary transfer of patients (especially during the COVID pandemic).
TP9.2.20Improving surgical discharge summaries
Authors: Elzaafarany Ahmed , Oyewole Bankole , Ng Vivian , Mangat Shannon , Cheng Amanda , Tawfik Ahmed
Published: October 2021

Introduction

Discharge summaries are a means of communication to the patient, the GP and for medical records. An initial audit showed surgical discharge summaries contained misleading information and sometimes omitted relevant information.

Changes were implemented to improve the accuracy of surgical discharge summaries.

Method

The initial audit assessed the accuracy of discharge summaries over a two-week period and the re-audit was conducted after implementation of change over a similar time period. Data was extracted from electronic patient records (EPR).

Change implementation included educating the surgical team on the need for accurate discharge summaries. The EPR team was notified of the intrinsic error in the PowerChart system which is widely used in various NHS Trust.

Results

Incidence of misdiagnosis or misleading diagnosis in discharge summaries reduced from 42% to zero, lack of relevant investigations decreased from 7% to 1%, No follow up status reduced from 23% to 10% (usually post appendicectomy patients which are not routinely followed up but this needs to be stated in the discharge summary for clarity), at both initial audit and re-audit all patients had relevant surgery or procedures done included in their discharge summaries while the rate at which relevant medications were not stated in the discharge summary decreased from 4% to zero.

Conclusions

Discharge summaries are vital for record keeping and are usually the only written information a patient receives regarding their hospital stay. It is important that errors in EPR systems be flagged up for review.
TP9.2.22A six year retrospective study of appendicular neoplasms and review of literature
Authors: Patel Maitreyi , Mohapatra Shrabani Das , Kirmani Naveed
Published: October 2021

Aims

The aim of this study was to evaluate the incidence of appendiceal neoplasm, identify possible association of pre and intra-operative factors associated with it, and to determine its clinical significance.

Methods

Using pathological reports from surgical specimens of appendix from January 2015 to September 2020, a single centre retrospective analysis was performed. Medical records of patients, pre-operative investigations, intra operative findings, histological reports and post operative management were evaluated.

Results

The incidence of appendiceal neoplasms was 2.33% (65/2791). They consisted of Neuroendocrine tumor (NET) in 35(53.85%), followed by Low grade mucinous neoplasm (LAMN) in 23(35.38%), Goblet cell carcinoid in three (4.62%), mucinous cystadenoma 2(3.08%), one (1.54%) adenocarcinoma and one (1.54%) metastasis. Appendicitis was the most common indication for surgery. 46(70.77%) patients had emergency surgery. 89.13% emergency surgeries was appendicectomy, NET being the most common tumor in 60.87%. 19(29.23%) patients had elective surgery, all had pre operative radiological investigation, LAMN being most common. Only five (7.69%) patients had intra operative suspicion of tumor. Ten patients required second procedure in the form of right hemicolectomy in nine, and cytoreducetive surgery in one. All patients were followed up as per national guidelines.

Conclusions

The incidence of appendiceal neoplasms though low, has been steadily rising. Its diagnosis is rarely evident on pre operative radiological investigations. Surgeons should be aware of these neoplasms and its frequent association with emergency appendicectomies done for suspected acute appendicitis.
TP10.1.5The reorganisation of Emergency General Surgery services during the COVID-19 pandemic in the UK: Outcomes of delayed presentation, mortality and BAME patients
Authors: Chan Anthony , Stathakis Panos , Goldsmith Paul , Smith Stella , Macutkiewicz Christian
Published: October 2021

Background

The COVID-19 pandemic is a global public health emergency. The reconfiguration of local healthcare systems to accommodate the increase in Critical Care capacity has put strain on ‘non-COVID’ specialities. This study characterises the utilisation of Emergency General Surgery (EGS) services at a busy UK university teaching hospital during the COVID-19 lockdown period to evaluate outcomes and to identify patient groups with worse outcomes.

Method

This retrospective study compares EGS admissions during the UK’s lockdown period (23rd March-28th May 2020) to the same period in 2019. Patient demographics were recorded together with details of their hospital stay and treatment outcomes.

Results

A total of 645 patients were included, comprising 223 in the COVID-19 and 422 in the non-COVID-19 periods. There was no difference in age, sex, co-morbidity or socioeconomical status. A lower proportion of Black, Asian and Minority Ethnic (BAME) patients were admitted during the COVID-19 period (20.6% vs 35.4%, p < 0.05). The duration of symptoms prior to presentation were longer, and admission Early Warning Scores and serum inflammatory markers were higher. More patients present with acute kidney injury (9.9% vs 4.7%, p = 0.012). There was no difference in perioperative outcomes or 30-day mortality, but more patients were readmitted following conservative management (10.6% vs 4.7%, p = 0.023).

Conclusion

We show that the UK reorganisation of EGS services has been successful in terms of outcomes and access to services despite a more unwell population. There was a lower proportion of BAME admissions suggesting additional barriers to access to healthcare under pandemic lockdown conditions.
TP10.1.6Short term outcomes of emergency colorectal cancer resections during COVID-19 pandemic;Experience of a district general hospital
Authors: Liyanage Aloka Suwanna Danwaththa , Gokul Krishnan , Babu Bheemanakone Harish
Published: October 2021

Aim

Surgical and oncological outcomes of emergency colorectal cancer (CRC) surgeries are poor compared to those of elective resections. SARS-Cov-2 ambience has added an additional risk on these patients during the course of their perioperative journey. The impact of peri-operative SARS-CoV-2 infection on the outcomes of these unique patients is still under scrutiny. We aimed to analyse a cohort of patients that underwent emergency CRC surgeries during pandemic in our setting.

Methods

We analysed a prospectively maintained database of all patients who underwent emergency CRC surgeries since 11th of March 2020 to 31st of December 2020. Primary outcome measures were Length of stay (LoS) and 90 day mortality. Secondary outcomes were post-operative complications, SARS-CoV-2 infection rates and 30 day readmission rates.

Results

We performed a total of 18 emergency CRC surgeries (Male: Female 1:1). Median age was 76.5 years (Range 39-89 years). Median LoS was 13 days (Range 5-110 days). 90 day mortality was 17% (3/18) and of the two patients who died (2/3), their cause of death was COVID-19 related. 4 (22%) patients had peri-operative SARS-CoV-2 infections. 30 day re-admission rate was 16% (3/18). 78% (14/18) of the patients had their cancer resected. 61% (11/18) of the procedures were palliative.

Conclusions

Peri-operative SARS-CoV-2 infection may have add on effect on the morbidity and mortality on patients undergoing emergency CRC surgeries. Data from large scale multicentre cohort studies would provide more insight in to this.
TP10.2.1Lessons Learnt in the Management of Acute Appendicitis During the Sars Covid-19 [Cv 19] First Wave
Authors: Ngugi Josephine , Patel Nikhita , Al-Whouhayb Maitham , Mathur Pawan
Published: October 2021

Aims

To evaluate the impact of CV19 on surgical technique and patient outcome in management of acute appendicitis during the 1st wave.

Method

Data was collected on patients presenting with appendicitis to ED. Group A: Jan-March 2020, pre COVID and Group B: April-June 2020: peri COVID

Results

There was no difference in sex, age and length of stay between groups. In group A [n = 194], 88% had lap appendicectomy vs Group B [n = 98], 97% had an open operation. Group A had a complication rate of 6% [wound infection] with no readmissions. Group B had 31% complication rate [intra-abdominal collection, bleeding, and ileus] requiring readmission.

685 surgical patients attended ED in the first half of 2020 of which 4 % had an appendicectomy. However the method of surgical access in the 1st wave significantly impacted on patient outcome, resource and re-admission rates.

Conclusion

In our study open appendicectomy undertaken due to concerns around COVID transmission during laparoscopic surgery during the 1st wave, increased rates of complications and readmission thus raising hospital costs and chances of COVID 19 infection in these patients.

As a result of this and due to greater confidence in laparoscopic surgery as a whole we have returned to undertaking laparoscopic appendicectomy in the current wave. Further analysis is underway assessing the impact of COVID on all emergency operations undertaken in the 1st wave.
TP10.2.3Restarting Elective Orthopaedic Surgery during the COVID-19 Pandemic: Experiences and Patient Outcomes
Authors: Vusirikala Anuhya , Saleh Marwan , Laurent Edward , Kuzhupilly Ranjith , Fahmy Amr , Tsekes Dimitrios
Published: October 2021

Aim

The novel coronavirus disease 2019 (COVID-19) resulted in postponing all non- emergency elective surgeries from April 2020. Restarting elective orthopaedic surgery is important to help people with chronic disabilities. Our hospital successfully restarted elective orthopaedic surgery during the pandemic to help improve the quality of life of patients.

This study describes the development of local protocols and pathways to allow for a safe restart of elective orthopaedic surgery in a COVID-19 free ‘green’ site. It also includes the morbidity and mortality outcomes of those patients who underwent non-emergency orthopaedic operations during this time.

Methods

A prospective cohort study evaluating patients undergoing non- emergency orthopaedic procedures through a COVID-19 free surgical pathway in a National Health Service acute general hospital in the United Kingdom from 18th May 2020- 10th July 2020. 104 patients were identified and their outcomes during the 2 week post-operative period was recorded.

Results

No patients developed COVID-19 infection in the two-week post-operative period. There were no intensive care unit admissions or in- hospital deaths during our study time frame. There was no statistical difference found in the development of complications for age (< 70 or >70), gender, body mass index or ASA physical status classification system grades.

Conclusions

This study describes a roadmap to setting up a protocolised elective operating service for orthopaedic surgery. It has shown that standardised protocols in a COVID-19 free ‘green’ site, pre-operative COVID-19 testing and adherence to national guidelines on self-isolation can help prevent developing COVID-19 infection post-operatively.
TP10.2.4Access surgery for dialysis patients during COVID-19
Authors: Liang Kaifeng , Lindsey Ben , Mohammed Ismail , Khurram Mohammed , Sammartino Cinzia , Sivaprakasam Rajesh
Published: October 2021

Aims

To describe the organisation of a triage system and COVID-19-free surgical pathway, and to assess the outcomes after its implementation for planned dialysis access surgery for patients during the first wave of the COVID-19 pandemic in the UK.

Methods

In response to the suspension of elective operations due to SARS-CoV-2 outbreak, we devised a COVID-19 free surgical pathway performed in NHS and an independent hospital. We audited the outcomes of its application in patients requiring access surgery between 17 April and 15 September 2020. The data was collated, analysed, and presented at clinical governess. We are looking to re-audit for the second wave in the coming months.

Results

A total of 235 cases were listed, and 203 procedures were performed. Thirty-two cases were cancelled and the top reason for cancellation was patient refusal. Of the procedures carried out, 47% (n = 96) were arteriovenous fistula formation, 42% (n = 84) were peritoneal catheter procedures, and 11% (n = 23) were arteriovenous grafts. The postoperative complication rate by day 7 was 13.3% (n = 27), by day 30 was 6.9% (n = 14) and they are similar to pre-COVID outcomes.

By performing a definitive dialysis access, we avoided the significant morbidity and mortality associated with tunnel-line based dialysis. No patients acquired COVID-19 or died from its related illnesses in 30 days.

Conclusion

Our results confirmed that our pathway was effective in delivering dialysis access in a timely manner and COVID safe. Our model is safe, easy to replicate COVID-19-free pathway and can be used during similar challenges in the future.
TP10.2.11The consequences of COVID-19 on the colorectal red-flag cancer pathway- A 3 month review 2019 to 2020
Authors: Sarah Small R , Coulson Rachael , Mcallister Ian
Published: October 2021

Aim

The COVID-19 pandemic is an evolving healthcare challenge introducing greater burden on existing resources. With 1,100 people in Northern Ireland diagnosed with colorectal cancer (CRC) per annum, concerns over disruption of cancer services and secondary consequences have been highlighted. We aim to evaluate the impact of COVID-19 on the CRC red flag pathway in comparison to the pre-COVID era.

Methods

Two comparative data sets were compiled through retrospective analysis of red-flag colorectal referrals over a 3-month period for both April to June 2019 and 2020. A comprehensive review of each patient’s electronic care record and medical notes was completed. Patient demographics, co-morbidity, referral information, time to hospital appointment and investigation modality were documented. For patients identified with CRC the stage and time to first definitive treatment was documented.

Results

A total of 47 CRCs were identified from both red-flag referral groups; 25 CRCs 2019 compared to 22 in 2020. Median age at time of referral was 79 years in 2019 compared to 71 years in 2020. Time to outpatient review was significantly less during 2020 compared to 2019; 16 days and 31 days respectively (p < 0.05). Time to first treatment was 103 days 2019 compared to 75 days 2020 (p < 0.05). Advanced diagnostic stage or increased number of emergency hospital presentations in the COVID-19 period was not demonstrated.

Conclusion

Despite disruption of established colorectal cancer services during the COVID-19 pandemic, we demonstrated patients waited less time to outpatient review and intervention. With comparative cases of CRC to the pre-COVID era diagnosed.
TP10.2.12Gallstone disease and COVID-19; A DGH perspective
Authors: Smyth Rachel , Samar Ali , Jiang Yuchen , Ding Davina , Foster Jeremy , Bond Amanda
Published: October 2021

Aims

In March 2020, the UK lockdown led to ‘non-essential’ services, such as the routine management of gallstone disease, being halted to facilitate increased demand on hospitals due to COVID-19. Conservative management was favoured over laparoscopic surgery to reduce the risk from aerosol generation. The aim of this study was to record the incidence and outcomes of patients presenting with gallstone disease during this period.

Methods

A Retrospective study was carried out looking at two patient groups; Group 1 who presented during the laparoscopic ban and Group 2 who presented afterwards.

Results

98 patients presented with gallstone disease during the initial UK lockdown. 25 patients presented acutely in Group 1 and 48 patients presented in Group 2, P < 0.05. 96% of patients in Group 1 were treated conservatively compared to 54% in Group 2, P<0.05. 40% of patients in Group 1 and 7% in Group 2 were readmitted within 60 days of initial presentation, P < 0.05.

Conclusion

During the initial lockdown less patients presented with gallstone disease. Those who did were managed conservatively and some came to harm. Recurrent readmissions, reduced laparoscopic surgery and cancelled elective operating lists, mean there are likely to be more patients waiting for definitive treatment for their gallstones than ever before. Therefore, it will be important going forward to recognise that ‘non-essential’ services must continue as close to ‘pre-COVID-19 levels’ as possible, in order to avoid the lengthening of waiting lists and the potential associated morbidity.
TP10.2.14Safe elective & emergency surgery: experience of a large tertiary centre during the first wave of the COVID-19 pandemic
Authors: Thompson Joseph , Giorga Andrea , Lo Terence , Baker Richard
Published: October 2021

Aims

To evaluate the impact of Trust infection prevention measures (including relocation of elective patients into a protected cold wing, vigilant testing and staff test and trace) on elective and emergency nosocomial transmission rates and to analyse post-operative mortality in COVID-19 patients. Additionally, we compared the numbers of elective and emergency procedures in 2020 to 2019.

Method

Retrospective analysis of 5069 consecutive patients who underwent procedures in theatre from 11/03/20 – 08/09/20. COVID-19 infection was defined by PCR and/or radiological confirmation. Analysis of nosocomial transmission of COVID-19 and mortality was conducted using patient notes and death certificates. The number of procedures was compared with the same study dates in 2019.

Results

Nosocomial transmission rate was 0.27% in elective admissions (10/3773) and 0.97% in acute admissions (20/2052). The overall mortality in 2020 was 2.7% (135/5069). Covid-negative mortality was 2.36% (119/5033). 74 patients tested positive for COVID-19 at any time (1.3%); mortality in patients who tested positive seven days pre- to 30 days post-procedure was 5.4% (4/74). There were 10282 elective procedures in 2019 compared with 3773 in the same period in 2020, representing a 63.3% reduction in elective activity.

Conclusion

Our hospital infection prevention measures have kept nosocomial transmission rates low, particularly for elective admissions. We have observed lower rates of post-operative mortality in COVID-19 patients than published in other centres. There has been a predictably significant reduction in elective activity, however based on our findings we believe our infection prevention measures could provide reassurances to safely increase elective surgery activity.
Peak power output testing: novel method for preoperative assessment of exercise capacity
Authors: Milliken Don , Rooms Martin , Moonesinghe S Ramani , Jhanji Shaman
Published: October 2021

Background

Assessment of exercise capacity is an important component of risk assessment before major surgery. Cardiopulmonary exercise testing (CPET) provides comprehensive assessment but is resource-intensive, limiting widespread adoption. Measurement of a patient’s peak power output (PPO) using a simplified test on a cycle ergometer has the potential to identify patients likely to have abnormal CPET findings and to be at increased perioperative risk. The aim of this study was to investigate the potential for PPO to identify those with abnormal CPET and to determine whether PPO predicted the risk of adverse postoperative outcomes.

Methods

In a retrospective analysis of a single-centre cohort, the ability of PPO to predict a high-risk CPET result in patients undergoing major cancer surgery was analysed. The assessment was validated in patients undergoing major abdominal surgery from a UK national multicentre cohort. The association between PPO and adverse postoperative outcomes to traditional CPET-derived variables were compared.

Results

In 2262 patients from a single centre, PPO was an excellent discriminator of high-risk CPET, with an area under the receiver operating characteristic curve (AUROC) of 0.901 (95 per cent c.i. 0.888 to 0.913). In the national cohort of 2742 patients, there was excellent discrimination, with an AUROC of 0.856 (0.842 to 0.871). A PPO cut-off of 1.5 W/kg may be appropriate for use in screening, with a sensitivity of 90 per cent in both cohorts. PPO and traditional CPET-derived predictors demonstrated similar discrimination of major postoperative complications and death. The association between PPO and major postoperative complications persisted on multivariable analysis.

Conclusion

These results suggest a role for the PPO test in preoperative screening and risk stratification for major surgery. Prospective evaluation is recommended.
Inhibition of the BMP pathway prevents development of Barrett’s-associated adenocarcinoma in a surgical rat model
Authors: Westra Wytske M , Straub Danielle , Milano Francesca , Buttar Navtej S , Wang Kenneth K , Krishnadath Kausilia K
Published: October 2021

Introduction

Esophageal adenocarcinoma (EAC) is an aggressive cancer, associated with reflux esophagitis and intestinal metaplasia (IM). One underlying biological mechanism, which possibly drives the development of EAC, is the dysregulated expression of Bone Morphogenetic Proteins (BMPs).

Aim

To investigate if local delivery of Noggin, a BMP antagonist, reduced EAC.

Methods

After obtaining proof of principal on local delivery of a Noggin/Sucralfate substance, a randomized controlled trial to test the effects of Noggin on EAC development was performed in a surgical rat model. In the model, an esophago-jejunostomy leads to development of reflux-esophagitis, IM and eventually EAC. Rats were treated by Noggin/Sucralfate or Sucralfate alone. Treatment was administered from 26 to 29 weeks after the operation.

Results

Of the 112 operated rats, 52 survived beyond 26 weeks. Finally, 25 rats treated with Noggin/Sucralfate and 21 with Sucralfate, were evaluated. At the end, 39 (85%) of the animals had IM while 28 (61%) developed cancer. There were significantly more cancers in the Noggin/Sucralfate arm (50%) versus the Sucralfate group (73%) (Chi square, P < 0.05). Most cancers were mucous producing T3 adenocarcinomas. There were no significant differences in the amount of IM, size or grade of the cancers, or expression of columnar and squamous markers between the two groups.

Conclusion

In this study, we demonstrated that inhibition of BMPs by Noggin reduced development of EAC in a surgical esophagitis-IM-EAC rat model. In future, effective targeting of the BMP pathway with selective BMP-inhibitors could become an important asset to improve EAC patient outcome.
Positive Peace Pillars and Sustainability Dimensions: An Analytical Framework
Authors: Simangan Dahlia , Sharifi Ayyoob , Kaneko Shinji
Published: October 2021

Despite broad recognition that peace and sustainability are interrelated, the pathways of their relationship remain ambiguous or nascent at best. We synthesized the literature relevant to the linkages between the two by framing our analysis around the pillars of positive peace and the dimensions of sustainability. Our review reveals that while the existing studies describe the conditions where peace and sustainability considerations interact, empirical evidence of their causal linkages appears limited. Nevertheless, this framing enabled us to consider some of the environmental, social, economic, and institutional conditions that influence the relationship between peace and sustainability. It also shows how our understanding of the peace–sustainability nexus can benefit from integrating environmental sustainability as one of the pillars of positive peace and negative peace as one of the dimensions of sustainability. This review presents opportunities for epistemic communities to navigate the factors and contexts that influence the pursuit of peace and sustainability.
Effects of increasing calcium propionate in a finishing diet on dry matter intake and glucose metabolism in steers
Authors: Rathert-Williams Abigail R , Salisbury Carlee M , Lindholm-Perry Amanda K , Pezeshki Adel , Lalman David L , Foote Andrew P
Published: October 2021

The objective of this study was to determine whether increasing propionate alters dry matter intake (DMI), glucose clearance rate, blood metabolites, insulin concentrations, and hepatic gene expression in steers fed a finishing diet. Holstein steers (n = 15; BW = 243 ± 3.6 kg) were individually fed a finishing diet ad libitum. Steers were allocated by body weight (BW) to receive: no Ca propionate (Control), 100 g/d Ca propionate (Low), or 300 g/d Ca propionate (High) in the diet. Orts were collected and weighed daily to determine DMI. Blood samples were collected on days 0, 7, and 21, and BW recorded on days 0, 14, and 28. An intravenous glucose tolerance test (IVGTT) was conducted on days 14 and 28 of the trial. Liver biopsies were collected on day 33 for gene expression analysis. Blood samples were analyzed for whole blood glucose and lactate, plasma non-esterified fatty acids (NEFAs), and insulin concentrations. Data were analyzed using a mixed model with treatment, day and their interaction included, with day and minute as a repeated measure. The control treatment had greater (P < 0.01) DMI than low and high steers. Body weight was increased in control steers on days 14 and 28 compared with the steers receiving the High treatment (P = 0.03 for the interaction). Blood glucose concentrations tended (P = 0.09) to be higher on day 21 than days 0 and 7 but was not affected by treatment (P = 0.58). Plasma NEFA concentrations were lower (P = 0.05) for control steers than other treatments, and greater (P = 0.002) on day 0 than days 7 and 21. Blood lactate concentrations were greater (P = 0.05) on day 7, than days 0 and 21, but not affected by treatment (P = 0.13). High steers had greater plasma insulin concentrations in response to the IVGTT than steers on the other treatments (P = 0.001). There was no treatment (P ≥ 0.16) or day effect (P ≥ 0.36) on glucose peak, plateau, or clearance rate. High steers had greater expression of solute carrier family 16 member 1 (SLC16A1; P = 0.05) and tended to have greater hepatic expression of solute carrier family 2 member 2 (SLC2A2; P = 0.07). These data indicate that increased propionate may decrease DMI and insulin sensitivity.
Imaging Evaluation of the Axilla—A National Survey of Clinical Practice Among Radiologists
Authors: Saksena Mansi , Warner Erica T , Chou Shinn-Huey S , Lamb Leslie , Narayan Anand , Coopey Suzanne , Lehman Constance D
Published: October 2021

Objective

To assess awareness and implementation of the American College of Surgeons Oncology Group Z0011 trial findings, approaches to axillary nodal imaging, and to identify differences in practice based on respondent characteristics.

Methods

An online survey was distributed to members of the Society of Breast Imaging. Questions regarded demographics, evaluation approaches, and impact of the Z0011 trial. Poisson regression with robust standard errors to regression was used to generate multivariable-adjusted relative risks and 95% confidence intervals (CIs) for associations.

Results

The response rate was 21.7% (430/2007). The majority (295/430, 68.6%) reported always performing axillary US in patients with a BI-RADS 4B, 4C, or 5 breast mass. Most respondents (299/430, 69.5%) were familiar with the findings of the Z0011 trial. Radiologists in academic practice were 0.67 (95% CI: 0.54–0.83) times less likely than private practice radiologists to perform axillary US in all masses and 1.31 (95% CI: 1.13–1.52) times more likely to be very familiar with the trial. Frequency of axillary US showed no association with time spent in breast imaging, years in practice, or presence of dedicated breast surgeons. Increased time in breast imaging and presence of dedicated breast surgeons was strongly associated with familiarity with the trial. No association was observed with years in practice. Most respondents (291/430, 67.7%) made little or no change to their practice based on trial findings.

Conclusion

There is wide variability in approaches to axillary nodal evaluation, demonstrating a need for improved education and guidelines for axillary imaging in breast cancer patients.
Neuromuscular Choristoma: Report of Five Cases With CTNNB1 Sequencing
Authors: Brandao Isabel Cristina Soares , de Souza Francineide Sadala , de Amoreira Gepp Ricardo , Martins Bernardo Jose Alves Ferreira , de Mendonca Cardoso Marcio , Sollaci Claudio , da Cunha Isabela Werneck , Kalil Ricardo Karam
Published: October 2021

Neuromuscular choristoma (NMC) are lesions of the peripheral nervous system characterized by an admixture of skeletal muscle fibers and nerves fascicles that are frequently associated with desmoid fibromatosis (DF). Mutations in CTNNB1, the gene for β-catenin protein, are common in DF and related to its pathogenesis. They are restricted to exon 3, with 3 point mutations: T41A, S45F, and S45P. To understand the pathogenesis of NMC, we tested CTNNB1 status in 5 cases of NMC whether or not they were associated with DF. The screening of mutations in CTNNB1 gene was based on amplicon deep sequencing using the ION Proton platform. Three patients had the S45F mutation; in 2 the mutation was common to both lesions and in one the DF was wild type while the NMC had the S45F mutation. One patient had a T41A mutation in the NMC and no associated DF. In the last patient, the DF lesion had a T41A mutation; there was no lesion with the S45P mutation. The presence of similar CTNNB1 mutations in NMC/DF-associated lesions and sporadic DF reinforces the relationship between both lesions and points to a common pathogenic mechanism.
A Questionnaire Survey of Personal and Occupational Variables Associated With SARS-COV-2 Infection in Health Care Personnel of the Spanish Central Military Hospital
Authors: Ajejas Bazán Mj , Fuentes Mora C , Ballester Orcal L E , Puerro Vicente M , Herrero Pérez L , Wärnberg J , Pérez Rivas F J , Pérez Farinós N
Published: October 2021

Introduction

Spain is the country with the highest number of health care workers affected by coronavirus disease 2019 (COVID-19) in the world. The aim of this study was to describe the epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection in health care worker (HCW) at the Gómez Ulla Military Hospital (HCDGU).

Materials and Methods

A case-control study was conducted during the first outbreak of COVID 19 at GUMH. The study was extended to the total number of HCW in the hospital who met the inclusion criteria. Health care worker of the HCDGU were civilian and military personnel that included nursing and medicine students of Spanish Military Academy, medicine specialty residents, and nursing residents of Medical Surgical Specialty in Operations (EMQO). A questionnaire of 33 items was prepared. The questionnaire was sent by e-mail to the entire population of study. With this questionnaire personnel were classified into sick (cases) or healthy.

Results and Conclusions

One hundred fifty professionals answered the questionnaire. Cases were defined as those who tested positive in the diagnostic tests (n = 28, 20.7%) and no cases were those who tested negative (n = 107, 79.3%). Therefore, the percentage of SARS-CoV-2 in the GUMH was 20.7%. Of the total number of cases, 64.3% were men (P < .05), with a mean age of 47.1 years (SD 13.3), a mean BMI of 25.3 (SD 3.8), and 48.2% being overweight. Of the total cases, 59.3% had “A” blood group type and 69.2% were Rh positive. 50% were physicians, 32.1% were nurses, and 17.9% were auxiliary nurses (P < .05). Cases and controls with vitamin D deficiency and who took supplements had a lower risk of suffering COVID-19, with significant differences. Fever, cough, and diarrhea were found in at least 50% of the samples with significant differences.
Pandemic Impacts on Cluster B Personality Disorders in the U.S. Navy: A Case Study in Context
Authors: Knox Derrick Maurice , Leshen Glennie E , Teisberg Madeline Brianne
Published: October 2021

This paper is a brief description of the impact that the SARS-CoV-2 global pandemic has had on both mental health and U.S. Navy policies through the narrative of a deployed enlisted sailor, medically evacuated from Japan. Although the introduction of vaccines and loosening of state-specific mandates have signaled a slow return to our “normal,” pre-pandemic, way of life, there is now an opportunity to look back and understand how the situation impacted the presentation and outcome of certain cases. We believe that the sailor presented introduces a discussion about the impacts of heightened restrictions on some personality types. As the pandemic has continued to impact and reshape every facet of force health protection, we believe that understanding the impact of public health orders on individuals with specific personality disorders or traits will help us provide care and leadership counsel going forward. The discussion within our case report provides insight and an opportunity for healthcare providers to reflect.
Gas flows in galaxy mergers: supersonic turbulence in bridges, accretion from the circumgalactic medium, and metallicity dilution
Authors: Sparre Martin , Whittingham Joseph , Damle Mitali , Hani Maan H , Richter Philipp , Ellison Sara L , Pfrommer Christoph , Vogelsberger Mark
Published: October 2021

In major galaxy mergers, the orbits of stars are violently perturbed, and gas is torqued to the centre, diluting the gas metallicity and igniting a starburst. In this paper, we study the gas dynamics in and around merging galaxies using a series of cosmological magnetohydrodynamical zoom-in simulations. We find that the gas bridge connecting the merging galaxies pre-coalescence is dominated by turbulent pressure, with turbulent Mach numbers peaking at values of 1.6–3.3. This implies that bridges are dominated by supersonic turbulence, and are thus ideal candidates for studying the impact of extreme environments on star formation. We also find that gas accreted from the circumgalactic medium (CGM) during the merger significantly contributes (27–51 per cent) to the star formation rate (SFR) at the time of coalescence and drives the subsequent reignition of star formation in the merger remnant. Indeed, 19–53 per cent of the SFR at $z$ = 0 originates from gas belonging to the CGM prior the merger. Finally, we investigate the origin of the metallicity-diluted gas at the centre of merging galaxies. We show that this gas is rapidly accreted on to the Galactic Centre with a time-scale much shorter than that of normal star-forming galaxies. This explains why coalescing galaxies are not well-captured by the fundamental metallicity relation.