bluuebunny/crossref_metadata_2025 huggingface dataset:
TP8.2.9 Development & Evaluation of LapPass™: The Laparoscopic Passport
Authors: Fong Michelle , Treglohan Jenny , Selvasekar Chelliah , Sedman Peter , Leeder Paul , Francis Nader
Published: October 2021

Aims

Laparoscopic surgery is technically challenging and assessment of competency is necessary to ensure patient safety and guide training. Existing tools of assessment are mostly subjective, with a growing need for objective credentialing. LapPass™ was developed by a UK-based laparoscopic society as an accessible simulation assessment tool. The aim of this study was to report on its development and preliminary findings of usability and validity.

Methods

LapPass™ consists of 4 tasks that test: bimanual dexterity, simulated appendicectomy, dissection and intracorporeal suturing. Participants were prospectively recruited from testing events. Online surveys were sent to assessors and participants to assess the usability, face and content validity of the tool. Options to respond were on a five-point Likert scale with ratings from strongly disagree (1) to strongly agree (5).

Results

LapPass was launched and offered to trainees as free-of-charge assessment tool. 31 participants and 12 assessors took part. The 1st time pass rate for bimanual dexterity was 19/29 (65.5%), appendicectomy 13/23 (56.5%), dissection 20/27 (74.1%) and intracorporeal suturing 6/19 (31.5%). The mean scores for participants’ usability and validity were 3.8 and 4.12 for bimanual dexterity; 3.96 and 4.37 for appendicectomy; 4.5 and 4.16 for dissection and 3.84 and 4.52 for intracorporeal suturing. Assessors' mean score of usability was 4.5 across all tasks. Assessors scored validity of bimanual dexterity 4.35, appendicectomy 4.42, dissection 3.71 and intracorporeal suturing 4.65.

Conclusion

LapPass™ is a an accessible objective assessment tool for laparoscopic basic surgical skills with preliminary data to confirm its usability and face and content validity.
TP8.2.16 A survey to assess the confidence and knowledge of Foundation Year one doctors to perform a Digital Rectal Examination
Authors: Sahni Dhruv , Carson Daniel , Khan Khurram
Published: October 2021

Aims

Digital Rectal Examination (DRE) is an essential component of comprehensive assessment of a surgical patients, both in acute and elective settings. Due to the intimate nature of the examination, this important examination is often not well taught. This study aims to assess the confidence and knowledge of the Foundation Year 1 (FY1) doctors in performing DRE.

Methods

FY1 doctors were invited for online voluntary anonymous survey via Google forms. The survey consisted of 16 questions on the indications, findings and interpretation of DRE. The purpose and aims of the study were explained in an invitation email and participants provided a declaration of consent, giving permission for their anonymous results to be used in the study.

Results

There were 24 responses, 79% had performed DRE (including on mannequins and simulations) less than 10 times. Two thirds of DRE were performed during the FY1 rotation and two thirds in the elective wards. Majority of respondents (83%) were moderately confident in performing and appreciating DRE findings. 63% respondents though that a chaperone is not mandatory if the gender of the doctor and patient was same. 58% respondents thought that hematuria is not an indication to preform DRE. Interpretation of DRE findings - approximately 80% respondents correctly interpreted the findings, however only 45% could formulate the correct initial management plan.

Conclusions

This study illustrates that FY1 doctors receive inadequate exposure to performing and interpreting DRE. Their teaching should be enhanced by providing them with more opportunities through simulation and dedicated teaching sessions.
TP8.2.17 Supplementing Undergraduate ENT Teaching: A Neglected Surgical Speciality?
Authors: Luff Edward , Gurung Pratha , Waters Chris
Published: October 2021

Aims

A 2020 survey of undergraduate ENT education found there was wide variability between Medical Schools despite a standardised curriculum, published by ENT UK. To improve this, a group of CTFs designed and led teaching sessions covering each aspect of ENT based on the ENT UK curriculum. The aim was to improve confidence in and knowledge of ENT conditions expected at junior doctor level.

Methods

Final year students participated in three 1-2 hour teaching sessions focused on ‘Otology’, ‘Rhinology’ and ‘Head & Neck’. Each session started with an MCQ assessing prior knowledge, with a post-teaching MCQ to assess for improvement. There was an additional questionnaire to measure confidence in several domains pre- and post-teaching, and of the undergraduate teaching they had received within their medical schools.

Results

Overall, students’ pre-ENT teaching and post-ENT teaching MCQ scores improved from 67% to 87%. The percentage of students who felt ‘fairly confident’ and/or ‘completely confident’ in the following domains were compared pre- and post-teaching respectively: recognising ENT conditions (26% vs 42%); managing & treating ENT conditions (5% vs 42%); and recognising surgical airways (3% to 40%). 47% of students found tutorials based on ENT ‘very useful’ for their learning, compared to 16% for outpatient clinics & lectures. 94% of students had received ENT teaching for a period of < 2 weeks, with 37% of those receiving <1 week.

Conclusions

This project demonstrates how a small series of curriculum specific ENT teaching can help final year students to supplement their knowledge and confidence in ENT.
TP9.1.3The Effect of Hip Fracture Anatomy and Surgical Modality on the Rate of Red Blood Cell Transfusion and Mortality: A Retrospective Analysis
Authors: Greenhalgh Michael , Gowers Benjamin , Iyengar Karthikeyan , Adam Riad
Published: October 2021

Aims

This study assesses the effect of hip fracture anatomy and operation performed on transfusion rates within our centre. We aim to identify patients most likely to require transfusion early, to improve outcomes.

Methods

A retrospective cohort study of 324 consecutive hip fracture patients presenting to a district general hospital over one year. Data was collected from patient records, local transfusion laboratory and the national hip fracture database.

Results

324 hip fractures were categorised as 188 (58%) intracapsular, 121 (37%) intertrochanteric and 15 (5%) subtrochanteric fractures. The most common operation performed was hemiarthroplasty (128), followed by dynamic hip screw fixation (75).

75 (23%) patients received a blood transfusion. 15% of intracapsular, 35% of intertrochanteric and 33% of subtrochanteric fractures received transfusions.

47% of long intramedullary nails, 45% of short intramedullary nails, 29% of dynamic hip screws, 18% of hemiarthroplasties and 9% of total hip arthroplasties resulted in blood transfusions.

One-year mortality was higher in the transfused cohort at 52% compared to 30.5% in non-transfused, with an odds ratio of 2.466 (95% CI 1.4555 to 4.178, p = 0.0008).

Conclusions

Almost a quarter of hip fracture patients received a blood transfusion, which was associated with an almost two and a half times increased risk of one-year mortality. Extracapsular (intertrochanteric and subtrochanteric) fractures most commonly led to transfusions. Long intramedullary nailings were most associated with transfusions and total hip arthroplasties the least. Patients more likely to require transfusion and subsequently have a higher one-year mortality risk can therefore be identified at presentation.
TP9.2.9Luminal Investigation Following CT Diagnosed Acute Diverticulitis
Authors: Gerrard Adam , Artioukh Dmitri
Published: October 2021

The commissioning guide for colonic diverticular disease by the Royal Collage of Surgeons (2014) states that all patients should undergo luminal investigations once an acute attack of diverticulitis has passed. The rational behind this is to ensure a malignant polyp is not missed, however there is mounting evidence and opinion that this may not be necessary.

We aim to evaluate how our unit follows the commissioning guide and investigate the number of subsequent polyps and cases of malignancy found.

Surgical inpatients with a CT proven diagnosis of acute diverticulitis within a one year period (2018) were included. Their CT scans were reviewed to confirm the diagnosis and electronic records examined to see if luminal investigations were requested, occurred and what the findings were.

There were 78 cases of CT confirmed diverticulitis. Of these 11 patients underwent emergency Hartmanns procedure. This left 67 patients in whom investigations were requested in 47. Within the 20 cases were follow up was not requested, 50% had a mitigating factor. 40/47 patients who had investigations booked underwent the requested test. In 6 cases a polyp was found and there were no cases of colorectal cancer.

Based on current guidance there is scope to improve the follow up investigations in this population of patients with CT proven diverticulitis. As no colorectal cancers were found this is in keeping with the growing notion that colonoscopy may be reserved for those with complicated diverticulitis on CT or with CT findings on a background of ‘red flag’ symptoms.
TP9.2.10The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: A multicentre cohort study
Authors: Hajibandeh Shahab , Hajibandeh Shahin , Shah Jigar , Maw Andrew , Mansour Moustafa , Satyadas Thomas
Published: October 2021

Aims

To evaluate the risk and predictors of postoperative mortality in octogenarians undergoing emergency laparotomy.

Methods

In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan–Meier survival statistics.

Results

A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR: 2.49,95% CI 1.82-3.38,P<0.0001) and peritoneal contamination (OR: 2.00, 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR: 1.92,95% CI 1.50-2.46,P<0.0001), peritoneal contamination (OR: 1.57,95% CI 1.07-2.48,P=0.020) and presence of malignancy (OR: 2.06,95% CI 1.36-3.10,P=0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011).

Conclusions

Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carries a high risk of immediate postoperative and 1-year mortality. There is a need to incorporate modern prognosticators into the available preoperative mortality risk assessment tools.
TP9.2.11Venous Thromboembolism Assessment and Thromboprophylaxis in Pregnant Women admitted to Hospital under Non-Obstetric Specialties
Authors: Hosny Shady Gaafar , Ghosh Trisha , Saksena Rhea , Suliman Ibnauf
Published: October 2021

Aims

During a non-obstetric admission, there is minimal awareness amongst other specialties regarding the need to reassess venous thromboembolism (VTE) prophylaxis requirements. The primary aim of this study was to review whether perinatal patients are accurately assessed for VTE risk factors during non-obstetric admissions and being prescribed appropriate thromboprophylaxis upon discharge.

Methods

Data collection was carried out by retrospectively identifying all admissions of pregnant women in hospital under a non-obstetric team over a period of six months.

Patients were scored according to their individual risk factors related to pregnancy and the admission. Comparison was made between the recommended and actual prophylaxis given.

Results

152 patients were included in the study. Only 13 women received appropriate VTE management whilst 35 patients were deemed high-risk and did not receive prophylaxis. VTE assessment was not documented in nearly 60% of patients. 68% of patients were found to be at intermediate risk.

Conclusion

Reassessment for risk of VTE in antenatal and postnatal patients is poorly documented when managed by non-obstetric led teams. Women with both established and transient risk factors for VTE are not receiving appropriate thromboprophylaxis. Raised awareness of this specific problem is required amongst non-obstetric teams.

Key Statement

Appropriate thromboprophylaxis is vital at the point of admission of a pregnant patient to hospital as this is associated with an 18-fold increased risk of VTE.

Further improvements need to be made in order to educate non-obstetric teams caring for obstetric patients regarding the importance of VTE risk assessment.
TP9.2.13Outcomes of Emergency Groin hernia repair: 30-months experience of a tertiary care hospital
Authors: Kumar Dileep , Tan Brandon , Guilbert Michael , Elsllabi Mohamed , Muthukumarasamy Girivasan
Published: October 2021

Aims

Repair of Emergency groin hernia is variable across different regions and even within same units. Mesh is increasingly used these days. We aim to evaluate peri-operative and long-term outcomes over last 30-months.

Methods

Retrospective analysis of all emergency groin hernia repairs from January 2018- July 2020 in a tertiary Centre. Case notes and electronic patient records (clinical portal, PACS system etc.) used for data collection.

Results

Of 89 emergency groin hernia repairs 62(69.7%) males, 32/89 (35.9%) indirect inguinal hernia and 29 (32.5%) femoral hernia. Median age 72 years (range 20-95), 74(83.1%) primary hernia and 15(16.9%) recurrent hernias. Femoral hernia was most common in females 25/27 (92.5%) in contrast 58/62 males (93.5%) had inguinal hernia. All patients, except 1(1.1%) laparoscopic, had open repair, 11/89 cases (12.3%) required bowel resection, of those 10 (90.9%) had suture repair. Additionally, 6/89 cases (6.7%) needed laparotomy. Of 68/89 (76.4%) cases who had mesh repair, 52(76.4%) were inguinal and 23.5% (16/68) femoral hernia. Only 55% femoral hernias repaired with mesh. Median LOS was 3 days (range 0-54), 6/89 cases (6.74%) had wound complications (3 wound infections, 2 haematoma and 1 fluid collection). With median 19 months (range 6-36 months) follow-up, 1(1.1%) recurrence each in both mesh and suture repair groups, no mesh infection and 2/89 (2.2%) 30-day mortality recorded.

Conclusion

Mesh repair is increasingly used in emergency groin hernia repair without increased risk of mesh infection, although suture repair is still preferred in groin hernias requiring bowel resection.
TP9.2.14A novel 'one stop' service for Gallstone (GS) disease utilizing Emergency General Surgery (EGS) ambulatory clinic (AC) and dedicated expedited theater lists for early Cholecystectomy
Authors: Majeed Talal , Baig Mirza Saboor , Buckley Katherine Alice
Published: October 2021

Introduction

GS related disease account for almost 1/3rd admissions and referrals in EGS 1. Rate of early cholecystectomy, as mandated by NICE guidelines, in a recent RCS annual report was only 0-30% of eligible patients.2

Aims

The aim was to determine if an improved rate of acute cholecystectomy (AC) had been achieved by; increasing elective capacity for emergency general surgeons (EGS), ring fencing hot lists for AC, increased use of NCEPOD list and campaign of awareness among theatre and anaesthetic staff.

Material and Methods

A retrospective study of rates of AC before and after implementation of changes in working practice was conducted using hospital episode data. All patients eligible for early cholecystectomy were included. AC rate, Intra and post -operative complications, length of stay and number of referrals to the elective upper gastrointestinal (UGI) service were determined.

Results

Conclusion

Acute cholecystectomy during acute admission by emergency surgical had been significantly improved. It is safe and does not increase post-operative LOS.
TP9.2.21Laparoscopy in Emergency General Surgery (The LEGS Study): NELA Database Analysis -Comparison of Outcomes in Laparoscopic versus Open Surgery
Authors: Parmar Kat , Badrick Ellena , Malcomson Lee , Renehan Andrew , Sharma Abhi , Heywood Nick
Published: October 2021

Introduction

Guidelines suggest the laparoscopic approach may be safe and feasible in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) rate of laparoscopic surgery remains low. Our earlier analysis of the NELA database identified factors associated with use of laparoscopy, then recommended further analysis to compare outcomes between laparoscopic and open surgery.

Methods

We obtained information from the NELA database (2013 - 2017) and performed logistic regression on all first operations during the hospital admission. Outcomes were compared between open and laparoscopic approach (fully laparoscopic, laparoscopic assisted and laparoscopic converted). The primary outcome was death during hospital admission; secondary outcomes were admission to intensive care unit (ICU), length of ICU stay and return to theatre.

Results

The cohort comprised 68,928 open (52% men, mean age 65) and 12,144 laparoscopic (51% men, mean age 58). In a model adjusted for all factors influencing primary or secondary outcomes (age, gender, p-possum, weekday versus weekend, operative time of day, malignancy, peritoneal soiling, CEPOD urgency, surgical grade and anaesthetist grade), death rates were significantly lower in the laparoscopic group (OR 0.65, 95% CI 0.59 – 0.71). Post-operative admission to ICU and ICU stay > 3 days were both significantly lower in the laparoscopic group (OR 0.59, 95% CI 0.56 – 0.62; OR 0.82, CI 0.75 – 0.89). There was no difference in return to theatre.

Conclusions

Outcomes for laparoscopy in emergency general surgery appear superior to open surgery, although there may be residual unmeasured confounding factors. Further analysis will compare outcomes between pathologies.
TP9.2.24Is preoperative ABO blood typing required in emergency appendicectomies?
Authors: Rodrigues Ricardo , Reece Ieuan , El-Masry Nabil
Published: October 2021

Aims

Intra-operative bleeding is very rarely a complication of laparoscopic appendicectomy. Despite this, it is often mandatory for any patient undergoing an emergency appendicectomy to have pre-operative ABO blood type sampling. This could be an unnecessary expense and may lead to patients being delayed for theatre. The aim of this study was to see how many patients who underwent an appendicectomy required a blood transfusion intra-operatively or within 30 days of their operation.

Methods

Data were collected retrospectively for patients of all ages who underwent an appendicectomy for suspected appendicitis at a single centre from March 2018 to May 2020. The primary outcome measure was intra-operative and post-operative blood transfusion up until 30 days after the operation.

Results

Over 26 months, 698 appendicectomies were performed. Preoperative ABO blood typing was performed in 95% (n = 663) of patients. Collectively, 1,305 blood samples were obtained at a combined total cost of £13,703 to the hospital. None of the patients required blood transfusion intra- or post-operatively. Pre-operative blood transfusion was performed in only three patients, all due to chronic anaemia. 21 (3%) patients were delayed in going to theatre whilst awaiting two valid ABO blood typing results.

Conclusions

Emergency appendicectomies very rarely experience complications associated with bleeding or requiring blood transfusion. Clinical guidelines should reflect this by avoiding recommendation of such tests in emergency appendicectomies, reducing delays to surgery and resulting in a more efficient allocation of financial and staff resources.
TP10.1.11Into the Pandemic and Out of the Fire?
Authors: Green Sophie , Ronan Dominic , Ralston David
Published: October 2021

Aim

The Covid-19 pandemic has seen various government restrictions on all aspects of daily life. We assessed whether these lifestyle alterations have affected the number, severity and presentation of burns seen at a Paediatric Burns Unit.

Methods

We looked at Paediatric Burns admissions to Plastic Surgery during the Covid-19 pandemic of March 2020 to Jan 2021 (DC), as well as comparison data prior to Covid-19 from April 2019 to February 2020 (PC). We also looked at specific periods of national lockdown. Using data from our electronic records we looked at varying aspects of a patient’s journey.

Results

In total 788 cases were admitted to the Burn’s team from April19 -January21. The mean age of patients both DC and PC were 4.7 years with the mean during the first lockdown of 5. The time to presentation PC was 2.6 days, DC was 1.79 days and 2.4 days during the first lockdown. This was not significant (p = 0.2). The median total body surface area (TBSA) was <1% in both PC and DC patients. Scalds made up 53% of the first lockdown injuries, this had no statistically significant difference as compared to PC and DC injuries (48% and 46% respectively).

Conclusions

Overall burns admissions during the Covid-19 pandemic did not significantly change as compared to the previous year. This contrasts published adult results, which demonstrates reduced burns admissions during Covid-19. We suggest this may be due to unchanged causative factors in paediatric burns which are predominantly found in domestic lockdown environments.
TP10.1.12Personal Protective Equipment impairs pulmonary gas exchange causing systemic hypercapnia-hypoxaemia and cerebral hyperperfusion-induced cephalalgia
Authors: James Osian , Stacey Benjamin , Hopkins Luke , Robinson David , Bailey Damian , Lewis Wyn
Published: October 2021

Aims

To what extent Personal Protective Equipment (PPE) impacts integrated cardiopulmonary-cerebrovascular function has not been examined. The hypothesis tested was that PPE adversely influences pulmonary gas exchange, resulting in systemic hypercapnic-hypoxaemia and cerebral hyperperfusion-induced cephalalgia.

Methods

Eight male Higher Surgical Trainees (aged 33 ± 2y) participated in a repeated measures crossover study, completing two-hour laparoscopic simulation tasks, on two separate occasions (separate days), once in standard operating attire, and once in full PPE (including FFP3 mask).

Results

Following two hours of simulation, full PPE (compared with standard operating attire) was associated with increased FICO2 (7.9% (±0.8%) vs. 7.1% (±1.2%); p = 0.025), decreased FIO2 (16.0% (±0.4%) vs. 16.6% (±0.5%); p = 0.011), and decreased peripheral O2 saturation (95% (± 1%) vs. 98% (±1%); p = 0.001). Headaches were reported by three participants in PPE (Chi2 3.692, p = 0.055), and was associated with increased Middle Cerebral Artery flow velocity; 82 (±4) cm/s, compared with 63 (±9) cm/s in the remaining five participants (p = 0.008). Skin temperature increased by 1.3 °C during simulation in PPE (p = 0.001), with an equal mean insensible fluid loss of 300ml under both conditions (p = 0.049).

Conclusions

Collectively, these findings highlight the integrated cardiopulmonary-cerebrovascular complications associated with PPE-induced impairment in pulmonary gas exchange. Protective countermeasures should be designed to prevent risk to healthcare staff and patients alike.
TP10.2.8Adaptation in providing renal access surgery service in response to covid-19 pandemic- a single centre experience
Authors: Mir S A , Kumar Avneesh , Chidambaram Nathan , Pararajasingham Ravi
Published: October 2021

Aim

Evaluate impact of Covid-19 pandemic on renal access surgery and changes in practice towards counteracting limitations to provide safe and effective peritoneal and haemodialysis.

Methods

Retrospective review of procedures for dialysis in ESRD patients from institutional databases in a single centre was carried out. Patients undergoing peritoneal catheter insertions (PD) or AV fistula formation (HD) between March 2020 and October 2020 were compared with similar period in 2019. Demographic, procedure and postoperative outcome data was collected.

Results

Between March and October 2019, 143 combined PD and HD procedures were performed compared to 98 in the same time period in 2020. The mean age of patients was 65 ± 15 years and 62 ± 12 years, respectively. In 2020, 26 patients had PD catheter insertion and 22 patients in 2019. 18% of these were performed laparoscopically in 2019 compared to 33% in 2020. The same day discharge rate increased to 34% from 22%.

Patients having complex fistula procedures including basilic vein transpositions and grafts requiring overnight stay dropped from 83% patients (n = 23) to 71% (n = 7) in 2020.

In 2019, 80% (n = 49) patients had radio-cephalic fistula performed as same day procedure increasing to 98% (n = 22) in 2020.

Day-surgery unit utilisation increased from 55% to 71%. Same day discharge rate increased from 53% to 66%. There were no readmissions.

Conclusions

Adaptations in terms of increased support for same day surgery even for complex renal access procedures has improved service. A greater proportion of renal access service can be same day procedures avoiding inpatient stay.
TP10.2.13Outcome of Acute appendicitis management during COVID-19 pandemic in a tertiary hospital
Authors: Lim Su Kwan
Published: October 2021

Aim

Coronavirus (COVID) has influenced the management of acute appendicitis. The Royal Colleges of Surgeons recommend best practice depending on local circumstances. The aim of this project is to assess the 30-day outcome of patients managed operatively and conservatively for acute appendicitis during the first wave of the pandemic in the UK.

Method

Patient data were collected prospectively at the end of March 2020, when Covid-19 became prevalent in the UK and lockdown started. Data was collected for patients admitted to the acute surgical unit for the admission dates of 20/03/2020 to 15/05/2020. At 30 days after admission, a search was done on the electronic clinical portal to check if the patient was readmitted for operation. The inclusion criteria are any patients above 16-year-old admitted through acute surgical unit with a clinical diagnosis of acute appendicitis or computed tomography scan findings of proven acute appendicitis.

Result

A total of 34 patients (median age, 33; range, 17-74) were identified from March 2020 to May 2020. All patients have covid-19 status as negative and were given intravenous antibiotics at point of admission. All patients received a course of seven-day of antibiotic. 17 patients underwent operation and 17 patients were managed conservatively. Only one patient who was treated conservatively for acute appendicitis, was re-admitted within 30 days of admission date.

Discussion

The readmission rate of patients treated conservatively for acute appendicitis after 30 days were low during the first wave of the pandemic.
The Miocene wetland of western Amazonia and its role in Neotropical biogeography
Authors: Hoorn Carina , Boschman Lydian M , Kukla Tyler , Sciumbata Matteo , Val Pedro
Published: October 2021

In the Miocene (23–5 Ma), a large wetland known as the Pebas System characterized western Amazonia. During the Middle Miocene Climatic Optimum (c. 17–15 Ma), this system reached its maximum extent and was episodically connected to the Caribbean Sea, while receiving sediment input from the Andes in the west, and the craton (continental core) in the east. Towards the late Miocene (c. 10 Ma) the wetland transitioned into a fluvial-dominated system. In biogeographic models, the Pebas System is often considered in two contexts: one describing the system as a cradle of speciation for aquatic or semi-aquatic taxa such as reptiles, molluscs and ostracods, and the other describing the system as a barrier for dispersal and gene flow for amphibians and terrestrial taxa such as plants, insects and mammals. Here we highlight a third scenario in which the Pebas System is a permeable biogeographical system. This model is inspired by the geological record of the mid-Miocene wetland, which indicates that sediment deposition was cyclic and controlled by orbital forcing and sea-level change, with environmental conditions repeatedly altered. This dynamic landscape favoured biotic exchange at the interface of (1) aquatic and terrestrial, (2) brackish and freshwater and (3) eutrophic to oligotrophic conditions. In addition, the intermittent connections between western Amazonia and the Caribbean Sea, the Andes and eastern Amazonia favoured two-way migrations. Therefore, biotic exchange and adaptation was probably the norm, not the exception, in the Pebas System. The myriad of environmental conditions contributed to the Miocene Amazonian wetland system being one of the most species-rich systems in geological history.
Mild repetitive head impacts alter perivascular flow in the midbrain dopaminergic system in awake rats
Authors: Cai Xuezhu , Harding Ian C , Sadaka Aymen H , Colarusso Bradley , Kulkarni Praveen , Ebong Eno , Qiao Ju , O'Hare Nick R , Ferris Craig F
Published: October 2021

Head injury is a known risk factor for Parkinson’s disease. Disruption in the perivascular clearance of metabolic waste and unwanted proteins is thought to be a contributing factor to disease progression. We hypothesized that repetitive mild head impacts, without evidence of structural brain damage, would increase microgliosis and AQP4 expression and depolarization and alter perivascular flow in the midbrain dopaminergic system. Adult male rats were subjected to sham, or two mild head impacts separated by 48 h. Three weeks later, fully awake rats were imaged using dynamic, contrast-enhanced MRI to follow the distribution of intraventricular gadobenate dimeglumine contrast agent. Images were registered to and analysed using a 3D MRI rat atlas providing site-specific data on 171 different brain areas. Following imaging, rats were tested for cognitive function using the Barnes maze assay. Histological analyses of tyrosine hydroxylase, microglia activation and AQP4 expression and polarization were performed on a parallel cohort of head impacted rats at 20 days post insult to coordinate with the time of imaging. There was no change in the global flux of contrast agent between sham and head impacted rats. The midbrain dopaminergic system showed a significant decrease in the influx of contrast agent as compared to sham controls together with a significant increase in microgliosis, AQP4 expression and depolarization. There were no deficits in cognitive function. The histology showed a significant level of neuroinflammation in the midbrain dopaminergic system 3 weeks post mild repetitive head impact but no loss in tyrosine hydroxylase. MRI revealed no structural brain damage emphasizing the potential serious consequences of mild head impacts on sustained brain neuroinflammation in this area critical to the pathophysiology of Parkinson’s.
Combined neurogenic pulmonary oedema and atypical Takotsubo cardiomyopathy in a patient with ischaemic stroke: a unique case report
Authors: Riva Letizia , Casella Gianni , Simonetti Luigi , Zini Andrea
Published: October 2021

Background

Neurogenic pulmonary oedema (NPO) and Takotsubo cardiomyopathy are rare complications of ischaemic stroke. They are considered to be due to an excess catecholamine release after sympathetic nervous stimulation following stroke onset. Among the different types of Takotsubo cardiomyopathy, apical ballooning is recognized as the typical form, but three atypical patterns have been described (midventricular, basal, and focal) which are more commonly observed in patients with neurological disorders.

Case summary

A 78-year-old woman was treated with intravenous alteplase and underwent mechanical thrombectomy for ischaemic stroke. During the procedure, her respiratory condition quickly worsened requiring invasive mechanical ventilation because of a wide and persistent reduction of the inspiratory oxygen fraction/arterial partial oxygen pressure ratio. Transthoracic echocardiography revealed moderate left ventricular systolic dysfunction with akinesis of the septal-apical and inferior-apical segments. Coronary angiography excluded obstructive lesions and/or evidence of acute plaque rupture. Ventriculography confirmed akinesis/dyskinesis of the inferior segment of the left ventricular apex associated with normal kinesis of the remaining segments. Chest X-ray revealed an infiltrative shadow on both lungs. After 24 h from NPO onset, her respiratory function improved and she was finally discharged on Day 7 without neurological defects. Left ventricular systolic dysfunction was reversible and ejection fraction normalized in 3 months.

Discussion

It is a very rare case of simultaneous NPO and Takotsubo cardiomyopathy following ischaemic stroke. Moreover, it is unique in that it is the first observation of NPO associated with an atypical pattern of Takotsubo cardiomyopathy, which is more frequent in patients with neurological disorders. A rapid recognition and treatment are essential for patient survival.
A case report of deglutition triggered atrial fibrillation in a patient with Laing distal myopathy
Authors: Alvarez Chikezie K , Swales Heather , Kluger Jeffrey
Published: October 2021

Background

Deglutition-induced atrial fibrillation is a rare clinical entity with a reported prevalence of 0.6%. Laing distal myopathy is a rare autosomal dominant muscular dystrophy that is the result of mutations within the slow skeletal muscle fibre myosin heavy chain gene (MYH7). Atrial fibrillation has not been previously reported in patients with Laing distal myopathy. We describe the first reported case of deglutition triggered atrial fibrillation in a female with a history of Laing distal myopathy.

Case summary

A 44-year-old female with a history of Laing distal myopathy diagnosed at age 32, began experiencing intermittent episodes of pre-syncope and palpitations which occurred after deglutition with food. An ambulatory 30-day patient triggered event monitor recorded episodes of atrial fibrillation with rapid ventricular response. Family history was significant for Laing distal myopathy, atrial fibrillation, as well as sudden cardiac death. Laboratory data, transthoracic echocardiogram, cardiac magnetic resonance imaging, and an exercise treadmill SPECT Imaging stress test were normal. An oesophagram revealed a mild oesophageal dysmotility with no other abnormalities. She was started on flecainide 50 mg p.o. every 8 h and verapamil 40 mg p.o. every 8 h with no further episodes of atrial fibrillation.

Discussion

Given the strong genetic component of this myopathy, one could postulate as to a possible genetic component in the development of atrial fibrillation in our patient. Although we cannot make definite correlation between deglutition-induced atrial fibrillation and Laing myopathy, it is important to report this unusual association which has not been described before.
Enhanced 3D visualization for planning biventricular repair of double outlet right ventricle: a pilot study on the advantages of virtual reality
Authors: Milano Elena Giulia , Kostolny Martin , Pajaziti Endrit , Marek Jan , Regan William , Caputo Massimo , Luciani Giovanni Battista , Mortensen Kristian H , Cook Andrew C , Schievano Silvia , Capelli Claudio
Published: October 2021

Aims

We aim to determine any additional benefit of virtual reality (VR) experience if compared to conventional cross-sectional imaging and standard three-dimensional (3D) modelling when deciding on surgical strategy in patients with complex double outlet right ventricle (DORV).

Methods and results

We retrospectively selected 10 consecutive patients with DORV and complex interventricular communications, who underwent biventricular repair. An arterial switch operation (ASO) was part of the repair in three of those. Computed tomography (CT) or cardiac magnetic resonance imaging images were used to reconstruct patient-specific 3D anatomies, which were then presented using different visualization modalities: 3D pdf, 3D printed models, and VR models. Two experienced paediatric cardiac surgeons, blinded to repair performed, reviewed each case evaluating the suitability of repair following assessment of each visualization modalities. In addition, they had to identify those who had ASO as part of the procedure. Answers of the two surgeons were compared to the actual operations performed. There was no mortality during the follow-up (mean = 2.5 years). Two patients required reoperations. After review of CT/cardiac magnetic resonance images, the evaluators identified the surgical strategy in accordance with the actual surgical plan in 75% of the cases. When using 3D pdf this reached only 70%. Accordance improved to 85% after revision of 3D printed models and to 95% after VR. Use of 3D printed models and VR facilitated the identification of patients who required ASO.

Conclusion

Virtual reality can enhance understanding of suitability for biventricular repair in patients with complex DORV if compared to cross-sectional images and other 3D modelling techniques.
The age-specific prognostic impact of the platelet-to-lymphocyte ratio on long-term outcome after acute coronary syndrome
Authors: Kazem Niema , Hofer Felix , Koller Lorenz , Hammer Andreas , Hofbauer Thomas M , Hengstenberg Christian , Niessner Alexander , Sulzgruber Patrick
Published: October 2021

Aims

Personalized risk stratification within the ageing society after acute coronary syndrome (ACS) remains scarce but in urgent need. Increased platelet activity together with inflammatory activation play a key role during ACS. We aimed to evaluate the age-specific prognostic potential of the platelet to lymphocyte ratio (PLR) on long-term cardiovascular mortality after ACS.

Methods and results

Patients presenting with ACS admitted to the Vienna General Hospital between December 1996 and January 2010 were enrolled within a clinical registry including assessment of peripheral blood samples. The impact of the PLR on survival was assessed by Cox-regression hazard analysis. We included a total of 681 patients with a median age of 64 years (interquartile range: 45–84). Two hundred (29.4%) individuals died during the median follow-up time of 8.5 years. A strong and independent association of the PLR with cardiovascular mortality was found in the total study population [adjusted (adj.) hazard ratio (HR) per 1 standard deviation (1 SD) of 1.07 (95% confidence interval, CI: 1.03–1.10); P < 0.001]. After stratification in individuals <65 years (n = 339) and ≥65 years (n = 342), a prognostic effect of the PLR on cardiovascular mortality was solely observed in elderly patients ≥65 years [adj. HR per 1 SD of 1.04 (95% CI: 1.00–1.08); P = 0.039], but not in their younger counterparts <65 years [adj. HR per 1 SD of 0.97 (95% CI: 0.83–1.14); P = 0.901].

Conclusion

The present investigation highlights a strong and independent age-specific association of the PLR with cardiovascular mortality in patients with ACS. The PLR only allows to identify patients ≥65 years at high risk for fatal events after ACS—even from a long-term perspective.
Duration of toothbrushing with fixed appliances: a randomized crossover clinical trial
Authors: Koretsi Vasiliki , Klinke Rebecca , Herreiner Philip , Proff Peter , Kirschneck Christian
Published: October 2021

Objective

Fixed orthodontic appliances might result in dental adverse effects, if sufficient oral hygiene is not maintained. Since recommendations on toothbrushing times are lacking scientific justification in orthodontic populations, the aim of the present study was to comparatively quantify the duration of toothbrushing with a manual and a powered toothbrush in two distinct age groups.

Trial design

Two-centre, two-period crossover balanced randomized clinical trial with computer-generated numbers and blinding at the outcome-assessing level.

Methods

Children and adults with fixed appliances with at least 22 aligned teeth were recruited at a university clinic and private practice in Bavaria, Germany. Plaque was disclosed with staining tablets and participants brushed their teeth with their habitual technique in front of a mirror and without interference until staining was, to their own satisfaction, completely removed. The primary outcome was duration of toothbrushing in seconds. Secondary outcomes were percentage plaque reduction and questionnaire data on dental attitudes and behaviours. Data were analysed with linear mixed models.

Results

Twenty-eight participants were randomized to the first and 27 to the second toothbrush sequence. The combined effect of age and toothbrush on the duration of toothbrushing was evident (n = 52, F(1, 50.8) = 5.1, P = 0.028). Children brushed 14.5 seconds less [n = 28, 95% confidence interval (CI) = −31.3 to 2.3, P = 0.090], yet adults 13.3 seconds more (n = 24, 95% CI = −4.6 to 31.3, P = 0.143) with the manual than powered toothbrush. Brushing times ranged from 2 minutes and 45 seconds to 3 minutes and 17 seconds with plaque reduction at 76% and good dental attitudes and behaviours.

Conclusions

Both children and adults with fixed appliances might equally reach an effective plaque reduction with either manual or powered toothbrushes and their habitual brushing technique in around three minutes, if plaque is visible.

Registration

DRKS—German Clinical Trials Register ID: DRKS00012463.

Funding

Oral-B Procter & Gamble.
‘Gott Strafe England’: Ivor Gurney’s Strafes and Ways
Authors: Brooks Martin
Published: October 2021

This essay describes Ivor Gurney’s use of the word ‘strafe’ in his poems of the First World War. At the outbreak of the War, the word was a new arrival in the English national consciousness. It had come to prominence in the German Army’s slogan, ‘Gott strafe England’ (‘God punish England’). Allied counterpropagandists soon redeployed this slogan as evidence that the German people were hateful and frenzied, and it gained currency as an informal English noun for a German artillery bombardment. In poems dating from during and after the War, Gurney draws on ‘strafe’s’ interlinguistic existence to express his contempt for the two powers’ propaganda. In treating the word as fluctuating between two languages, Gurney stages his separation from both English and German narratives of nationhood. Tracking his use of the word ‘strafe’ shows how he described the importance of individual experiences for understanding the War, portrayed a sense of ‘Wonder’ that he suggested could define soldier poets, and expressed his post-war belief that England had betrayed him. By outlining how Gurney attached these possibilities to ‘strafe’, this essay contributes to the wider critical understanding of how and why he wrote about his War experiences.
Engaging with Public Opinion at the Micro-Level: Citizen Dialogue and Participation in German Foreign Policy
Authors: Opitz Christian , Pfeifer Hanna , Geis Anna
Published: October 2021

This article analyzes how and why foreign policy (FP)-makers use dialogue and participation processes (DPPs) with (groups of) individual citizens as a source of public opinion. Taking Germany as a case study and drawing on DPP initiatives by the Federal Foreign Office (Auswärtiges Amt, AA) since 2014, we analyze the officials’ motivation for establishing such processes and find four different sets of motivation: (1) image campaigning, (2) educating citizens, (3) listening to citizens, and (4) changing the citizens’ role in FP. Our article makes three contributions. First, we provide a novel typology of the sources of public opinion upon which FP-makers can draw. Second, our study points to the importance of, and provides a framework for, analyzing how officials engage with public opinion at the micro-level, which has so far been understudied in FP analysis. Finally, our empirical analysis suggests that both carefully assessing and influencing public opinion feature prominently in motivation, whereas PR purposes are of minor importance. Recasting the citizens’ role in FP gains in importance over time and may mirror the increased need to legitimize FP in Western democracies vis-à-vis their publics.
The Contribution of Plasma Urea to Total Osmolality During Iatrogenic Fluid Reduction in Critically Ill Patients
Authors: Nihlén Sandra , Frithiof Robert , Titze Jens , Kawati Rafael , Rasmusson Johan , Rylander Christian , Pikwer Andreas , Castegren Markus , Belin Anton , Hultström Michael , Lipcsey Miklos
Published: October 2021

Hyperosmolality is common in critically ill patients during body fluid volume reduction. It is unknown whether this is only a result of decreased total body water or an active osmole-producing mechanism similar to that found in aestivating animals, where muscle degradation increases urea levels to preserve water. We hypothesized that fluid volume reduction in critically ill patients contributes to a shift from ionic to organic osmolytes similar to mechanisms of aestivation. We performed a post-hoc analysis on data from a multicenter observational study in adult intensive care unit (ICU) patients in the postresuscitative phase. Fluid, electrolyte, energy and nitrogen intake, fluid loss, estimated glomerular filtration rate (eGFR), and estimated plasma osmolality (eOSM) were registered. Contributions of osmolytes Na+, K+, urea, and glucose to eOSM expressed as proportions of eOSM were calculated. A total of 241 patients were included. eOSM increased (median change 7.4 mOsm/kg [IQR−1.9–18]) during the study. Sodium's and potassium's proportions of eOSM decreased (P < .05 and P < .01, respectively), whereas urea's proportion increased (P < .001). The urea’s proportion of eOSM was higher in patients with negative vs. positive fluid balance. Urea's proportion of eOSM increased with eOSM (r = 0.63; adjusted for eGFR r = 0.80), but not nitrogen intake. In patients without furosemide and/or renal replacement therapy (n = 17), urea’s proportion of eOSM and eOSM correlated strongly (r = 0.92). Urea’s proportion of eOSM was higher in patients not surviving up to 90 d. In stabilized ICU patients, the contribution of urea to plasma osmolality increased during body water volume reduction, statistically independently of nitrogen administration and eGFR. The shift from ionic osmolytes to urea during body fluid volume reduction is similar to that seen in aestivating animals.

ClinicalTrials.org Identifier: NCT03972475.
A genetic toolkit for studying transposon control in the Drosophila melanogaster ovary
Authors: ElMaghraby Mostafa F , Tirian Laszlo , Senti Kirsten-André , Meixner Katharina , Brennecke Julius
Published: October 2021

Argonaute proteins of the PIWI clade complexed with PIWI-interacting RNAs (piRNAs) protect the animal germline genome by silencing transposable elements. One of the leading experimental systems for studying piRNA biology is the Drosophila melanogaster ovary. In addition to classical mutagenesis, transgenic RNA interference (RNAi), which enables tissue-specific silencing of gene expression, plays a central role in piRNA research. Here, we establish a versatile toolkit focused on piRNA biology that combines germline transgenic RNAi, GFP marker lines for key proteins of the piRNA pathway, and reporter transgenes to establish genetic hierarchies. We compare constitutive, pan-germline RNAi with an equally potent transgenic RNAi system that is activated only after germ cell cyst formation. Stage-specific RNAi allows us to investigate the role of genes essential for germline cell survival, for example, nuclear RNA export or the SUMOylation pathway, in piRNA-dependent and independent transposon silencing. Our work forms the basis for an expandable genetic toolkit provided by the Vienna Drosophila Resource Center.