702 COMMUNICATION CHALLENGES BETWEEN DOCTORS & RELATIVES DURING THE COVID-19 PANDEMIC: SIMPLE INTERVENTIONS WITH MEANINGFUL IMPACT

Background

& Aims Visiting restrictions during the COVID-19 pandemic resulted in reduced and inconsistent communication with the next-of-kin of elderly inpatients. This project aimed to improve communication between doctors and patients’ relatives in accordance with the GMC Good Medical Practice guidelines which outline that doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.

Methods

We created a virtual whiteboard on an elderly care ward in an inner London hospital documenting patient demographics, details of named next-of-kin and when they had been contacted. We aimed to update next-of-kin within 48-hours of ward admission and subsequently twice weekly. The outcome was measured via identical ‘pre- and post-intervention’ questionnaires recording the next-of-kin’s satisfaction with communication from the doctors. Questionnaires included 11 questions utilising a 5-point Likert scale for satisfaction. Results were anonymised and analysed using Microsoft Excel.

Results

Satisfaction with communication improved in 10 of the 11 domains of the questionnaire following intervention. Cumulative satisfaction scores post-intervention (N = 13) in comparison to pre-intervention (N = 25) were closer to the total possible satisfaction score per question for these 10 domains. The mean cumulative satisfaction score across all domains was 60% post-intervention compared with 44% pre-intervention. Satisfaction following intervention was particularly improved in the domains of frequency of communication (60% post-intervention.

32.8% pre-intervention) and how adequately questions and concerns were addressed (69.2% post-intervention; 45.6% pre-intervention).

Conclusion

During the COVID-19 pandemic healthcare professionals have had to adapt in communicating with patients’ next-of-kin. Our Introduction of robust standards and a virtual whiteboard to track communication resulted in improved satisfaction and proved useful in adapting to remote communication. We propose that similar practice and standards are extended across additional wards to encourage widespread optimal and consistent communication between doctors and patients’ relatives, an integral part of patient care.

421 Migratory Foreign Bodies in Theaero-Digestive Tract: The Importance of Computerised Tomography (CT) Imaging

Aim

We discuss this case to stress the role of computerized tomography imaging in diagnosis of foreign bodies of the upper aerodigestive tract and propose an algorithm for management of such cases.

Case Presentation

A 35-year-old male presented with dysphagia and swelling in the left lower part of the neck for 2 days. He gave a history of suspected fish bone ingestion one week prior, followed by pain and discomfort in the throat. Patient underwent upper gastrointestinal endoscopy, which was inconclusive. The patient was reassured and sent home.

Examination showed 3 x 4cm soft tender swelling in the left lower part of the neck. Computed tomography showed heterogeneously enhancing soft tissue density with multiple air shadows in the left para-pharyngeal space [fig 1]. Long, narrow, calcified lesion was present in the midst of the soft tissue density, suspected to be a fish bone [fig 2].

Vertical incision was made along the anterior border of the left sternocleidomastoid muscle and 20 ml pus was drained. Carotid sheath was identified and was swollen, surrounded by extensive granulation tissue. Fish bone was found adjacent to the thyroid lobe [Fig 3], was removed - it was serrated and four cm in length [Fig 4]. Repeat endoscopy and a barium meal showed no leak. He was discharged with oral antibiotics for two weeks with no further follow up.

Conclusions

Accidental fish bone ingestion is a very common situation in otarhynological emergencies. The role of CT imaging in the management of rare instances like perforation and migration of foreign bodies can prevent serious and life-threatening complications.

354 Virtual Consultation in Vascular Practice: The New Normal

Aim

Face to face vascular clinics were suspended at a major trauma centre at the beginning of the COVID-19 pandemic, however Royal Stoke Hospital Vascular team were still undertaking emergency vascular operations. Consequently, virtual telephone consultations were set up and delivered to facilitate post-operative follow ups. The objective of this improvement study is to compare the virtual clinic documentation against The Royal College of Surgeons of England (RCS Eng) Best Practice Guidance on Conducting Virtual Consultations, which was published in June 2020. This is important as good documentation is vital to patient care as well as being a medico-legal document.

Method

We retrospectively identified 30 vascular patients operated between May 2021 and June 2021; 10 of which had had a virtual telephone clinic and the majority underwent an amputation. We audited the clinic note documentation against the RCS Eng guidelines.

Results

Total of 9 RCS Eng guidelines were identified and audited. The first cycle revealed poor areas in documentation of the surgeon introducing themselves, confirmation of patient details, obtaining consent to proceed, summary of consult and plan discussed.

Findings were presented at the trust governance meeting. Areas which required improvement in documentation were highlighted. In addition to education of surgeons, it was decided to introduce a checklist as a requirement.

Conclusions

Clinic note documentation is of paramount importance as it has legal and medical ramifications. The education of surgeons and introduction of a checklist to ensure compliance with RCS Eng guidelines and we will re-audit to ensure improvement.

Change of Hemoglobin Level among Exclusively Breastfed Term and Preterm Babies up to Six Months of Age

There is progressive increase of Hb levels is observed during course of intrauterine development of fetus but high concentrations found at birth. In preterm neonate normal Hb is characteristically deviated from term neonate. Breast milk is the only natural ideal food for both term and preterm babies from birth up to 6 months. Preterm milk was found to contain significantly higher concentrations nutrients particularly iron than term milk. Preterm human milk is more suitable for the premature infant than term human milk. As Hb concentration varies in term and preterm babies in different counties in different feeding practices. The purpose of this longitudinal descriptive study is to find out the pattern of changes in the Hb level among exclusively breastfed preterm and term infants during the first six months of life. This study was carried in the Neonatal Intensive Care Unit (NICU), Mymensingh Medical College Hospital (MMCH), Mymensingh from September 2016 to February 2018. One hundred fifty (150) neonates both term and preterm were included in this study and followed up to 6 months of age. After admission informed written consent was taken from parents, thorough history taking and clinical examination were done. Data were collected in a pre-designed case record form. All the babies of Group A provided 2mg/kg iron supplementation from 6 weeks for 2 months for universal recommendation. Hb level was measured of all exclusively breast feed babies at admission after birth then next follow-up at 6 weeks, 3 months and 6 months. All information regarding history, anthropometrics measurement, Hb level was recorded in structural questionnaire. Data analysis was done by SPSS version 20.0. Male were predominant in both groups. Most of the preterm (72.0%) and term babies (65.3%) were delivered by vaginal route. Mean Hb level was found significantly higher among preterm babies than term babies after birth were 16.55g/dl and 15.98g/dl respectively. Sharp fall of Hb concentration was observed after birth up to 6 weeks in both preterm and term babies but Hb level was found significantly lower in preterm in comparison to term babies (9.27gm/dl vs. 9.58gm/dl). In term babies, even after 6 weeks fall of Hb level continued to 3 months of age followed by gradual increase up to 6 months without iron supplementation. Hb level of in preterm babies gradually increased from 6 weeks up to 6 months with universal iron supplementation. Hb level fall sharply up to 6 weeks in both exclusively breastfed term and preterm babies but even after 6 weeks term babies experienced gradual fall of Hb levels up to 3 months. Hb level increases in exclusively breast-fed term babies without iron supplementation from 3 months of age. Hb level in exclusively breastfed preterm babies increase from 6 weeks onward might be effect of universal iron supplementation.

Neurological manifestation with special reference to HIV-associated neurocognitive disorder (HAND) among people on anti-retroviral treatment in India

OBJECTIVE

The neurological manifestations and their severity in patients on antiretroviral treatment (ART) are currently unexplained. ‎We aimed at studying the prevalence of HIV Associated Neurological Disorders (HAND) among people on antiretroviral treatment, using the International HIV Dementia Scale (IHDS).

PATIENTS AND METHODS

A predesigned and pretested proforma including the International HIV Dementia Scale (IHDS) was administered to 100 HIV patients attending to ART center of KIMS teaching Hospital (Koppal, Karnataka) from January 2020 to March 2020. The data was analyzed SPSS version 15 software. Descriptive statistics were used for demographic characteristics. The Student's t-test and chi-square test methods were applied to determine the relationship between qualitative characteristics.

RESULTS

The prevalence was found to be 59%. Out of 100, 57 HIV patients scored less than 10 whereas 43 HIV patients scored ≥10 on the IHDS scale. The mean age of the study population was 39.14 ±13.01 years; the total IHDS score was 9.96±1.53 and the CD4 count was 427.91±226.0. This study demonstrated that the patients with CD4 count more than 350 (i.e., 63.60%) had a better IHDS score.

CONCLUSIONS

Neurocognitive disorder was found to be more common than anticipated. All ICTC Centers need to consider assessing HIV-associated neurocognitive disability (HAND), and the International HIV Dementia Scale (IHDS) as one instrument for such assessment.

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.

Up-regulation of GINS1 highlighted a good diagnostic and prognostic potential of survival in three different subtypes of human cancer

Cancer is a fatal malignancy and its increasing worldwide prevalence demands the discovery of more sensitive and reliable molecular biomarkers. To investigate the GINS1 expression level and its prognostic value in distinct human cancers using a series of multi-layered in silico approach may help to establish it as a potential shared diagnostic and prognostic biomarker of different cancer subtypes. The GINS1 mRNA, protein expression, and promoter methylation were analyzed using UALCAN and Human Protein Atlas (HPA), while mRNA expression was further validated via GENT2. The potential prognostic values of GINS1 were evaluated through KM plotter. Then, cBioPortal was utilized to examine the GINS1-related genetic mutations and copy number variations (CNVs), while pathway enrichment analysis was performed using DAVID. Moreover, a correlational analysis between GINS1 expression and CD8+ T immune cells and a the construction of gene-drug interaction network was performed using TIMER, CDT, and Cytoscape. The GINS1 was found down-regulated in a single subtypes of human cancer while commonly up-regulated in 23 different other subtypes. The up-regulation of GINS1 was significantly correlated with the poor overall survival (OS) of Liver Hepatocellular Carcinoma (LIHC), Lung Adenocarcinoma (LUAD), and Kidney renal clear cell carcinoma (KIRC). The GINS1 was also found up-regulated in LIHC, LUAD, and KIRC patients of different clinicopathological features. Pathways enrichment analysis revealed the involvement of GINS1 in two diverse pathways, while few interesting correlations were also documented between GINS1 expression and its promoter methylation level, CD8+ T immune cells level, and CNVs. Moreover, we also predicted few drugs that could be used in the treatment of LIHC, LUAD, and KIRC by regulating the GINS1 expression. The expression profiling of GINS1 in the current study has suggested it a novel shared diagnostic and prognostic biomarker of LIHC, LUAD, and KIRC.

Genome-wide identification and expression analysis of Polyamine Uptake Transporter gene family in sweet orange (Citrus sinensis)

Polyamine uptake transporter (PUT) plays important roles in polyamine homeostasis, but knowledge regarding PUT family genes in sweet orange (Citrus sinensis) remains elusive. Herein, our study aimed to perform a genome-wide identification of the PUT gene family in C. sinensis. A total of eight putative PUT genes (CsPUT1-CsPUT8) were identified in the sweet orange genome and distributed on three chromosomes. The CsPUT genes were divided into two major groups according to the phylogenetic tree analysis, with high similarities in protein domains and gene structure organization. The CsPUT genes were differentially expressed in different tissues, with the highest transcript levels being in the flowers and roots. Interestingly, the CsPUT genes were significantly induced by polyamines, putrescine, spermidine and spermine, indicating that CsPUT were possibly associated with intracellular polyamine transport and uptake. In addition, CsPUT showed differential expression in callus treated with ABA, cold, salt or osmotic shock. CsPUT4 was selected as a candidate for functional analysis of PUT. Overexpression of CsPUT4 elevated endogenous polyamine content and led to enhanced cold tolerance in transgenic callus cultures. Overall, these data provide valuable information for better understanding the potential biological functions of PUT genes in future.

Sinonasal teratocarcinosarcoma, A rare neoplasm; Case report and literature review

Introduction/Objective

Sinonasal teratocarcinosarcoma (SNTCS) is an unusual neoplasm with high malignant potential. Histologically it consists of epithelial and mesenchymal constituents, with a combination of teratoma and carcinosarcoma. It primarily occurs in the nasal cavity and paranasal sinuses. This aggressive neoplasm has a high recurrence rate with a five-year survival of 30-50 percent. To this date, less than a hundred cases have been mentioned in the literature. Early diagnosis and management of the tumor can enhance the prognosis.

Methods/Case Report

We present to you a case of a 63-year-old woman presenting with epistaxis, nasal congestion, and blockage. The tumor was completely removed surgically and postoperative radiation therapy was given. Grossly the tumor was gray-white, with a solid texture. Postsurgical microscopic examination of the sections from different areas showed variegated appearance having a mix of teratoid; carcinomatous; sarcomatous and primitive neuroectodermal elements. Immunohistochemical staining revealed tumor cells expressing desmin, EMA, and cytokeratin. The follow-up examination was done after a year and showed no sign of recurrence.

Results (if a Case Study enter NA)

N/A

Conclusion

Because of the scarcity and mixed cell lines of this tumor pathological diagnosis of the neoplasm is hard. Since this neoplasm is highly malignant and locally aggressive proper identification and removal are necessary for improving morbidity as well as mortality.

Mortality and long-term outcomes of palliative inotropes in ischemic and non-ischemic cardiomyopathy

Background

Palliative inotropes are frequently utilized for symptom management in patients with end stage heart failure who are unable to undergo durable advanced heart failure therapies. With the advent of improved medical management and early intervention, palliative inotropes may allow for improved patient outcomes than seen previously. In this study, we aim to investigate the survival and outcomes of palliative inotrope therapy and its impacts on ischemic versus non-ischemic cardiomyopathy.

Methods

We retrospectively analyzed 220 patients with American Heart Association Stage D heart failure who were discharged with palliative inotrope therapy after January 1, 2010. Patients who underwent mechanical circulatory support (MCS) or those who underwent heart transplant were excluded. Those with a history of coronary artery disease, myocardial infarction, history of percutaneous intervention, or coronary artery bypass grafting were assigned to ischemic cardiomyopathy (ICM), while patients without these findings were assigned to non-ischemic cardiomyopathy (NICM). Statistical analysis was completed using Chi-Square and Student's t-tests, wherein p<0.05 was considered statistically significant.

Results

Of the 220 patients, 87 had NICM as opposed to 133 with ICM. Mean age was found to be higher among patients with ICM (70 [62–79]) compared to NICM (65 [55–72], p-value <0.01). No significant difference was seen in total days on inotrope therapy (p=0.6). While more patients in both groups were placed on milrinone as opposed to dobutamine, there was no difference between patients with ischemic and NICM (p=0.66 and 0.51 respectively). Although a greater number of patients with NICM had been lost to follow up, admitted to hospice, or expired at 2 years (p<0.01), survival at 3 months, 1 year, and 2 years showed no difference between both groups. No difference was seen in number of hospitalizations or clinic visits in one year. Both groups had similar complication rates with intravenous-access related PICC line infections and new arrhythmias. (See Table).

Conclusion

Despite more frequent use of durable mechanical support devices, many patients who are deemed unsuitable for invasive measures are treated with palliative inotrope therapy. We have found that there is no significant difference in survival, complications, and outcomes of patients on palliative inotropes among ischemic and NICM. These findings show the versatility of palliative inotrope therapy in end stage heart failure. Further studies with larger populations need to be evaluated.

Funding Acknowledgement

Type of funding sources: None.

1549 Patient Perception on Hand Trauma Management Through a Plastic Surgery Trauma Clinic

Aim

We assessed patient perceptions of hand trauma management through a plastic surgery trauma clinic. We also assessed effects of educating patients about outcomes of their condition on their desire to have prompt surgery.

Method

A prospective survey review was conducted at our plastic surgery trauma clinic. Patients included were those referred due to simple hand trauma. Any patients needing urgent admissions were excluded. An anonymous survey assessing patient perceptions before and after education about delay in surgery was distributed.

Results

Of 100 patients, there were mixed expectations regarding trauma clinic; 38% (n = 38) expect an operation, 32% (n = 32) expect no operation and 30% (n = 30) expect either option. 90% (n = 90) expect surgery within a week (50% n = 50) or within a day (40% n = 40); 10% expect it (n = 10) within a few weeks. After educating patients about no negative effects on their condition from surgical delay, 43% (n = 17) fewer patients desired surgery within a day, and 8% (n = 3) fewer patients desired surgery within a week. 190% (n = 19) more patients were willing to have surgery within a few weeks. 79% (n = 79) would rather come back at a guaranteed surgical slot than stay in hospital until a slot is available. 72% (n = 72) considered knowledge about long-term outcomes associated with surgical delay to influence their decision more than anaesthetic type (12% n = 12) and personal circumstances (16% n = 16).

Conclusions

If appropriate patients are assured that their condition will not be affected by surgical delay, fewer patients may stay in hospital with financial benefits of reduced bed occupancy and reduced covid risks.

204 A Systematic Review of Clinical Outcomes for Outpatient vs Inpatient Shoulder Arthroplasty

Aim

Outpatient shoulder arthroplasty is growing in popularity as a cost-effective and potentially equally safe alternative to inpatient arthroplasty. We investigated literature relating to outpatient shoulder arthroplasty, looking at clinical outcomes, complications, readmission, and cost compared to inpatient arthroplasty.

Method

We systematically searched Medline, Embase, PubMed using relevant search terms. Methodological quality of included studies was assessed using Methodological Index for Non-Randomised Studies score.

Results

We included 17 studies in our review with 11 included in the meta-analyses. A meta-analysis of hospital readmissions demonstrated that there was no statistically significant difference between outpatient and inpatient cohorts (OR = 0.89, 95% CI: 0.63-1.25, p = 0.49, I2=56%). Pooling results for all post-operative complications identified decreased complications in those undergoing outpatient surgery (OR = 0.70; 95% CI: 0.52-0.94, p = 0.02, I2=50%). No statistically significant difference was identified with respect to medical complications (OR = 0.86, 95% CI: 0.74-1.01, p = 0.07, I2=0%) or surgical complications (OR = 0.71, 95% CI: 0.45-1.12, p = 0.14, I2=26%). Considerable cost saving of between $3 614 – $53 202 (19.7 – 69.9%) per patient were present in the outpatient setting.

Conclusions

Shoulder arthroplasty in the outpatient setting is as safe as shoulder arthroplasty in the inpatient setting, with a significant reduction in cost. There is no demonstrable statistically significant difference with regards to readmissions between outpatient and inpatient shoulder arthroplasty. In the appropriately selected patient, outpatient shoulder arthroplasty is safe and cost-effective; however, we still need to work towards understanding who the appropriate patients are for this post-operative care pathway.

246 FRActure Clinic Treatment: a sURvey of patient Experience (FRACTURE)

Aim

BOAST guidelines on fracture clinics suggest a standard of care that all patients with significant injury should expect to receive in a Trauma & Orthopaedics outpatient setting in the United Kingdom.

Method

A prospective analysis of 358 patients presenting to fracture clinic at Gloucestershire Hospitals NHS Foundation Trust from September to November 2020. Patients completed an anonymous questionnaire based on BOAST guidelines.

Results

Most patients received a written management plan (82%), but only some received a leaflet (36%) and definite information about their procedure (47%). Most patients felt a leaflet (72%) and information about procedures (87%) would be useful. Patients were generally seen early or within 30 minutes of their appointment time (77%), but some waited more than 30 minutes (23%). Most patients found X-rays easily (91%) and rated staff (97%) and fracture clinic experience (93%) as very good or good. Comments included noting an efficient and friendly service, with suggestions on providing more information on waiting times and procedures to be performed.

Conclusions

Our study showed high patient satisfaction with fracture clinic and particularly positive feedback about staff. Areas of improvement include providing more leaflets and information about practical procedures. Following this audit, we will produce leaflets on common conditions and record videos on common procedures such as application of casts, splints and removal of k-wires or sutures, which can be accessed by patients prior to their appointment. The audit could be repeated at a regional or national level to help centres assess the level of care provided.

Association of indoor air pollution on cognitive dysfunction among elderly

OBJECTIVE

Cognitive dysfunction among the elderly is a devastating condition preceded by accumulation of neuropathology leading to accelerated cognitive decline. Many epidemiologic studies have reported the relation between indoor air pollution exposure and cognitive impairment. To clarify the nature of the association, a comprehensive systematic review and meta-analysis were performed.

MATERIALS AND METHODS

The analysis included all observational studies, including cross-sectional studies, prospective and retrospective cohort studies. Experimental studies, randomized controlled trials (RCTs), and controlled clinical trials were excluded. Studies on the relationships of indoor air pollution and cognition published before 30 April 2021 which are peer-reviewed scientific publications available in English were included after performing a structured literature search through electronic databases, including PubMed, Embase, Cochrane Library, and clinical trial.gov. A total of 146 articles were collected, and after screening thoroughly only, 9 studies were selected. Meta-analysis for the final set of selected studies was performed using the R software.

RESULTS

The quality of all the studies was adequate as almost all reported an association between at least one pollutant and cognitive dysfunction. However, relatively few studies considered outcomes that provide the most substantial evidence for a causal effect. In total, 5 studies have reported on cognitive function. The pooled mean of cognitive function was 12.16 (95% CI: 10.73 to 13.58). However, the heterogeneity was very high (I2=100%; chi-square test for heterogeneity = p<0.001). We used a modified JBI structured risk of the bias assessment tool, and it was minimal among the included studies as most of the studies have followed a random sampling method and explicitly mention it in their methods.

CONCLUSIONS

Exposure to indoor air pollution through fuels used for cooking and heating was significantly associated with cognitive dysfunction among elderly women. Given the limitations, a more extensive meta-analysis and longitudinal studies are recommended to investigate the biological mechanism behind the impact of indoor air pollution on cognitive health.

"LONG COVID": an insight

We aimed this systematic review to analyze and review the currently available published literature related to long COVID, understanding its pattern, and predicting the long-term effects on survivors. We thoroughly searched the databases for relevant articles till May 2021. The research articles that met our inclusion and exclusion criteria were assessed and reviewed by two independent researchers. After preliminary screening of the identified articles through title and abstract, 249 were selected. Consequently, 167 full-text articles were assessed and reviewed based on our inclusion criteria and thus 20 articles were regarded as eligible and analyzed in the present analysis. All the studies included adult population aged between 18 and above 60 years. The median length of hospital stay of the COVID-19 patients during the acute infection phase ranged from 8 days to 17 days. The most common prevalent long-term symptoms in COVID-19 patients included persistent fatigue and dyspnea in almost all of the studies. Other reported common symptoms included: shortness of breath, cough, joint pain, chest pain or tightness, headache, loss of smell/taste, sore throat, diarrhea, loss of memory, depression, anxiety. Associated cardiovascular events included arrhythmias, palpitations and hypotension, increased HR, venous thromboembolic diseases, myocarditis, and acute/decompensated heart failure as well. Among neurological manifestations headache, peripheral neuropathy symptoms, memory issues, concentration, and sleep disorders were most commonly observed with varying frequencies. Mental health issues affecting mental abilities, mood fluctuations namely anxiety and depression, and sleep disorders were commonly seen. Further, diarrhea, vomiting, digestive disorders, and Loss of appetite or weight loss are common gastrointestinal manifestations. Therefore, appropriate clinical evaluation is required in long COVID cases which in turn may help us to identify the risk factors, etiology, and to my help, we treat them early with appropriate management strategies.

A threefold approach including quantum chemical, molecular docking and molecular dynamic studies to explore the natural compounds from Centaurea jacea as the potential inhibitors for COVID-19

In the current report, we studied the possible inhibitors of COVID-19 from bioactive constituents of Centaurea jacea using a threefold approach consisting of quantum chemical, molecular docking and molecular dynamic techniques. Centaurea jacea is a perennial herb often used in folk medicines of dermatological complaints and fever. Moreover, anticancer, antioxidant, antibacterial and antiviral properties of its bioactive compounds are also reported. The Mpro (Main proteases) was docked with different compounds of Centaurea jacea through molecular docking. All the studied compounds including apigenin, axillarin, Centaureidin, Cirsiliol, Eupatorin and Isokaempferide, show suitable binding affinities to the binding site of SARS-CoV-2 main protease with their binding energies -6.7 kcal/mol, -7.4 kcal/mol, -7.0 kcal/mol, -5.8 kcal/mol, -6.2 kcal/mol and -6.8 kcal/mol, respectively. Among all studied compounds, axillarin was found to have maximum inhibitor efficiency followed by Centaureidin, Isokaempferide, Apigenin, Eupatorin and Cirsiliol. Our results suggested that axillarin binds with the most crucial catalytic residues CYS145 and HIS41 of the Mpro, moreover axillarin shows 5 hydrogen bond interactions and 5 hydrophobic interactions with various residues of Mpro. Furthermore, the molecular dynamic calculations over 60 ns (6×106 femtosecond) time scale also shown significant insights into the binding effects of axillarin with Mpro of SARS-CoV-2 by imitating protein like aqueous environment. From molecular dynamic calculations, the RMSD and RMSF computations indicate the stability and dynamics of the best docked complex in aqueous environment. The ADME properties and toxicity prediction analysis of axillarin also recommended it as safe drug candidate. Further, in vivo and in vitro investigations are essential to ensure the anti SARS-CoV-2 activity of all bioactive compounds particularly axillarin to encourage preventive use of Centaurea jacea against COVID-19 infections.

Significance of HbA1c levels in diabetic retinopathy extremes in South Africa

BACKGROUND

Diabetic retinopathy (DR) is one of the leading causes of blindness in sub-Saharan Africa and globally, placing a huge disease burden on patients and the public health system. DR varies in severity from non-proliferative to proliferative DR (PDR).

OBJECTIVES

Using a monitor of medium- to long-term blood glucose control, to determine the association between glycated haemoglobin (HbA1c) levels in patients with PDR and those with no DR.

METHODS

A prospective, cross-sectional study was conducted at McCord Provincial Eye Hospital in Durban, South Africa. We studied only patients diagnosed with diabetes mellitus (DM) for &gt;1 year who had either PDR or no DR, and compared their HbA1c levels. Patients with non-proliferative DR were not included.

RESULTS

Patients with PDR had significantly higher HbA1c levels than those with no DR. Patients with type 1 DM had higher HbA1c levels than patients with type 2 DM in both the PDR and no-DR groups. Older patients (&gt;70 years) had lower HbA1c levels than younger patients. Gender, race and duration of diabetes had no influence on HbA1c levels.

CONCLUSIONS

PDR was associated with higher HbA1c in type 2 DM in all races and age groups and was independent of duration of disease. The trend was the same for type 1 DM, but significance could not be reached, probably because of small numbers in this subset of patients.

Shock Ignition Laser-Plasma Interactions in Ignition-Scale Plasmas

We use a subignition scale laser, the 30 kJ Omega, and a novel shallow-cone target to study laser-plasma interactions at the ablation-plasma density scale lengths and laser intensities anticipated for direct drive shock-ignition implosions at National Ignition Facility scale. Our results show that, under these conditions, the dominant instability is convective stimulated Raman scatter with experimental evidence of two plasmon decay (TPD) only when the density scale length is reduced. Particle-in-cell simulations indicate this is due to TPD being shifted to lower densities, removing the experimental back-scatter signature and reducing the hot-electron temperature. The experimental laser energy-coupling to hot electrons was found to be 1%-2.5%, with electron temperatures between 35 and 45 keV. Radiation-hydrodynamics simulations employing these hot-electron characteristics indicate that they should not preheat the fuel in MJ-scale shock ignition experiments.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave

BACKGROUND

There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period.

METHODS

We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission.

RESULTS

There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery.

CONCLUSIONS

There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Detection of Aflatoxins in Peanut Oils Marketed in Peshawar, Pakistan Using Thin Layer Chromatography

Background: Aflatoxins (AFs) are natural toxins produced by fungus belonging to genus Aspergillus. These toxins are the secondary metabolites, which may cause teratogenic, mutagenic, and carcinogenic effects due to contamination of food. Peanut is an economi- cally important crop, grown in many parts of the world. The main aim of this survey was to detect AFs in peanut oils marketed in Peshawar, Pakistan. Methods: During September 2020 to February 2021, a total of 60 peanut oil samples were obtained from retail stores and markets; 20-each from three different areas of Pesh- awar (University, City, and Cantt), Pakistan. AFB1, AFB2, AFG1, and AFG2 were deter- mined using Thin Layer Chromatography. Data analysis was done using SPSS 21.0. Results: Prevalence rates of AFB1, AFB2, AFG1, and AFG2 in peanut oils were 70, 51.7, 3.3, and 0%, respectively. The mean of total AFs was 8.59 μg/kg ranged from 0.12 to 55 μg/kg. Totally, 5% (3 out of 60) of the samples were found contaminated with AFB1 above the permissible limits (20 μg/kg) according to national regulation. There was significant difference (p<0.05) between AF levels in the samples from different three areas of Peshawar. Conclusion: Although, the majority of samples of peanut oils in Peshawar (Pakistan) were safe for consumption, monitoring of AFs must be carried out on a regular basis in the case of peanut oil consumed in this region. This study suggested that farmers, food processors, and local processors should be aware of acceptable hygiene practices for the cultivation, protection, transportation, processing, and handling of peanut oil.

Exploring factors influencing physiotherapists' perceptions of measuring reactive balance following a theory-based multi-component intervention: a qualitative descriptive study

Purpose: Reactive balance is a critical consideration for mobility and fall avoidance, but is under-assessed among physiotherapists. The objective of this study was to explore factors influencing physiotherapist perceptions about measuring reactive balance upon completion of a 12-month theory-based, multi-component intervention to increase use of a measure of reactive balance.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 28 physiotherapists treating adults with balance impairment in three urban Canadian rehabilitation hospitals that participated in the intervention. Interviews explored perceptions of reactive balance measurement and perceived changes in clinical behavior. Thematic analysis involved multiple rounds of coding, review and discussion, theme generation, and interpretation of findings through individual analysis and team meetings.Findings: Participants expressed contrasting views about integrating reactive balance measurement in their practice, despite consistent acknowledgement of the importance of reactive balance for function. Three themes were identified highlighting factors that mediated perceptions about measuring reactive balance: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Conclusions: The findings highlight that decision making for measuring reactive balance in rehabilitation settings is complex. There is a need for additional work to facilitate long-term implementation of clinical reactive balance measurement, such as refining patient criteria for administration, ensuring sufficient time to establish a trusting relationship, and developing and testing strategies to address physiotherapist fear.IMPLICATIONS FOR REHABILITATIONReactive balance is important for falls prevention and mobility, but is under-assessed among physiotherapists.This study identified three factors that influenced uptake of reactive balance measurement among physiotherapists in rehabilitation settings: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Knowledge of the identified factors may assist with design and use of reactive and other balance measurements.Strategies aimed at developing trusting relationships between physiotherapist and patient along with addressing physiotherapist fear could facilitate the uptake of clinical reactive balance measurement.

Assisted ventilation immediately after birth with self-inflating bag versus T-piece resuscitator in preterm infants

OBJECTIVE

To compare proportions of target range tidal volumes achieved with the self-inflating bag vs. the T-piece in resuscitation of preterm newborns at delivery.

STUDY DESIGN

This randomized controlled trial was conducted at a tertiary Children's Hospital. 20 preterm infants≤32 weeks' gestational age with no congenital anomalies who needed positive pressure ventilation after birth were enrolled. Positive pressure ventilation was provided with the self-inflating bag or T-piece resuscitator. The primary outcome was proportion of inflations within a target range of 4-8 ml/kg. Chi-square and logistical regression analyses were performed.

RESULTS

In the self-inflating bag (SIB) group 29% of inflations (117/419) and in the T-Piece (TP) group 51% of inflations (300/590) delivered expiratory tidal volume (TVe) of 4-8 ml/kg (p <  65.001). In the SIB group 60% of all inflations (254/419), and in the TP group 35% of all inflations (204/590) delivered TVe <  4 ml/kg (p <  0.001). In the SIB group 11% of all inflations (48/419), and in the TP group, 15% of all inflations (86/590) delivered TVe >  8 ml/kg (p = 0.18). The OR of having expiratory tidal volume of 4-8 ml/kg using the T-piece was 1.8 (CI 1.1-3.1), p = 0.02.

CONCLUSION

Manual inflations provided by the TP deliver expiratory tidal volumes in the range of 4-8 ml/kg more consistently than SIB.

Description of Lutziella swatensis sp.n. (Trematoda: Dicrocoelidae) from Rattus rattus in Swat, Pakistan

A new species of the genus Lutziella (Rohde, 1966) Yamaguti, 1971 is described here and named Lutziella swatensis sp.nov. from the liver of rat (Rattus rattus L.). The new species is characterized by having body flat, smooth, longer than broad with maximum width at the level of the ovary, oral sucker with weak musculature, pharynx small; eosophagus long; caeca of irregular shape which bifurcate on the anterior border of the ovary in to unequal portions, acetabulum weakly muscular, post-testicular, testes lobed, cirrus pouch somewhat median, small in size containing winding seminal vesicle, prostatic complex and short ejaculatory duct. Genital pore median. Ovary post testicular, submedian; seminal receptacle overlapping ovary, laurer's canal present. Vitellaria follicular extending on each side from almost the level of testes to anterior portion of posterior half of the body. Uterus filled with eggs occupying most of the body, eggs oval rather small, numerous, brownish in colour, excretory vesicle tubular with terminal pore. Lutziella swatensis n. sp. is the second species of the genus known from Pakistan as well as the second species described from murid rodents in the world.

Cognitively targeted transperineal prostate biopsy in patients with previous abdominoperineal excision of the rectum

Introduction:

Prostate biopsy is performed using an ultrasound probe placed in the rectum with either a transrectal or, increasingly popular, transperineal approach. This is not possible in patients with abdominoperineal excision of the rectum due to the lack of rectum. In our case series, we present a technique for prostate biopsy in this cohort and our outcomes.

Method:

The study population consisted of three consecutive patients who presented to our institution between 2018–2019 with an elevated level of prostate-specific antigen, a history of abdominoperineal excision of the rectum and undergone multiparametric magnetic resonance imaging of the prostate at our institution before a biopsy. Transperineal prostate biopsies were performed under general anaesthesia using a curved uniplanar ultrasound transducer with an attached guide to stabilise the needle. Free-hand biopsies were taken using an 18-gauge biopsy needle with an automatic spring-driven device. Multiple biopsy cores were directed to multiparametric magnetic resonance imaging target areas by visual registration.

Results:

Three men with a median age of 69 years (range 68–75 years) were included in this case series with serum index prostate-specific antigen values between 6.5–14 ng/ml. All three patients had Prostate Imaging Reporting and Data System 5 lesions identified on multiparametric magnetic resonance imaging scans. All three men were diagnosed with clinically significant prostate cancer (>Gleason grade group 2). On average, 13 biopsy cores (range: 12–15) were obtained with a median core length of 9 mm (range: 6–20 mm). All patients were discharged home on the day of the procedure and had none had postoperative complications.

Conclusion:

The use of multiparametric magnetic resonance imaging and cognitive targeted transperineal biopsy provides an option for diagnosing prostate cancer in this challenging group of patients. Level of evidence: 4

Green synthesis of silver nanoclusters via Melia azedarach plant and their potential towards catalytic reduction of 4-nitrophenol

Biomolecules present in the plant extracts have potential to reduce metal ions to nanoclusters by a single-step green synthesis approach. In the current study, we have synthesized the silver nanoclusters (AgNCs) from a medicinal plant, Melia azedarach and studied their catalytic activity toward the reduction of 4-nitophenol to 4-aminophenol and organic dyes. Morover, the phytochemical analysis of the plant extract was carried out in order to determine the bioactive compounds present in it. Metallic nature of the synthesized AgNCs was verified by X-ray diffraction study, while their morphology and size of was confirmed by transmission electron microscopy and Zetasizer, respectively. The study revealed that they were 56±2 nm in size and formed clusters. Fourier transformed infrared spectroscopy gives information about the different functional groups present in synthesized these NCs. Furthermore, the important catalytic applications, such as catalytic reduction of 4-nitrophenol in the presence of mild reducing agent NaBH4 and the catalytic degradation of organic dyes was monitored by FTIR. Therefore, these results indicate that the obtained nanomaterials have important applications in industrial areas.                     KEY WORDS: Green synthesis, Silver nanoclusters, Catalytic reduction, Characterization   Bull. Chem. Soc. Ethiop. 2021, 35(1), 197-206. DOI: https://dx.doi.org/10.4314/bcse.v35i1.17

The use of Facebook in a community pharmacist-led weight management programme – a London-based proof of concept study

Introduction

In the United Kingdom (UK), 63% of adults are overweight,(1) costing the NHS £6.1 billion/year. With the public using digital technology over healthcare professionals (HCPs) for health advice, this warrants an investigation of technology use in community pharmacy, given its previous successful use.(2)

Aim

To determine the feasibility and perceptions of a community pharmacist (CP)-led weight management programme (WMP), enhanced by a Facebook support group (FSG).

Methods

A proof of concept study was conducted between January-March 2020. Recruitment was via a pharmacy, the university and a community Facebook group. Inclusion criteria: over 18 years; overweight; no medical conditions. Participants attended face-to-face meetings (ftf) with a CP and final year pharmacy student (PS) on two occasions (0 (baseline) and 4 weeks). At baseline, participants were given the NHS weight loss programme and set weight loss goals. During ftf, participants had height, weight, and waist circumference (WC) measurements by a CP/PS and discussed eating habits, exercise and alcohol. In between ftf, participants accessed the FSG (created (December 2019) and moderated by a CP). Here, they received posts about diet, exercise and motivation. Participants were to have their measurements taken ftf at 8-weeks, however, COVID-19 meant participants had to self-declare these via video call. Following the 8-week programme, participants completed a 4-section survey about their experience (signing up to the service; comparison to previous weight loss attempts; the FSG and overall perceptions). Question types included multiple choice, Likert scale and free text comments. Data were analysed in Excel (Microsoft Corporation 2016) with changes in height, weight, waist circumference, alcohol and exercise being calculated.

Results

Fifty-five participants were recruited. 18 were lost to follow-up, most (n=12/18) citing COVID-19. Of the 37 participants remaining (70.3% female, mean age=37 years), 22 were obese, the rest overweight. Mean weight loss, mean percentage weight loss and mean WC reduction at 4-weeks was 1.6 kg (SD+/- 1.7 kg), 1.8% (SD+/- 1.9%) and 2 cm (SD+/- 1.96 cm) respectively. At week 8 measurements were self-declared. Mean weight loss at 8-weeks from baseline was 2.7 kg (SD +/- 2.6 kg) and mean percentage weight loss was 3% (SD+/- 3%). Only five participants’ self-declared WC measurements at 8-weeks with mean reduction being 3.6 cm. Five participants moved to healthier BMI classifications by week 8. All participants accessed the FSG at least weekly with 13 accessing it daily. Diet posts were the most popular (n=20/37). Participants learned about portion control and increasing fruits/vegetables intake. All participants would recommend the programme to their friends/family.

Conclusion

An 8-week CPWMP, enhanced with FSG, supported participants to lose a mean of 3% body weight. Participants accessed the page regularly and were positive about its usefulness. One limitation was that the COVID-19 lockdown prevented the 8-week ftf, therefore, self-declared measurements were used. The pandemic has highlighted the importance of pharmacy embracing technology for service delivery, particularly when in-person contact is limited. The implication of this study is that it provides proof that the concept of digital service delivery could work in practice.

References

1. GOV.UK. Tackling obesity: empowering adults and children to live healthier lives [Internet]. Department of Health and Social Care. 2020 [cited 2020 Aug 18]. Available from: https://www.gov.uk/government/publications/tackling-obesity-government-strategy/tackling-obesity-empowering-adults-and-children-to-live-healthier-lives

2. Crilly P, Kayyali R. A Systematic Review of Randomized Controlled Trials of Telehealth and Digital Technology Use by Community Pharmacists to Improve Public Health. Pharmacy 2020;8(3):137. Available from: https://www.mdpi.com/2226–4787/8/3/137

Evaluation of sulfadimidine, amprolium and triquen to treat coccidiosis in wild pigeons

Coccidiosis remains one of the major problems in poultry all over the world. Very limited data on anticoccidial drugs in wild pigeons is available. The current study was aimed to understand the comparative efficacy of sulfadimidine, amprolium and triquen in wild pigeons of Dir district, Pakistan suffering from coccidiosis. The faecal matter of wild pigeons were purchased from the local market for coccidian infection. Results revealed that 88.8% (16/18) were found infected with Eimeria spp. Three positive groups were treated with sulfadimidine (0.2mg/L), amprolium (25mg/L) and triquen. Sulfadimidine was most effective (45%) followed by amprolium (44.6%) while triquen (24.0%) showed less effectiveness against coccidiosis in pigeons. Number of oocysts were 79, 81 and 80 before treatment and 60, 44 and 44 after treatment with sulfadimidine, amprolium and triquen respectively. This study showed that sulphadimidine, amprolium and triquen could not significantly reduce the coccidiosis in pigeons. Further studies are required to clear the mechanism of anti-coccidial drugs in wild pigeons.

Morphometrics of the indian false vampire bat (Megaderma lyra) from district Jhelum, Pakistan

During the present study thirteen Megaderma lyra bats were observed roosting in dark, domed shaped room of Rohtas Fort, district Jhelum. Out of these, six specimens were captured from the roosting site, using hand net. All captured specimens were male. These bats were identified through their unique facial features, an erect and elongated nose-leaf, large oval ears that joined above the forehead and no tail. Mean head and body length of captured specimens was 80 mm, forearm length was 67 mm while average lengths of 3rd, 4th and 5th metacarpals were 51.73 mm, 55.17 mm and 60.42 mm, respectively. Mean skull length was 29.84 mm, breadth of braincase was 12.77 mm. Average Penis length of two specimens was 6.6 mm and total bacular length was 3.08 mm respectively. This is the first record of Megaderma lyra from district Jhelum.

Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate?

BACKGROUND AND AIMS

Approximately 75% of patients admitted with small bowel obstruction have intra-abdominal adhesions as their cause (adhesive small bowel obstruction). Up to 70% of adhesive small bowel obstruction cases, in the absence of strangulation and bowel ischemia, can be successfully treated with conservative management. However, emerging evidence shows that surgery performed early during the first episode of adhesive small bowel obstruction is highly effective. The objective of this narrative review is to summarize the current evidence on adhesive small bowel obstruction management strategies.

MATERIALS AND METHODS

A review of the literature published over the last 20 years was performed to assess Who, hoW, Why, When, What, and Where diagnose and operate on patients with adhesive small bowel obstruction.

RESULTS

Adequate patient selection through physical examination and computed tomography is the key factor of the entire management strategy, as failure to detect patients with strangulated adhesive small bowel obstruction and bowel ischemia is associated with significant morbidity and mortality. The indication for surgical exploration is usually defined as a failure to pass contrast into the ascending colon within 8-24 h. However, operative management with early adhesiolysis, defined as operative intervention on either the calendar day of admission or the calendar day after admission, has recently shown to be associated with an overall long-term survival benefit compared to conservative management. Regarding the surgical technique, laparoscopy should be used only in selected patients with an anticipated single obstructing band, and there should be a low threshold for conversion to an open procedure in cases of high risk of bowel injuries.

CONCLUSION

Although most adhesive small bowel obstruction patients without suspicion of bowel strangulation or gangrene are currently managed nonoperatively, the long-term outcomes following this approach need to be analyzed in a more exhaustive way, as surgery performed early during the first episode of adhesive small bowel obstruction has shown to be highly effective, with a lower rate of recurrence.

Inhibition of soluble epoxide hydrolase offers protection against fructose-induced diabetes and related metabolic complications in rats

Stabilization of epoxyeicosatrienoic acids (EETs) levels via soluble epoxide hydrolase (sEH) deletion or its pharmacological inhibition have been shown to have beneficial effects on inflammation, ischemia, hypertension and diabetes. Owing to the diverse role of EETs, current study was designed to evaluate the therapeutic potential of 1-trifluoromethoxyphenyl-3-(1-propionylpiperidine-4-yl) urea (TPPU), a novel sEHI against fructose-induced diabetes and related complications in rats. Sprague-Dawley rats (200 - 230 g) were divided into four different groups, each containing 10 animals. One group served as a normal control and received standard diet and drinking water. The second group served as a diseased control and received standard diet, 25% fructose in drinking water and was treated with vehicle only. The third and fourth groups received standard diet, 25% fructose in drinking water and TPPU (2 mg/kg) or metformin (150 mg/kg), respectively. All treatments were given orally for 12 weeks. At the end of the study, blood samples were collected to measure serum insulin levels and other biochemical parameters. Animals were dissected to collect tissue specimens for histological and immunohistochemistry analysis. Animals fed on fructose and treated with vehicle demonstrated elevated blood insulin and glucose levels as well as high levels (P < 0.001) of triglycerides (TGs), cholesterol, low-density lipoprotein (LDL) and homeostatic model assessment of insulin resistance (HOMA-IR) compared to naive rats. Similarly, the levels of alkaline phosphatase (ALP), alanine aminotransferase (ALT), urea and uric acid were significantly (P < 0.001) increased in vehicle treated fructose fed animals. TPPU (2 mg/kg p.o.) and simultaneously fed on fructose for 12 weeks substantially decreased HOMA-IR levels, lowered blood glucose, serum cholesterol, LDLs and TGs) while high-density lipoproteins (HDL) levels were increased compared to untreated animals. Metformin, a standard reference drug showed similar results. Microscopic studies of liver and pancreatic sections of TPPU treated animals showed marked improvement in cellular architecture compared to untreated animals. Current study demonstrated profound therapeutic potential of TPPU against fructose induced-diabetes and related metabolic complications which was evident by its attenuating effect fructose-induced hyperglycemia, hyperlipidemia and impaired renal and hepatic serum markers.

Long-term follow-up of thoracoscopic ablation for long-standing persistent atrial fibrillation

Background

Catheter ablation in patients with long-standing persistent AF (LSPAF) remains challenging and often requires repeated procedures with variable results. We report long-term outcomes of a bipolar thoracoscopic pulmonary vein and left atrial posterior wall ablation for LSPAF, and compare continuous and interval rhythm monitoring.

Methods

Seventy-seven LSPAF patients who underwent thoracoscopic pulmonary vein and box isolation between 2009–2017 in two Dutch centers were included. Follow-up consisted of continuous rhythm monitoring using an implanted loop recorder or 24-h Holter at 3/6/12/24/60 months.

Results

Mean age was 59±8 years with a median AF duration of 3.8 [1.2–6.3] years. In the total cohort, at 2-year follow-up, 86.0% of patients were in sinus rhythm, 12.3% were in paroxysmal AF and 1.6% in persistent AF. At 5 years, 62.9% of patients were in sinus rhythm, 20.0% in paroxysmal AF, 14.3% in persistent AF and 2.9% was experiencing atrial flutter. Continuous rhythm monitoring was performed in 46% of patients. Comparing continuous and interval rhythm monitoring, freedom from any atrial arrhythmia episode at 2- and 5 years was 60.0% and 49.9% in the continuous group and 93.8% and 51.9% in the interval monitoring group, respectively (p=0.02, Breslow-Wilcoxon test). In patients with continuous rhythm monitoring the mean atrial arrhythmia burden was reduced from 99.1% preoperatively to 0.1% at the end of the blanking period and 7.3% at 2-year follow-up.

Conclusions

Thoracoscopic box ablation is highly effective in restoring sinus rhythm at medium term follow-up. However, it is not a curative treatment as demonstrated by the 50% arrhythmia-free survival at long-term follow-up. Whether this is due to the progressive nature of AF needs further investigation. Continuous rhythm monitoring shows earlier recurrence detection with a potential early treatment adaptation.

Funding Acknowledgement

Type of funding source: None

Introducing new and repurposed TB drugs: the endTB experience

In 2015, the initiative Expand New Drug Markets for TB (endTB) began, with the objective of reducing barriers to access to the new and repurposed TB drugs. Here we describe the major implementation challenges encountered in 17 endTB countries. We provide insights on how national TB programmes and other stakeholders can scale-up the programmatic use of new and repurposed TB drugs, while building scientific evidence about their safety and efficacy. For any new drug or diagnostic, multiple market barriers can slow the pace of scale-up. During 2015-2019, endTB was successful in increasing the number of patients receiving new and repurposed TB drugs in 17 countries. The endTB experience has many lessons, which are relevant to country level introduction of new TB drugs, as well as non-TB drugs and diagnostics. For example: the importation of TB drugs is possible even in the absence of registration; emphasis on good clinical monitoring is more important than pharmacovigilance reporting; national guidelines and expert committees can both facilitate and hinder innovative practice; clinicians use new and repurposed TB drugs when they are available; data collection to generate scientific evidence requires financial and human resources; pilot projects can drive national scale-up.