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