Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

Navigating SARS-CoV-2-related immunopathology in Crohn's disease: from molecular mechanisms to therapeutic challenges

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) not only posed major health and economic burdens to international societies but also threatens patients with comorbidities and underlying autoimmune disorders, including Crohn's disease (CD) patients. As the vaccinated population is gradually relieved from the stress of the latest omicron variant of SARS-CoV-2 due to competent immune responses, the anxiety of CD patients, especially those on immunosuppressive treatment, has not subsided. Whether the use of immunosuppressants for remission of CD outweighs the potential risk of severe coronavirus disease 2019 (COVID-19) has long been discussed. Thus, for the best benefit of CD patients, our primary goal in this study was to navigate the clinical management of CD during the COVID pandemic. Herein, we summarized COVID-19 outcomes of CD patients treated with immunosuppressive agents from multiple cohort studies and also investigated possible mechanisms of how SARS-CoV-2 impacts the host immunity with special consideration of CD patients. We first looked into the SARS-CoV-2-related immunopathology, including lymphocytopenia, T-cell exhaustion, cytokine storms, and their possible molecular interactions, and then focused on mechanistic actions of gastrointestinal systems, including interruption of tryptophan absorption, development of dysbiosis, and consequent local and systemic inflammation. Given challenges in managing CD, we summarized up-to-date clinical and molecular evidence to help physicians adjust therapeutic strategies to achieve the best clinical outcomes for CD patients.

Evaluation of a Military Global Health Engagement Mission for Critical Wartime Surgical Specialty Readiness

INTRODUCTION

Surgical volume at Military Treatment Facilities (MTFs) has been gradually decreasing for roughly the past 2 decades. The Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program linked surgical volume and readiness using a tool known as the KSA metric. However, the extent to which military medical missions contribute to the readiness of critical wartime specialties has not been evaluated using this metric.

METHODS

In this study, a retrospective analysis was conducted using the surgical case logs from the US Naval Ship (USNS) Comfort missions in 2018 and 2019. The comprehensive case log data were categorized by year, surgeon, procedure, and location. The analysis focused on providing detailed descriptive statistics, including percentages pertaining to the types of procedures performed during these missions. The 2018 mission was 11 weeks in duration, and supported activities in Ecuador, Peru, Colombia, and Honduras. The USNS Comfort mission in 2019 lasted 6 months (June-November 2019), and visited 12 countries in Central America, South America, and the Caribbean.

RESULTS

The 2019 mission case log, spanning 6 months, was evaluated using the KSA score in order to assess readiness and compare against 6 months of MTF KSA values within the same calendar year. In 2019, the orthopedic surgeon aboard the USNS Comfort had a total KSA score of 44,006, but the 6-month USNS Comfort mission only contributed 5,364 points (12% of the annual score). The general surgery practice aboard the USNS Comfort produced lower KSA scores compared to each surgeon's respective MTF practice (Table III). Analyzing the cases logged by general surgeons also highlights minimal surgical diversity during these missions, with more than 90% of cases being hernia repairs or laparoscopic cholecystectomies (Table I). In addition, 35% of total procedures performed in 2018 and 2019 were performed laparoscopically.

CONCLUSIONS

The analysis of operative data from the 2019 USNS Comfort mission, in comparison with the surgeons' work at their respective MTFs, reveals limited benefit in the ability of hospital-ship missions to bolster surgical readiness as measured by the KSA score. However, this is not a reflection on the value of Global Health Engagement (GHE) itself but a review of the way in which it is leveraged to support surgical readiness. Military surgeons participate in GHE as part of a larger strategy to strengthen relationships with partner nations, improve military medical force interoperability, and bolster partner nation medical capacity and capabilities. The KSA score offers an excellent tool to compare readiness metrics across significantly different GHE missions, and facilitates the opportunity for future prospective studies to improve case volume, diversity, and ultimately readiness.

Strategic Aeromedical Evacuations of the French Armed Forces in French Guiana From 2018 to 2020

INTRODUCTION

The French Armed Forces are deployed in French Guiana (FG) to protect national territory and ensure the security of strategically important sites. Military health support (MHS) provides medical support for missions in this tropical environment, which is hazardous and where confrontations are possible. MHS must organize tactical and strategic evacuations (Strat-AEs), so that an optimal level of care can be delivered. Overall, Strat-AE activity has been described previously but no specific data related to FG has been reported. The main objective of this study was to provide an overview of military Strat-AEs from FG.

METHODS

We conducted a retrospective cohort study from January 01, 2018 through 31 December, 2020. All patients who required a military Strat-AE were included, and we collected sociodemographic characteristics, medical information, service-related injuries and illnesses, and the reason for and conditions of evacuation.

RESULTS

We analyzed 210 patients and 199 were included. Most were noncommissioned members (63.3%) and belonged to the Army (75.4%) and the Gendarmerie (15.6%). Injury or illness was duty-related in 66.2% of patients. The main cause for evacuation was nonbattle injury (63.3%), followed by illness (27.1%). Battle stress and injury accounted for 9.5%. The main reasons for evacuation were surgical conditions (58.3%), particularly orthopedic (47.2%). Medical (22.1%), psychiatric (18.6%), and dental (1.0%) disorders followed. Most patients were categorized by the flight surgeon as P3 (98.5%), the lowest level of priority, and D4 (82.9%), the lowest level of dependency. The escort used during evacuation was identical to that recommended by the requester in 83.5% of cases. The final destination was mainly a hospital (89.9%). The time lag between injury or onset of illness and the request for evacuation was significantly longer when local health resources were insufficient.

CONCLUSION

The particularity of FG is a local health care system that provided initial care before the evacuation. To reduce the number of Strat-AEs in FG, the risk of nonbattle injury must be lessened and improvements must be made to the local health care system and to the partnership between civilian and military health services.

COVID-19 research response to immediate demands: setting priorities with key stakeholders to enable health services research in NSW, Australia

PURPOSE

COVID-19 has caused unprecedented disruption to health systems. There is much to be gained by capturing what was learned from changes and adaptations made by health services and systems. The Ministry of Health in New South Wales (NSW), Australia, sought to prioritise health services research (HSR) to address critical issues arising from the COVID-19 pandemic. We tested a priority setting methodology to create priorities for a specific funding opportunity and to extract generalisable lessons.

DESIGN/METHODOLOGY/APPROACH

A virtual roundtable meeting of key stakeholders was held in June 2020. We used a modified Nominal Group Technique (NGT) for priority setting, with potential items (n = 35) grouped under headings. Data was analysed through a reflective deliberative process.

FINDINGS

We engaged 89 senior policy makers, health service executives, clinicians and researchers in the roundtable. The NGT proved an efficient method with participants reaching consensus on eight priorities. Findings included strong support for learning from the rapid response to COVID-19 and addressing needs of vulnerable populations and the health workforce. Opinions differed about strategic areas investment and where learnings should be via internal evaluation rather than funded research. Three of the eight recommended priorities were included in the funding opportunity.

RESEARCH LIMITATIONS/IMPLICATIONS

Coronavirus disease 2019 (COVID-19) required unprecedented change and adaptations within health systems, and rapid, applied health services research can help to create, understand and (where relevant) sustain change beyond the immediate impact of the pandemic. While final decisions may be dependent on a wider range of considerations by government, stakeholder enthusiasm for engagement in priority setting exercises may be dampened if they do not perceive their application in decision-making.

PRACTICAL IMPLICATIONS

A modified nominal group technique can be used to set research priorities in constrained conditions by engaging large numbers of stakeholders in rankings and then using an online delivery of a roundtable and to reach consensus on priorities in real time. Recommended priorities for health services research can be readily generated through rapid engagement but does not guarantee their application.

SOCIAL IMPLICATIONS

Australia's swift response to COVID-19 pandemic in 2020 was perceived as a relative success due to the rapid public health and policy response and a relatively low number of cases. This response was underpinned by systematic knowledge mobilisation including support for targeted and prioritised health services research to fill knowledge gaps.

ORIGINALITY/VALUE

Setting priority processes can provide rich, engaged input to support government funding decisions about HSR. A wide range of dynamic and iterative processes influence decision-making in a rapidly evolving situation in the health system response to COVID-19. It is crucial to consider how major investment decisions will support a value-based healthcare system.

The Long Haul to Surgery: Long COVID Has Minimal Burden on Surgical Departments

Many patients infected with the SARS-CoV-2 virus (COVID-19) continue to experience symptoms for weeks to years as sequelae of the initial infection, referred to as "Long COVID". Although many studies have described the incidence and symptomatology of Long COVID, there are little data reporting the potential burden of Long COVID on surgical departments. A previously constructed database of survey respondents who tested positive for COVID-19 was queried, identifying patients reporting experiencing symptoms consistent with Long COVID. Additional chart review determined whether respondents had a surgical or non-routine invasive procedure on or following the date of survey completion. Outcomes from surgeries on patients reporting Long COVID symptoms were compared to those from asymptomatic patients. A total of 17.4% of respondents had surgery or a non-routine invasive procedure in the study period. A total of 48.8% of these patients reported experiencing symptoms consistent with Long COVID. No statistically significant differences in surgical outcomes were found between groups. The results of this analysis demonstrate that Long COVID does not appear to have created a significant burden of surgical disease processes on the healthcare system despite the wide range of chronic symptoms and increased healthcare utilization by this population. This knowledge can help guide surgical operational resource allocation as a result of the pandemic and its longer-term sequelae.

Nutritional support team intervention in surgical ICUs and its effect on nutrition delivery and quality in critically ill patients

RATIONAL

Critically ill surgical patients pose one of the greatest challenges in achieving nutritional goals. Several published papers have demonstrated clear benefits when nutrition support (NS) is managed by a multidisciplinary nutrition support team (NST). We hypothesized that implementing a NST in a surgical intensive care unit (ICU) would increase the number of patients achieving their nutritional goals.

MATERIAL AND METHOD

Multicenter "BEFORE & AFTER" study. In the BEFORE phase, an audit of the previous state of NS was conducted in three ICUs without a NST.

INTERVENTION

Implementation of a NST and protocol. In the AFTER phase, a new audit of NS was conducted. Continuous variables (presented as mean ± SD or median Q1-Q3) were tested using the t-test and Mann-Whitney U test. Categorical variables (presented as frequencies and percentages) were assessed using the chi-square test. A binomial logistic regression model was performed, with independent variables introduced using a stepwise forward method. A difference was considered to be significant with a two-sided P-value <0.05. Statistical analysis was conducted using IBM-SPSS 26.

RESULTS

A total of 83 patients were included in the BEFORE phase, and 85 in the AFTER phase. The latter group showed a higher frequency of nutritional risk and malnutrition (SGA B+C odds ratio 2.314, 95% CI 1.164-4.600). Laparoscopy was more frequently utilized as a surgical technique in the AFTER phase. No differences were observed in ICU and hospital LOS or 90 days' survival rates. Two variables remained independent factors to predict NS achievement: NST implementation (odds ratio 3.582, 95% CI 1.733-7.404), and surgical technique (odds ratio 3.231, 95% CI 1.312-7.959).

CONCLUSION

NST positively impacts the chance of achieving NS goals in critically ill surgical patients.

A Retrospective Analysis of Pinnaplasty Outcomes: The Welsh Experience

Prominent ears (PEs) are the most frequent congenital external ear deformity, occurring in ∼5% of the population. Although the deformity does not usually cause functional difficulties, it can significantly affect the patient's psychological and social health. The authors aim to present the Welsh experience of pinnaplasty, reviewing our outcomes and complications. A retrospective cross-sectional study was performed of all patients undergoing pinnaplasty in Morriston Hospital, Swansea, Wales. We represent the tertiary plastic surgery referral unit across Wales. We included all patients undergoing pinnaplasty between 2015 and 2022 inclusive. We excluded patients undergoing revision procedures or those who had no follow-up. Over the 7-year period, 236 pinnaplasties were performed and 203 were included in the analysis. Ninety-six percent of cases were performed using a cartilage-sparing approach, which represents the mainstay in our unit. The mean follow-up length for our cases was 12 months. Revision procedures were required in 4% of cases. Three hematomas (1.5%) and one (0.5%) wound dehiscence due to infection were recorded and required a return to the operating room. Suture extrusion was noted in 5% of cases (10 patients); 4.5% (9) cases were affected by either hypertrophic or keloid scarring. Across the United Kingdom, cosmetic procedures have come under scrutiny, namely, because of a difficult economic climate. In the era of tight fiscal control in health care, it is pertinent to analyze the outcomes and performance metrics of our operations regularly, thus aiding in the development of an established evidence base to advocate for our respective patients.

Impact of COVID-19 pandemic on adolescents undergoing metabolic bariatric surgery

BACKGROUND

While the lasting effect of the COVID-19 pandemic continues to unfold, the impact on adolescents undergoing bariatric surgery remains unseen.

OBJECTIVE

We examined the impact of the pandemic on adolescents undergoing metabolic bariatric surgery.

SETTING

Academic hospital, New York, NY.

METHODS

A single-institution review of prospectively collected data evaluated adolescents who underwent laparoscopic sleeve gastrectomy between 2010 and 2023, forming two cohorts: pre-COVID (before March 1, 2019) and COVID (after March 1, 2020). Absolute and percent weight loss and body mass index (BMI) change at 6 and 12 months postsurgery were compared between cohorts. Multivariable linear regression models were constructed to estimate the association between weight loss, adjusting for age, gender, ethnicity, and BMI.

RESULTS

A total of 358 patients were included: 245 in the pre-COVID cohort and 113 in the COVID cohort. There were no significant differences in baseline characteristics. There were no significant differences between cohorts at 6 months in weight loss (21.6 kg vs. 22.5 kg, P = .43), percent weight loss (18% vs. 18%, P = .63), and BMI change (8.0 vs. 8.4, P = .39) which was maintained at 12 months. In multivariate models, after adjusting for age, gender, ethnicity, and baseline BMI, undergoing surgery during the pandemic was not associated with a difference in weight loss or BMI change at 6 and 12 months postoperatively.

CONCLUSION

Despite the severe societal impact of the COVID-19 pandemic, laparoscopic sleeve gastrectomy remained a durable intervention for adolescent obesity, with no observed differences in weight loss in patients undergoing surgery during the pandemic compared to prepandemic.

Impact of the COVID-19 Pandemic on the Surgical Management of Head and Neck Non-Melanoma Skin Cancers in a Maxillofacial Center of Cluj-Napoca

Background: The COVID-19 era has been a bleak period for both cancer and non-cancer patients, with delayed non-emergency treatments, such as for non-melanoma skin cancer (NMSC). This study aimed to evaluate how the treatment of NMSC patients was influenced by the management of the COVID-19 pandemic in an Eastern European Maxillofacial Surgery center. Materials and Methods: A total of 176 patients with a histopathological diagnosis of head and neck NMSC who were surgically treated in Cluj-Napoca Emergency County Hospital between 2016 and 2022 were included in this study, and divided into two samples, pre-pandemic (2016-2019) and COVID-19 (2020-2022) periods. Results: The pandemic presented with a decrease of 46.15% in patients' hospitalization, with wealthy and educated patients being prevalent. Even if the waiting time for surgery was increased, the stage of cancer and preference method for reconstruction did not differ. Despite the lower addressability of NMSC patients during the pandemic, there were no changes in surgical treatment. Conclusions: During COVID-19, the number of patients was reduced, with a longer waiting time for surgery, but without any changes in tumor stage and treatment preferences. However, the benefit of removing a cancer tumor is higher compared to the risk of developing COVID-19 infection during hospitalization.

The role of videolaryngoscopy in cleft surgery: A single center comparative study before and during the COVID-19 pandemic

BACKGROUND

Cleft lip and palate (CLCP) surgeries necessitate precise airway management, especially in pediatric cases with anatomical variations. The Covid-19 pandemic posed unprecedented challenges to anesthesiology practices that required adaptations to ensure patient safety and minimize viral transmission. Videolaryngoscopy (VL) emerged as a valuable tool in airway management during the pandemic, offering improved intubation success rates and reduced aerosol generation risks.

METHODS

This retrospective study compared anesthesiology practices in CLCP surgeries before (2015-2019) and during the Covid-19 (2019-2022) pandemic at a tertiary care center. Patient demographics, anesthesia techniques, intubation difficulty, airway management, and intraoperative and postoperative follow-up were analyzed from anesthesia records.

RESULTS

This study included 1282 cases. Demographics were similar between periods. During the pandemic, there was a significant decrease in the number of patients under one year old (p < 0.001) and a higher prevalence of micrognathia and comorbidities (p = 0.001 and p = 0.038, respectively). Difficult intubation and intraoperative complication rates decreased during the pandemic, but they were not statistically significant. VL usage during the pandemic contributed to improved extubating success (p < 0.001).

CONCLUSIONS

VL usage and improved patient outcomes were observed during the pandemic, potentially due to proactive measures and infection control protocols. Decision-making processes for extubation and intensive care unit stay became crucial during the pandemic. Understanding the role of VL and its adaptations during the Covid-19 pandemic is vital for optimizing perioperative care in CLCP surgeries and other procedures requiring airway management. The findings highlight the resilience of healthcare systems and the importance of evidence-based practices under challenging circumstances.

The Use of Artificial Intelligence for Orthopedic Surgical Backlogs Such as the One Following the COVID-19 Pandemic: A Narrative Review

➤ The COVID-19 pandemic created a persistent surgical backlog in elective orthopedic surgeries. ➤ Artificial intelligence (AI) uses computer algorithms to solve problems and has potential as a powerful tool in health care. ➤ AI can help improve current and future orthopedic backlogs through enhancing surgical schedules, optimizing preoperative planning, and predicting postsurgical outcomes. ➤ AI may help manage existing waitlists and increase efficiency in orthopedic workflows.

The COVID-19 Pandemic and Routine Prenatal Care: Use of Online Visits

OBJECTIVE

To evaluate whether prenatal visits or screening/testing were fewer or occurred later during the initial phase of the COVID-19 pandemic in 2020 (CINT) as compared to the prior year (PreCINT).

METHODS

A retrospective cohort study compared CINT (n = 2,195) to PreCINT (n = 2,395) at seven public hospitals in New York City. The primary outcome was total number of prenatal-care visits. Secondary outcomes were components of prenatal-care visits completion, timing of standard pregnancy screening tests, and adverse neonatal outcomes.

RESULTS

CINT patients had more total prenatal-care visits (B = 1.30, 95% CI:1.04, 1.56, p < 0.001), lower odds for initiation of prenatal care which was inadequate according to widely used criteria (OR:0.39, 95% CI:0.34, 0.45, p < 0.001), and lower gestational age at initial visit (B=-4.51, 95% CI:-5.10, -3.93, p < 0.001) than PreCINT patients. In-person visits did not differ between the two groups. PreCINT patients had no televisits, while CINT patients had a median of one televisit (Median = 1, p < 0.001). CINT patients had increased odds for group B Streptococcus screening (OR:1.27, 95% CI: 1.10, 1.48, p = 0.001), quadrivalent screening (OR:1.30, 95% CI:1.15, 1.48, p < 0.001), and anatomy sonogram (OR:2.30, 95% CI:2.04, 2.59, p < 0.001) but decreased odds for glucose challenge test screening (OR:0.81, 95% CI:0.72, 0.91, p < 0.001). Adverse neonatal outcome did not differ between CINT and PreCINT pregnancies.

CONCLUSIONS FOR PRACTICE

Despite the difficulties and perceived dangers of in-person visits during the COVID-19 pandemic, the COVID-19 pandemic had little negative impact upon the outpatient prenatal care received by patients in this hospital system.

When should lockdown be implemented? Devising cost-effective strategies for managing epidemics amid vaccine uncertainty

During an infectious disease outbreak, public health policy makers are tasked with strategically implementing interventions whilst balancing competing objectives. To provide a quantitative framework that can be used to guide these decisions, it is helpful to devise a clear and specific objective function that can be evaluated to determine the optimal outbreak response. In this study, we have developed a mathematical modelling framework representing outbreaks of a novel emerging pathogen for which non-pharmaceutical interventions (NPIs) are imposed or removed based on thresholds for hospital occupancy. These thresholds are set at different levels to define four unique strategies for disease control. We illustrate that the optimal intervention strategy is contingent on the choice of objective function. Specifically, the optimal strategy depends on the extent to which policy makers prioritise reducing health costs due to infection over the costs associated with maintaining interventions. Motivated by the scenario early in the COVID-19 pandemic, we incorporate the development of a vaccine into our modelling framework and demonstrate that a policy maker's belief about when a vaccine will become available in future, and its eventual coverage (and/or effectiveness), affects the optimal strategy to adopt early in the outbreak. Furthermore, we show how uncertainty in these quantities can be accounted for when deciding which interventions to introduce. This research highlights the benefits of policy makers being explicit about the precise objectives of introducing interventions.

Does Covid-19 influence the dynamics of envenomation by animals in a country strongly affected by both conditions? Epidemiological data from Brazil

The impact of Covid-19 on envenomations by venomous animals in countries heavily affected by both conditions has not been quantified yet. Brazil shows high incidence of envenomations by scorpions, spiders and snakes and was heavily affected by waves of Covid-19. To determine how the pandemic impacted the epidemiology of envenomations by those three groups of venomous animals, we used online databases from two surveillance sources on number of cases and mortality. During the years before and during the pandemic, scorpion stings typically occurred in adults of both sexes in urban zones in the Southeast and Northeast regions. Spider bites occurred mainly in the South region, in adults of both sexes in urban zone. Snakebites affected mainly rural adult men in the Amazon. Between 2007 and 2021, overall incidence of cases by scorpions, spiders and snakes decreased after the beginning of the pandemic, snakebites did not show changes after the pandemic started in Brazil, but cases by scorpions and spiders decreased. No changes in the incidence of deaths were observed. On national level, Covid-19 affected some demographic, clinical and epidemiological aspects in cases by scorpions, spiders and snakes.

Ethical issues in the operating room: A scoping review

BACKGROUND

For the patients receiving care in the operating room, it emphasizes that the ethical behavior and attitude of health professionals should be aligned with patients' basic human rights. Surgical ethics may provide an ethical alternative in a specific operating room context. However, it is unclear how actively research is being conducted in this regard.

AIM

This study determines the direction of future research by identifying ethical issues experienced in the operating room.

METHOD

This scoping review is based on the methodological framework suggested by Arksey and O'Malley in 2005. PubMed, CINAHL, EMBASE, WOS, Cochrane, KISS, and KMbase databases were searched from January 2012 to May 2022. Two researchers independently screened the searched articles by reviewing the titles, abstracts, and full texts. Consequently, 19 studies were selected.

FINDINGS

Five categories were identified: Professional ethics, Organizational ethics, Patients' rights, Patient safety, and Allocating resources. The derived categories covered all the same content as the International Council of Nurses' (ICN) code of ethics, with the exception of one element, that is, global health.

CONCLUSIONS

This study highlights ethical issues in the operating theatre and emphasizes the need for individual and organizational strategies aligned with the ICN code of ethics. Future research should cover a wider range of issues, employ diverse perspectives and methodologies, and enhance ethical practices to improve understanding and ethical practices in the field.

Trends in cataract surgery and healthcare system response during the COVID-19 lockdown in Malaysia: Lessons to be learned

Background

Elective surgeries were suspended during the national lockdown in March 2020 to curb the spread of the COVID-19 pandemic in Malaysia. We sought to evaluate the impact of the lockdown on cataract surgeries and suggest lessons for future outbreaks.

Study design

We conducted an interrupted time series analysis to examine rates of cataract surgery before and during the lockdown.

Methods

We used national cataract surgical data between 2015 and 2021 from the Malaysian Cataract Surgery Registry. Segmented regression with a seasonally adjusted Poisson model was used for the analysis. Stratified analyses were performed to establish whether the effect of the lockdown on cataract surgeries varied by hospital designation, type of cataract service, sex, and age groups.

Results

Cataract surgeries began falling in March 2020 at the onset of the lockdown, reached a trough in April 2020, and subsequently increased but never recovered to pre-lockdown levels. Cataract surgical rates in December 2021 were still 43 % below the expected surgical volume, equivalent to 2513 lost cataract surgeries. There was no evidence of a differential effect of the lockdown between COVID-19 designated and non-COVID-19 designated hospitals. The relative decrease in cataract surgical rates appears to have been greatest in outreach services and in people 40 years and older.

Conclusions

The lockdown caused an immediate reduction in cataract surgical rates to nearly half of its baseline rate. Despite its gradual recovery, further delays remain to be expected should there be no redistribution or increase in resources to support backlogs and incoming new cases.

The impact of elective surgery postponement during COVID-19 on emergency bellwether procedures in a large tertiary centre in Singapore

The coronavirus disease 2019 (COVID-19) pandemic drove many healthcare systems worldwide to postpone elective surgery to increase healthcare capacity, manpower, and reduce infection risk to staff. The aim of this study was to assess the impact of an elective surgery postponement policy in response to the COVID-19 pandemic on surgical volumes and patient outcomes for three emergency bellwether procedures. A retrospective cohort study of patients who underwent any of the three emergency procedures [Caesarean section (CS), emergency laparotomy (EL), and open fracture (OF) fixation] between 1 January 2018 and 31 December 2021 was conducted using clinical and surgical data from electronic medical records. The volumes and outcomes of each surgery were compared across four time periods: pre-COVID (January 2018-January 2020), elective postponement (February-May 2020), recovery (June-November 2020), and postrecovery (December 2020-December 2021) using Kruskal-Wallis test and segmented negative binomial regression. There was a total of 3886, 1396, and 299 EL, CS, and OF, respectively. There was no change in weekly volumes of CS and OF fixations across the four time periods. However, the volume of EL increased by 47% [95% confidence interval: 26-71%, P = 9.13 × 10-7) and 52% (95% confidence interval: 25-85%, P = 3.80 × 10-5) in the recovery and postrecovery period, respectively. Outcomes did not worsen throughout the four time periods for all three procedures and some actually improved for EL from elective postponement onwards. Elective surgery postponement in the early COVID-19 pandemic did not affect volumes of emergency CS and OF fixations but led to an increase in volume for EL after the postponement without any worsening of outcomes.

Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management

OBJECTIVES

This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery.

METHODS

An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles.

RESULTS

Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination.

DISCUSSION

Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation.

CONCLUSION

Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

Examining nurses' understanding and knowledge about preparation for COVID-19 in Ardabil hospitals in Iran

AIMS

The purpose of this study was to evaluate the preparedness of Iranian nurses for potential pandemics.

BACKGROUND

Nurses play a critical role in managing pandemics. They require adequate training, proper equipment, and organizational support to be well-prepared.

METHODS

A descriptive cross-sectional study was conducted in Ardabil, Iran, from July to September 2023, involving 233 nurses from five hospitals. The number of nurses required for each hospital was calculated based on the proportion of nurses in each hospital. Data was collected through a paper-based form that included information about the participants' demographic characteristics and their level of pandemic preparedness in health services. The collected data was analyzed using descriptive statistics to determine the demographic characteristics and levels of pandemic preparedness. Pearson's test was also conducted to establish a relationship between different dimensions of pandemic preparedness.

RESULTS

Most participants relied on clinical measures and supported using human resources and environmental methods to curb the transmission of a pandemic. They felt assured in their ability to explain the preventive measures against the pandemic. However, fewer respondents had access to healthcare improvement programs, and only a few worked remotely from home.

CONCLUSIONS

According to our study, 90.1% of nurses believe hand washing is the most effective way to prevent spreading infections. Additionally, healthcare professionals can use various tools to respond to the pandemic, including screening for COVID-19 at work, health and wellness programs, telecommuting, COVID-19 Safe programs, social media, and posters. Nurses need continuous education in hand hygiene, health programs, remote work options, and pandemic-safe programs to control infections, reduce risks, and optimize patient care during the pandemic.

The continued financial effect of COVID: Increasing costs for non-elective major lower extremity amputations

Background

The COVID-19 pandemic necessitated changes in processes of care, which significantly impacted surgical care. This study evaluated the impact of these changes on patient outcomes and costs for non-elective major lower extremity amputations (LEA).

Methods

The 2019-2021 Florida Agency for Health Care Administration database was queried for adult patients who underwent non-elective major LEA. Per-patient inflation-adjusted costs were collected. Patient cohorts were established based on Florida COVID-19 mortality rates: COVID-heavy (CH) included nine months with the highest mortality, COVID-light (CL) included nine months with the lowest mortality, and pre-COVID (PC) included nine months before COVID (2019). Outcomes included in-hospital patient outcomes and hospitalization cost.

Results

6132 patients were included (1957 PC, 2104 CH, and 2071 CL). Compared to PC, there was increased patient acuity at presentation, but morbidity (31%), mortality (4%), and length of stay (median 12 [8-17] days) were unchanged during CH and CL. Additionally, costs significantly increased during the pandemic; median total cost rose 9%, room costs increased by 16%, ICU costs rose by 15%, and operating room costs rose by 15%. When COVID-positive patients were excluded, cost of care was still significantly higher during CH and CL.

Conclusions

Despite maintaining pre-pandemic standards, as evidenced by unchanged outcomes, the pandemic led to increased costs for patients undergoing non-elective major LEA. This was likely due to increased patient acuity, resource strain, and supply chain shortages during the pandemic.

Key message

While patient outcomes for non-elective major lower extremity amputations remained consistent during the COVID-19 pandemic, healthcare costs significantly increased, likely due to increased patient acuity and heightened pressures on resources and supply chains. These findings underscore the need for informed policy changes to mitigate the financial impact on patients and healthcare systems for future public health emergencies.

The impact of COVID-19 on surgical cases at a large quaternary referral hospital

Introduction

Coronavirus-19 (COVID) stressed healthcare systems by increasing hospital admissions and in-hospital mortality. The impact of COVID on surgical patients is unknown. The purpose of this study was to evaluate how the COVID pandemic affected surgical patients at a large quaternary referral hospital.

Methods

A retrospective review of patients undergoing surgical procedures was performed to evaluate patients undergoing surgery. The impact of COVID on surgical patients was divided into four timeframes based on government regulations: pre-COVID (January 1, 2020 to March 15, 2020), suspended (March 16, 2020 to May 4, 2020), backlogged cases (May 5, 2020 to June 14, 2020), and restoration (June 15, 2020 to September 30, 2020). Differences between patient characteristics and outcomes during these timeframes were evaluated.

Results

A total of 21,424 surgical cases were performed between January 1, 2020 and September 30, 2020. During the suspended timeframe (when all elective cases were cancelled), the percentage of surgeries increased in men (53.8% compared to 49.2% pre-COVID; P < 0.01), in Black and Hispanic patients (23.1% and 15.3%, respectively; P < 0.05), and in Medicaid and self-pay patients (16.3% compared to 9.9% pre-COVID; P < 0.01). All service lines experienced similar trends in overall case volume except obstetrics (constant), trauma, vascular, and thoracic (which increased during the suspended timeframe).

Conclusions

COVID-19 induced stresses in surgical patients, altering payor mix and impacting minority groups at a large quaternary referral hospital.

Impact of COVID-19 Pandemic on Utilization of Healthcare Services and Spending Patterns in Dubai, United Arab Emirates: A Cross-Sectional Study

BACKGROUND

The COVID-19 pandemic affected the utilization of healthcare services in many parts of the world. The response to the healthcare burden imposed by the COVID-19 pandemic was associated with ensuring the provision of optimum healthcare services. This study aimed to estimate the effect of the COVID-19 pandemic on health services utilization and spending patterns in Dubai, the UAE.

METHODS

This cross-sectional study used secondary data on healthcare utilization and spending to compare between 2019 and 2020. The data was extracted from the health insurance claims on the eClaimLink platform. Descriptive and inferential statistics were used to calculate the percent change of service utilization and spending and percentages of total claims by each encounter type across major diagnostic categories (MDCs).

RESULTS

In 2020, there was an overall reduction in outpatient visits and inpatient admissions of 27% and 21%, respectively, compared to 2019. Outpatient visits and prescriptions decreased across all the MDCs except mental and behavioral disorders, which showed an increase of 8% in outpatient visits and 29% in prescriptions. The admissions to the healthcare facilities were also reduced significantly across various MDCs, ranging from 10% to 44%. Similarly, a downward trend was seen in diagnostics for different MDCs. An increase in expenditure on diagnostics and drugs for neoplasm was reported, despite a corresponding decrease in outpatient and inpatient admissions for the same.

CONCLUSION

A significant decrease in overall healthcare utilization and corresponding healthcare spending, resulting from a decline in outpatient and inpatient volume in healthcare facilities at all the levels (hospitals, clinics, speciality centres), was reported during the pandemic. The impact of the pandemic on mental health was reported by this study, as it showed an upward trend in utilization and spending. For the neoplasms, although the utilization declined, the expenditure on diagnostics and drugs during each encounter increased significantly.

Cost-Effectiveness of Universal Asymptomatic Preoperative SARS-CoV-2 Polymerase Chain Reaction Screening: A Cost-Utility Analysis

BACKGROUND

An early report has shown the clinical benefit of the asymptomatic preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening test, and some clinical guidelines recommended this test. However, the cost-effectiveness of asymptomatic screening was not evaluated. We aimed to investigate the cost-effectiveness of universal preoperative screening of asymptomatic patients for SARS-CoV-2 using polymerase chain reaction (PCR) testing.

METHODS

We evaluated the cost-effectiveness of asymptomatic screening using a decision tree model from a payer perspective, assuming that the test-positive rate was 0.07% and the screening cost was 8500 Japanese yen (JPY) (approximately 7601 US dollars [USD]). The input parameter was derived from the available evidence reported in the literature. A willingness-to-pay threshold was set at 5 000 000 JPY/quality-adjusted life-year (QALY).

RESULTS

The incremental cost of 1 death averted was 74 469 236 JPY (approximately 566 048 USD) and 291 123 368 JPY/QALY (approximately 2 212 856 USD/QALY), which was above the 5 000 000 JPY/QALY willingness-to-pay threshold. The incremental cost-effectiveness ratio fell below 5 000 000 JPY/QALY only when the test-positive rate exceeded 0.739%. However, when the probability of developing a postoperative pulmonary complication among SARS-CoV-2-positive patients was below 0.22, asymptomatic screening was never cost-effective, regardless of how high the test-positive rate became.

CONCLUSIONS

Asymptomatic preoperative universal SARS-CoV-2 PCR screening is not cost-effective in the base case analysis. The cost-effectiveness mainly depends on the test-positive rate, the frequency of postoperative pulmonary complications, and the screening costs; however, no matter how high the test-positive rate, the cost-effectiveness is poor if the probability of developing postoperative pulmonary complications among patients positive for SARS-CoV-2 is sufficiently reduced.

National Cross-Sectional Epidemiological Analysis of the Impact of Pandemic COVID-19 on Vascular Procedures in Public Health System: 521,069 Procedures Over 4 Years

BACKGROUND

During the COVID-19 pandemic, there was a dramatic increase in healthcare demand. Resources were redirected to care patients with COVID-19. Therefore, surgical treatments were affected, including those of vascular diseases. There are no studies evaluating the whole impact of the COVID-19 pandemic, considering all types of vascular procedures, both elective and urgent, in a large country. The aim of the present study was to analyze the impact on all types of vascular procedures performed in Brazilian public hospitals during the COVID-19 pandemic.

METHODS

Cross-sectional population-based analysis of publicly available data referring to vascular procedures. Surgeries 2 years before the pandemic onset (2018-2019) and 2 years during pandemic (2020-2021) were included.

RESULTS

We observed a total of 521,069 procedures. Decrease was observed in elective abdominal aortic aneurysm repairs both open surgery (P = 0.001) and endovascular surgery (P < 0.001), emergency open abdominal repairs (P = 0.005), elective thoracic aortic aneurysm repairs (P = 0.007), elective open peripheral aneurysm repairs (P = 0.038), carotid endarterectomies (P < 0.001) and angioplasties (P = 0.001), open revascularizations for peripheral arterial disease (P < 0.001), surgical treatment of chronic venous disease (P < 0.001) and sympathectomies for hyperhidrosis (P < 0.001). However, there was an increase of lower limb amputations (P = 0.027) and vena cava filter placements (P = 0.005). There was a reduction of almost US$17 million in financial investments.

CONCLUSIONS

The reorganization of health systems led to a significant reduction in vascular procedures and decrease in financial investments. On the other hand, there was a significant increase in the number of lower limb amputations and vena cava filter placements.

COVID-19 Outbreak Impact on Cancer Multidisciplinary Team Meetings. A Multicenter French Experience

Multidisciplinary team meeting (MDT) became a standard of care in cancer management. The COVID-19 epidemic induced unprecedented pressure on the health system. The impact of this health crisis on MDTs held within a regional French health structures was analyzed. A decrease in the total number of records discussed in hematological, digestive, thoracic, gynecological and genitourinary MDTs was observed following the 1st wave of the COVID-19 pandemic. This decrease was generally maintained during the 2nd and 3rd wave. MDTs activity back in order from the 4th wave. The COVID-19 pandemic has challenged MDTs settings. The implementation of virtual technologies offers an opportunity to improve MDTs organization.

Postoperative thrombotic events following major surgery in patients with a history of COVID-19: a retrospective cohort analysis of commercially insured beneficiaries in the USA

PURPOSE

We sought to evaluate the synergistic risk of postoperative thrombosis in patients with a history of COVID-19 who undergo major surgery. Major surgery and SARS-CoV-2 infection are independently associated with an increased risk of thrombosis, but the magnitude of additional risk beyond surgery conferred by a COVID-19 history on the development of perioperative thrombotic events has not been clearly elucidated in the literature.

METHODS

We conducted a retrospective cohort study among commercially insured adults in the USA from March 2020 to June 2021 using the Optum Labs Data Warehouse (OLDW), a longitudinal, real-world data asset containing deidentified administrative claims and electronic health records. We compared patients with prior COVID-19 who underwent surgery with control individuals who underwent surgery without a COVID-19 history and with control individuals who did not undergo surgery with and without a COVID-19 history. We assessed the interaction of surgery and previous COVID-19 on perioperative thrombotic events (venous thromboembolism and major adverse cardiovascular events) within 90 days using multivariable logistic regression and interaction analysis.

RESULTS

Two million and two-hundred thousand eligible patients were identified from the OLDW. Patients in the surgical cohorts were older and more medically complex than nonsurgical population controls. After adjusting for confounders, only surgical exposure-not COVID-19 history-remained associated with perioperative thrombotic events (adjusted odds ratio [aOR], 4.07; 95% confidence interval [CI], 3.81 to 4.36). The multiplicative interaction term (aOR, 1.25; 95% CI, 0.96 to 1.61) and the synergy index (0.76; 95% CI, 0.56 to 1.04) suggest minimal effect modification of prior COVID-19 on surgery with regards to overall thrombotic risk.

CONCLUSIONS

We found no evidence of synergistic thrombotic risk from previous COVID-19 in patients who underwent selected major surgery relative to the baseline thrombotic risk from surgery alone.

Multi-institutional Analysis of Endoscopic Sellar Surgical Volumes During the COVID-19 Pandemic

OBJECTIVE

We sought to quantify trends in operative volumes and complications of endoscopic sellar surgery before and after the COVID-19 pandemic onset.

STUDY DESIGN

We performed a retrospective analysis.

SETTING

TriNetX database analysis.

METHODS

All adults undergoing neuroendoscopy for resection of pituitary tumor (Current Procedural Terminology code 62165) with diagnosis of benign/malignant neoplasm of pituitary gland (D35.2/C75.1) or benign/malignant neoplasm of craniopharyngeal duct (D35.3/C75.2) were included using the TriNetX database for 2 years before (pre-COVID group) and 2 years after (post-COVID group) February 17, 2020.

RESULTS

A total of 1238 patients in the pre-COVID group and 1186 patients in the post-COVID group were compared. Age, gender, and race were statistically similar between the groups (P > .05). Surgical volume decreased by 6% in the post-COVID group. In 2020 Q2, operative volume decreased by 19%, and in 2021 Q4 (peak COVID-19 caseload in the United States), operative volumes decreased by 29% compared to 2 years prior. Postoperative complications including meningitis (P = .49), cerebrospinal fluid leak (P = .36), visual field deficits (P = .07), postoperative pneumonia or respiratory failure (P = .42), and 30-day readmission rates (P = .89) were similar between the 2 groups.

CONCLUSION

Overall, endoscopic sellar surgery may continue to fluctuate with increased COVID-19 outbreaks. Patient outcomes do not appear to be worsened by decreased operative volumes or delays in nonurgent surgeries.

Access to Surgery for Endometrial Cancer Patients During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study

OBJECTIVES

To assess the impact of the COVID-19 pandemic on endometrial cancer stage and surgical treatment in Ontario, Canada.

METHODS

This descriptive study identified cases from January 1, 2017 to December 31, 2021 from endometrial cancer hysterectomy specimens in the Ontario Health-Cancer Care Ontario, ePath system. Endometrial biopsy records from January 1, 2016 to December 31, 2021 were matched to surgical specimens by provincial health card number. Time to surgery and surgical stage were compared before (2017-2019) and during (2020-2021) the COVID-19 pandemic.

RESULTS

There were 10 446 women treated with hysterectomy for endometrial cancer in Ontario from 2017-2021. In April and May 2020, corresponding with the provincial state of emergency, there was a 56% relative reduction in endometrial biopsies. Despite this 2-month reduction in endometrial biopsy volume, there was no change in surgical volume for endometrial cancer treatment. The median time from endometrial biopsy to surgery was 56 days (IQR 40, 80) during the pandemic (2020-2021) compared to 58 days (IQR 43, 82) prior to the pandemic (2017-2019) (P < 0.001). There was no upstaging of endometrial cancer during the COVID-19 pandemic.

CONCLUSIONS

The Ontario healthcare system continued to prioritize service delivery to endometrial cancer patients during the COVID-19 pandemic, despite the increase in virtual care and decrease in operating room time. There were no significant surgical delays or upstaging of endometrial cancer.

The Impact of the COVID-19 Pandemic on Reconstructive Surgery and Training Programs in Sub-Saharan Africa: A Cross-Sectional Survey

Background

In Sub-Saharan Africa, which already faces challenges due to a lack of surgeons and facilities, the COVID-19 pandemic could significantly disrupt surgical activities and training programs. "2nd Chance", a non-governmental organization providing training program to enhance local reconstructive surgery capacity in this region since 2015, could play a crucial role in addressing these issues. We aimed to investigate the impact of the COVID-19 on the activity of sub-Saharan African reconstructive surgeons collaborating with "2nd Chance" organization and evaluate its effect on the organization's training programs.

Methods

In the course of 2022, an online cross-sectional survey was conducted among reconstructive surgeons working in sub-Saharan African countries and collaborating with "2nd Chance". The survey consisted of 57 questions covering demographics, impacts of COVID-19 on personal life, clinical and training activities.

Results

Of 469 surgeons eligible for the study, 240 were included and 51 responded. The impact of COVID-19 was felt personally in terms of health and stress. Clinical activities were severely affected, with some reporting higher mortality due to surgical cancellations and delays. Regarding training, there was a shift from practical to theoretical learning, though overall impact was moderate. One-third of participants were able to attend "2nd Chance" workshops. Among the 17 planned workshops, 9 were successfully conducted, and 4 of them exclusively featured African trainers.

Conclusion

The COVID-19 pandemic had substantial consequences on reconstructive surgery in sub-Saharan Africa, impacting more clinical practices than training programs. Collaboration between African and European trainers proved essential during the pandemic. In future pandemics, South-South collaborations should be prioritized.

Optimizing Surgical Care Amidst COVID-19: A Scoping Review of Practices and Policies

BACKGROUND

The coronavirus disease (COVID-19) pandemic significantly disrupted surgical care worldwide, affecting different specialties in various ways. Lockdowns, surges in COVID-19 cases, and changes in hospital policies notably impacted patient attendance, management practices, and access to surgical services. This scoping review examines the adverse impacts of the COVID-19 pandemic on surgical services and the policies adopted to address these care barriers.

METHODS

We conducted a comprehensive literature review using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Our search, spanning 31 December 2019, to 29 January 2023, focused on understanding the multifaceted impacts of COVID-19 on surgical services, particularly across different specialties.

RESULTS

An analysis of 75 articles indicated that the pandemic challenged surgeons worldwide to maintain a balance between delivering emergency and elective surgical care, and implementing safety measures against viral transmission. There was a marked decline in the surgical volume, leading to extended waitlists and decreased operating theater usage. Strategies such as prioritizing medically necessary and time-sensitive surgeries and integrating telemedicine have emerged as pivotal for ensuring the continuity of urgent care. Despite the reduced rates, essential surgeries such as appendectomies and cancer-related operations continued, yet faced hurdles, including reduced staffing, limited operating theater capacity, and complications in patient transfers.

CONCLUSIONS

This review emphasizes the steep reduction in surgical service utilization at the beginning of the pandemic and emergence of new compounded barriers. Policies that designated surgeries as essential, and focused on equitable and timely access, were effective. Incorporating these findings into post-pandemic assessments and future planning is crucial to sustain adequate surgical care during similar health emergencies.

Long- and Short-Term Trends in Outpatient Attendance by Speciality in Japan: A Joinpoint Regression Analysis in the Context of the COVID-19 Pandemic

The COVID-19 pandemic resulted in a decline in outpatient attendance. Therefore, this study aimed to clarify long- and short-term clinic attendance trends by speciality in Japan between 2009 and 2021. A retrospective observational study of Japan's claims between 2009 and 2021 was conducted using the Estimated Medical Expenses Database. The number of monthly outpatient claims in clinics was used as a proxy indicator for monthly outpatient attendance, and specialities were categorised into internal medicine, paediatrics, surgery, orthopaedics, dermatology, obstetrics and gynaecology, ophthalmology, otolaryngology, and dentistry. The annually summarised age-standardised proportions and the percentage of change were calculated. Joinpoint regression analysis was used to evaluate long-term secular trends. The data set included 4,975,464,894 outpatient claims. A long-term statistically significant decrease was observed in outpatient attendance in internal medicine, paediatrics, surgery, ophthalmology, and otolaryngology during the pandemic. From March 2020 to December 2021, which includes the COVID-19 pandemic period, outpatient attendance in paediatrics, surgery, and otolaryngology decreased in all months compared with that of the corresponding months in 2019. For some specialities, the impact of the pandemic was substantial, even in the context of long-term trends. Speciality-specific preparedness is required to ensure essential outpatient services in future public health emergencies.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Nonelective coronary artery bypass graft outcomes are adversely impacted by Coronavirus disease 2019 infection, but not altered processes of care: A National COVID Cohort Collaborative and National Surgery Quality Improvement Program analysis

Objective

The effects of Coronavirus disease 2019 (COVID-19) infection and altered processes of care on nonelective coronary artery bypass grafting (CABG) outcomes remain unknown. We hypothesized that patients with COVID-19 infection would have longer hospital lengths of stay and greater mortality compared with COVID-negative patients, but that these outcomes would not differ between COVID-negative and pre-COVID controls.

Methods

The National COVID Cohort Collaborative 2020-2022 was queried for adult patients undergoing CABG. Patients were divided into COVID-negative, COVID-active, and COVID-convalescent groups. Pre-COVID control patients were drawn from the National Surgical Quality Improvement Program database. Adjusted analysis of the 3 COVID groups was performed via generalized linear models.

Results

A total of 17,293 patients underwent nonelective CABG, including 16,252 COVID-negative, 127 COVID-active, 367 COVID-convalescent, and 2254 pre-COVID patients. Compared to pre-COVID patients, COVID-negative patients had no difference in mortality, whereas COVID-active patients experienced increased mortality. Mortality and pneumonia were higher in COVID-active patients compared to COVID-negative and COVID-convalescent patients. Adjusted analysis demonstrated that COVID-active patients had higher in-hospital mortality, 30- and 90-day mortality, and pneumonia compared to COVID-negative patients. COVID-convalescent patients had a shorter length of stay but a higher rate of renal impairment.

Conclusions

Traditional care processes were altered during the COVID-19 pandemic. Our data show that nonelective CABG in patients with active COVID-19 is associated with significantly increased rates of mortality and pneumonia. The equivalent mortality in COVID-negative and pre-COVID patients suggests that pandemic-associated changes in processes of care did not impact CABG outcomes. Additional research into optimal timing of CABG after COVID infection is warranted.

Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries

BACKGROUND

The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC).

METHODS

In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing.

FINDINGS

Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement.

INTERPRETATION

Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC.

FUNDING

Bill & Melinda Gates Foundation.

Impact of Covid-19 Pandemic on the Utilization and Delivery of Healthcare Services among Outpatients during the Early Phase of the Pandemic in Nigeria

During the early phase of the COVID-19 pandemic, some infection control measures were implemented to keep people safe and control the spread of the virus. These measures however were observed to cause significant delay or interruption in the delivery and utilization of healthcare services. The purpose of this study was to determine the impact of the COVID-19 pandemic on the utilization and delivery of healthcare services by outpatients in Nigeria during the early phase of the pandemic. A retrospective cross-sectional study design was utilized. We sampled 373 outpatients who had received healthcare services before and during the pandemic in the University College Hospital, Ibadan using convenience sampling. Descriptive and inferential statistics (t-test) were carried out and the level of significance was set as P<0.05. Healthcare utilization was significantly impacted by the pandemic as there was a reduction in hospital visits by patients during the pandemic (P<0.0003). Restriction of movement and fear of contracting the virus was identified as reasons for the reduction in healthcare services utilization in about 59% of the participants. Patients rated the quality healthcare services delivered to them as 'average' during the pandemic as opposed to 'good' before the pandemic. The findings of this study showed that the COVID-19 pandemic had a significant impact on patients' utilization of healthcare services as well as the delivery of adequate healthcare services in the hospital during the early phases of the pandemic. Therefore, we recommend that efforts be made to improve hospitals and nationwide preparedness for future pandemics to prevent healthcare interference and delay.

A Novel Low-Cost, Open-Source, Three-Dimensionally Printed Thyroplasty Simulator

OBJECTIVE

Training of surgical procedures on awake patients, such as medialization thyroplasty, poses challenges to educators and trainees. Three-dimensionally (3D)-printed simulators provide opportunity to practice in low-stakes settings. We present the first 3D-printed thyroplasty simulator incorporating a cartilaginous framework, endolaryngeal soft tissue housed in a 3D-printed manikin with endoscopic visualization.

METHODS

Male and female laryngeal cartilages and endolarynx molds were 3D printed from an existing open-source design. Cartilage models were made of heat-treated polylactic acid (HTPLA), a material chosen for its thermal stability, allowing drilling. They were combined with molded silicone endolarynges modeling glottic insufficiency. Larynges were set in a 3D-printed head-and-neck manikin with an attached borescope for internal visualization similar to distal chip laryngoscopy. Eight laryngologists evaluated the simulator by drilling a thyroplasty window, inserting an implant for medialization, and rating the model using a modified Michigan Standard Simulation Experience Scale (1 = strongly disagree, 5 = strongly agree).

RESULTS

The model was well rated in educational value (mean 4.7, standard deviation [SD] 0.3), fidelity (mean 3.8, SD 0.2), and overall value (mean 4.8, SD 0.5). Qualitative assessment concluded the model was anatomically realistic and that HTPLA was a good approximation of the density and texture of thyroid cartilage. The materials for one larynx cost $4.09.

CONCLUSION

This high-fidelity 3D-printed simulator demonstrates educational value for thyroplasty training. The low-cost, open-source design has broad implications for universal access to this simulator platform.

Eco-Friendly and COVID-19 Friendly? Decreasing the Carbon Footprint of the Operating Room in the COVID-19 Era

Surgery is one of the most energy-intensive branches of healthcare. Although the COVID-19 pandemic has reduced surgical volumes, infection control protocols have increased the ecological footprint of surgery owing to the extensive use of personal protective equipment, sanitation, testing and isolation resources. The burden of environmental diseases requiring surgical care, the international commitment towards environmental sustainability and the global efforts to return to the pre-pandemic surgical workflow call for action towards climate-friendly surgery. The authors have searched the peer-reviewed and gray literature for clinical studies, reports and guidelines related to the ecological footprint of surgical care and the available solutions and frameworks to reduce it. Numerous studies concede that surgery is associated with a high rate of energy utilization and waste generation that is comparable to major non-medical sources of pollution. Recommendations and research questions outlining environmentally sustainable models of surgical practices span from sanitation and air quality improvement systems to the allocation of non-recyclable consumables and energy-efficient surgical planning. The latter are particularly relevant to infection control protocols for COVID-19. Paving the way towards climate-friendly surgery is a worthy endeavor with a major potential to improve surgical practice and outcomes in the long term.

COVID-19 Diagnosis in Patients With Acute Abdominal Pain Without Respiratory Symptoms: A UK Emergency General Surgical Unit Experience

BACKGROUND

Recent evidence has emerged reporting atypical clinical symptoms of the novel coronavirus (COVID-19). There is a sparsity of existing studies examining COVID-19-related abdominal pain and the role of investigative imaging for the virus in these patients. Study aims were to determine COVID-19 incidence in those with acute abdominal pain in the absence of respiratory symptoms and to assess the diagnostic performance of CT thoracic imaging in such patients.

METHODS

Retrospective analysis of all consecutive patients admitted to our emergency general surgical unit between 1st March 2020 and 31st May 2020 was performed. In adherence with national guidelines, all patients underwent nasal and oro-pharyngeal COVID-19 RT-PCR swabs as well as thoracic and abdominal computed tomography (CT) on admission.

RESULTS

From 112 patients admitted with acute abdominal pain in the absence of respiratory symptoms, 16 (14.3%) tested positive for COVID-19 on RT-PCR swab testing. Overall, 50% (8/16) of these patients had no intra-abdominal pathology on CT. The sensitivity and specificity of CT thoracic imaging for diagnosing COVID-19 was 43.8% and 91.7%, respectively. Patients with positive COVID-19 swabs had higher C-reactive protein levels, lower potassium levels and a higher proportion of those with a low lymphocyte count.

DISCUSSION

One in seven patients with abdominal pain without any respiratory symptoms tested positive for COVID-19. Half of these patients represented COVID-19 manifesting primarily as acute abdominal pain. Combined swab testing and CT imaging should be performed in all abdominal pain presentations due to the varying diagnostic performance of thoracic CT in diagnosing COVID-19.

The impact of COVID-19 pandemic on free tissue transfer outcomes: A NSQIP analysis

BACKGROUND

The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures.

METHODS

Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016-2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha < 0.05.

RESULTS

When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic.

CONCLUSION

Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure.

PLANNING TO 'NEW NORMAL' DURING COVID-19 PANDEMIC AT GENERAL SURGERY DEPARTMENT: A TURKEY EXPERIENCE

Planning of non-postponable treatments for cancer, trauma, emergency diseases, and follow-up and treatment of chronic diseases are inevitable for the ongoing pandemic and future pandemics. In this study, we evaluated the capacity of surgical applications and treatments made to the surgery department in the first 3 months of the onset of the COVID-19 pandemic. A retrospective cohort study was performed from March 12, 2020 to June 1, 2020. COVID-19 negative general surgery patients were included. Demographics, diagnosis and management were recorded, as well as bed turnover and length of stay in the hospital. Similar data were collected on patients admitted during the same period in 2019 and 2018 to allow for comparison. A total of 1764 operations were included. There was a reduction in surgeries when comparing 2020 with 2019 and 2018 (164 vs. 713 and 890); however, there was no difference in the length of stay in the hospital (4.12 vs. 4.37 and 4.07 days, p=0.626). During 2020, appendectomies decreased (53 vs. 102 and 100, p=0.013). There was no difference in the number of emergency oncologic surgeries during 2020 as compared with 2019 and 2018 (16 vs. 8 and 13, p=0.149). In conclusion, COVID-19 significantly impacted the number of admissions to general surgery. However, cancer and emergency operations continued to be required, thus provisions need to be made to enable planning these interventions.

Tele-mentoring - a way to expand laparoscopic simulator training for medical students over large distances: a prospective randomized pilot study

BACKGROUND

Studies have shown the clinical benefits of laparoscopic simulator training. Decreasing numbers of operations by surgical residents have further increased the need for surgical simulator training. However, many surgical simulators in Sweden are often insufficiently used or not used at all. Furthermore, large geographical distances make access to curriculum-based surgical simulator training at established simulator centres difficult. The aim of this study was to evaluate whether tele-mentoring (TM) could be well tolerated and improve basic laparoscopic surgical skills of medical students 900 km away from the teacher.

METHODS

Twenty students completed an informed consent and a pre-experimental questionnaire. The students were randomized into two groups: (1) TM (N = 10), receiving instructor feedback via video-link and (2) control group (CG, N = 10) with lone practice. Initial warm-up occurred in the Simball Box simulator with one Rope Race task followed by five consecutive Rope Race and three Peg Picker tasks. Afterwards, all students completed a second questionnaire.

RESULTS

The whole group enjoyed the simulator training (prescore 73.3% versus postscore 89.2%, P < 0.0001). With TM, the simulator Rope Race overall score increased (prescore 30.8% versus postscore 43.4%; P = 0.004), and the distance that the laparoscopic instruments moved decreased by 40% (P = 0.015), indicating better precision, whereas in the CG it did not. In Peg Picker, the overall scores increased, whereas total time and distance of the instruments decreased in both groups, indicating better performance and precision.

CONCLUSIONS

Simulation training was highly appreciated overall. The TM group showed better overall performance with increased precision in what we believe to be the visuospatially more demanding Rope Race tasks compared to the CG. We suggest that surgical simulator tele-mentoring over long distances could be a viable way to both motivate and increase laparoscopic basic skills training in the future.

Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration)

Context

The COVID-19 pandemic and subsequent lockdowns adversely affected global healthcare services to varying extents. To accommodate its added burden, emergency services were affected along-with elective surgeries.

Aims

To quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the pandemic, across various hospitals in India.

Settings and Design

Multi-centric retrospective study.

Methods and Material

A research consortium led by World Health Organization (WHO) Collaboration Center (WHOCC) for Research in Surgical Care Delivery in Low-and Middle-Income countries, India, conducted this study with 5 centers. All surgeries performed during April 2020 (Wave I), November 2020 (Recovery I), and April 2021 (Wave II) were compared with those performed in April 2019 (pre-pandemic period).

Statistical Analysis Used

Microsoft Excel 2019 and SPSS Version 20.

Results

The total number of surgeries reduced by 77% during Wave I, which improved to a 52% reduction in Recovery I compared to the pre-pandemic period. However, surgeries were reduced again during Wave II to 68%, but the reduction was less compared to Wave I. Emergency and essential surgeries were affected along with the elective ones but to a lesser extent.

Conclusions

The present study has quantified the effects of the pandemic on surgical-care delivery across a timeline and documented a reduction in overall surgical volumes during the peaks of the pandemic (Wave I and II) with minimal improvement as the surge of COVID-19 cases declined (Recovery II). The surgical volumes improved during the second wave compared to the first one which may be attributable to better preparedness. Cesarean sections were affected the least.

P, Venugopal B. Resilience of hospital and allied infrastructure during pandemic and post pandemic periods for maternal health care of pregnant women and infants in Tamil Nadu, India - A counterfactual analysis

COVID-19 has impacted the healthcare system across the globe. The study will span three pandemic waves in 2020, 2021, and 2022. The goal is to learn how the pandemic affects antenatal care (ANC) and emergency delivery care for pregnant women in Tamil Nadu, India, and how medical services respond. The study employs counterfactual analysis to evaluate the causal impact of the pandemic. A feedforward in combination with a simple auto-regressive neural network (AR-Net) is used to predict the daily number of calls for ambulance services (CAS). Three categories of the daily CAS count between January 2016 and December 2022 are utilised. The total CAS includes all types of medical emergencies; the second group pertains to planned ANC for high-risk pregnant women and the third group comprises CAS from pregnant women for medical emergencies. The second wave's infection and mortality rates were up to six times higher than the first. The phases in wave-II, post-wave-II, wave-III, and post-wave-III experienced a significant increase in both total IFT (inter-facility transfer) and total non-IFT calls covering all emergencies relative to the counterfactual, as evidenced by reported effect sizes of 1 and a range of 0.65 to 0.85, respectively. This highlights overwhelmed health services. In Tamil Nadu, neither emergency prenatal care nor planned prenatal care was affected by the pandemic. In contrast, the increase in actual emergency-related IFT calls during wave-II, post-wave-II, wave-III, and post-wave-III was 62%, 160%, 141%, and 165%, respectively, relative to the counterfactual. During the same time periods, the mean daily CAS related to prenatal care increased by 47%, 51%, 38%, and 38%, respectively, compared to pre-pandemic levels. The expansion of ambulance services and increased awareness of these services during wave II and the ensuing phases of Covid-19 pandemic have enhanced emergency care delivery for all, including obstetric and neonatal cohorts.

The effect of COVID-19 pandemic on perioperative factors: data from the Swedish Perioperative Register

BACKGROUND

The COVID-19 pandemic has affected healthcare organizations in many areas. The aim of this study was to describe surgical interventions, anesthesia, and postoperative outcomes in adult patients during the first wave and 1 year into the COVID-19 pandemic in Sweden, and to compare these outcomes with outcomes during the same period the year before the pandemic.

METHODS

Data were collected from the Swedish PeriOperative Register, and included 417, 233 perioperative registration of patients ≥ 18 years old between period 1 (March-June 2019), period 2 (March-June 2020), and period 3 (March-June 2021).

RESULTS

Compared with pre-pandemic (period 1), the number of surgical interventions decreased by 28% in the first wave (period 2); 1 year into the pandemic (period 3), the number of interventions was still 7.5% lower than pre-pandemic. The largest drops between periods 1 and 2 were noted in the specialties of ear, nose, and larynx surgery, - 55.6%; teeth, jaws, mouth, and pharynx surgery, - 45.0%; endocrine system surgery, - 38.8%. The number of acute surgeries remained stable during all three periods. Volatiles were more frequently used for the maintenance of general anesthesia in period 2 than in either period 1 or 3 (p < 0.001). Minor differences were noted throughout the periods in postoperative nausea and vomiting as well as postoperative pain.

CONCLUSIONS

The COVID-19 pandemic has had an impact on perioperative care in Sweden. During the first wave of the pandemic, the number of surgical interventions decreased, but the number of acute surgeries remained stable compared with pre-pandemic numbers. Perioperative organizations have had and will continue to have challenges handling the increased number of patients needing perioperative care.

The Impact of the COVID-19 Pandemic on Surgical Services in Brazil's Healthcare System: A Retrospective Cross-Sectional Study

Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery, leading to the cancellation and postponement of various health services, including surgery. Numerous countries closed their borders and established laws mandating the use of face masks and social distancing and enforced lockdowns, and various activities were constrained. Brazil, the largest and most populous country in Latin America, also experienced a rapid and sustained surge in infections and deaths. Brazil was the most severely impacted nation in Latin America. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aimed to assess the impact of the COVID-19 pandemic on surgical services throughout the entire period. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022 and compared the following indicators: (1) number of hospital admissions, (2) length of hospital stay (LOS) (in days), and (3) volume of urgent and elective procedures. Data was divided into four time periods, pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the number of admissions and LOS based on surgical procedures performed by stratifying according to region, sex, age, and type of surgery (urgent versus elective). Results The number of admissions for surgical procedures ranged between 859,646 and 4,015,624 for 2019, 686,616 and 3,419,234 for 2020, 787,791 and 3,829,019 for 2021, and 760,512 and 3,857,817 for 2022 for the category of region; 4,260,900 and 5,991,775 for 2019, 3,594,117 and 4,984,710 for 2020, 4,182,640 and 5,590,808 for 2021, and 4,077,651 and 5,561,928 for 2022 for the category of sex; and 2,170,288 and 3,186,117 for 2019, 1,516,830 and 2,825,189 for 2020, 1,748,202 and 3,030,272 for 2021, and 1,900,023 and 2,859,179 for 2022 for the category of age. The variable age showed a comparable trend, albeit with an expressive decline for surgeries in the age range of 0-19 years. The LOS (in days) for surgical procedures ranged between 110,157 and 910,846 for 2019, 58,562 and 897,734 for 2020, 67,926 and 904,137 for 2021, and 100,467 and 823,545 for 2022. Thoracic surgery indicated no statistically significant difference in the number of admissions and LOS. Elective surgeries had a decline in the number of admissions and LOS, a 13% and 9.3% decline between 2019 and 2020, respectively. Urgent surgeries experienced a slight decrease in admissions and LOS, with a decline of 2.4% and 2.8% between 2019 and 2020, respectively. Conclusions Population characteristics, such as age, sex, and region, showed decreased hospital admissions during the pandemic, followed by a recovery toward pre-pandemic levels afterward. The number of surgical admissions and the length of hospital stays decreased during the pandemic but gradually returned to pre-pandemic levels in the recovery and post-pandemic phases. Notably, thoracic surgery remained statistically consistent across all periods, indicating its emergency nature compared to other surgeries. Thus, we conclude that the pandemic had minimal impact on thoracic surgery cases, contributing to a stable trend.

Perspectives on training in obstetrics and gynaecology during the COVID-19 pandemic: Thematic analysis of trainee responses from a pan-European survey

Background

Coronavirus disease 19 (COVID-19) has affected many aspects of the lives of medical professionals. Postgraduate training has also been affected and mitigation plans are still ongoing.

Objective

To understand the perspectives of trainees in obstetrics and gynaecology (ObGyn) during the pandemic.

Materials and Methods

A cross-sectional exploratory survey conducted electronically from 20th of April 2020 to 1st July 2020.

Main outcome measures

The original questionnaire comprised of 40 questions and a free-text option. The free-text questions covered five main domains: effect of the pandemic on training, worries about training, acquisition of skills during the pandemic, training period and extensions and responsibilities outside training during the pandemic. The responses to these questions in the survey were analysed using pragmatic thematic analysis.

Results

Trainees felt there was lack of training as well as training opportunities. Some took the pandemic as an opportunity to gain new skills. Trainees were also worried about time in training and uncertainty about extensions. Lastly, many had concerns pertaining to patient care, an inability to contribute to departmental organisation, and dissatisfaction with the implemented policies.

Conclusion

The difficulties in Obstetrics and gynaecology training due to the pandemic need to be mitigated. When planning for reshaping the training programmes to accommodate for the discrepancies caused, trainers need to consider the perspectives of trainees and actively involve them in the decision making, designing and executing future plans.

What is new?

Efforts are currently underway to address the training time lost during the pandemic in Europe. Recognising the paramount importance of providing exceptional care for women and children across the continent, it becomes imperative to consider the valuable perspectives and insights offered by those who represent the future generation of specialists in the field.

Changes in Surgical Volume in Military Medical Treatment Facilities and Military Surgeon Clinical Combat Readiness During the COVID-19 Pandemic

Mini-abstract In this retrospective study, we evaluated changes in measures of surgeon clinical combat readiness within the military health system during the COVID-19 pandemic. We found a 36% reduction in surgical knowledge and skills as compared to pre-COVID. Sizable reductions were encountered for surgery for colectomy (-50%) and aneurysm repair (-61%).

Bariatric Patient Engagement in a Pre-surgery Virtual Patient Navigation Platform (VPNP)

BACKGROUND

This study analyzed patient engagement with a virtual patient navigation platform (VPNP) designed to help guide bariatric surgery candidates through the complex pre-operative workup for surgery.

METHODS

Data on baseline sociodemographic and medical history was collected on patients enrolled in the bariatric program at a single academic institution between March and May 2021. The System Usability Scale (SUS) survey was administered to assess VPNP usability. Two groups emerged: "engaged" (ENG; n = 30) who activated their accounts and completed the SUS, and "not-engaged" (NEG; n = 35) who did not activate their accounts (n = 13) or did not use the app (n = 22) and were therefore ineligible for the SUS survey.

RESULTS

Analyses demonstrated that only insurance status differed between groups (private insurance: 60% versus 34.3% for ENG versus NEG, respectively; p = 0.038). SUS survey analysis demonstrated high perceived usability (median score = 86.3), corresponding to the 97th percentile of usability. The top three reasons for disengagement included being too busy (22.9%), not being interested (20%), and being unsure about the purpose of the app (20%).

CONCLUSIONS

The VPNP scored in the 97th percentile of usability. However, given a majority of patients did not engage with the app, and engagement was associated with completing pre-surgery requirements faster (unpublished), future work will focus on mitigating identified reasons for patients not engaging.

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair

INTRODUCTION

Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial.

METHODS AND ANALYSIS

WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks.

TRIAL REGISTRATION NUMBER

ISRCTN identifier: 15052559.