Colorectal cancer care in the COVID-19 era: outcomes from a 'mixed site' model

INTRODUCTION

The COVID-19 pandemic has presented many challenges to colorectal cancer (CRC) care. Many organisations opted to perform CRC resections in 'cold' sites. Infrastructure in Northumbria Healthcare NHS Foundation Trust (NHCT) necessitated co-locating CRC care with 'hot' COVID streams but with additional precautions. This study aimed to evaluate that approach for a consecutive series of CRC cases, diagnosed before and during the COVID-19 pandemic.

METHODS

A prospectively populated data set of CRC patients diagnosed between 1 April 2019 and 30 September 2020 was used. Patients presenting before 1 April 2020 were considered 'pre-COVID' and those presenting subsequently as 'COVID era'.

RESULTS

Some 344 cases were diagnosed in the 12 months 'pre-COVID' and 166 in the 6 months of the 'COVID era'. The median numbers of days from referral to diagnosis (21 vs 20, p=0.373) and operation (63 vs 61, p=0.208) were unchanged. The 'COVID era' saw an increase in the proportion of radiological diagnoses (39.5% vs 53.0%, p=0.004) with an associated decrease in endoscopic diagnoses (56.7% vs 45.8%, p=0.021). Rates of inoperable (1.5% vs 1.2%, p=0.821), obstructing (11.0% vs 16.2%, p=0.272) and perforated tumours (0.6% vs 1.5%, p=0.492) remained the same. One patient developed COVID-19 perioperatively. Rates of laparoscopic operation (59.5% vs 61.8%, p=0.751), anastomotic leak (6.4% vs 5.9%, p=0.891), re-operative surgery (10.4% vs 4.4%, p=0.138), primary stoma (40.5% vs 32.4%, p=0.244) and 90-day mortality (0.6% vs 1.5%, p=0.492) did not change.

CONCLUSIONS

With appropriate infection control measures, it may be safe to continue providing standard elective and urgent CRC care without access to a 'COVID clean' site.

138 We Tried This At Home – Safety Analysis and Outcome of Community Resource Services

Introduction

There are several data sets published for acute frailty services in hospital but there is a lack of supporting data in the emerging field of Intermediate Care. Gwent has well-established Community Resource Teams (CRT) that were set up as “Hospital at Home” services. The objective being to treat frail, acute or sub-acute medically ill patients in their own environment by a consultant-led hospital-like team using a Comprehensive Geriatric Assessment. Although “Hospital at Home” services are often preferred by the patient and are in-line with Health board strategies “Care Closer to home” and “Clinical Futures”; it is important to ask ourselves whether we are able to deliver clinical care in the community safely?

Method

One year of data from 2018 was extracted from the CRT Portal, analysed and then validated by the health board’s performance teams. From the established data set, origin of referrals and discharge outcomes were identified. Finally, at 28 days of discharge from Gwent CRTs mortality and hospital admission rates were examined.

Results

4,308 out of 5,395 referrals (85%) were accepted to Gwent CRTs of which 59.60% (2,863) referrals were from primary care and 33.54% (1,445) were from secondary care. Our admission rates to secondary care services were 15.27% (658) whilst mortality rate was 3.92% (169). After successful medical management from Gwent CRTs of 3,481 patients in their own place of residence, 28 day hospital admission rate was 13.84% (482) whilst 28 day mortality rate (expected and unexpected) was 6.89% (240).

Conclusion

Although no equivalent data is currently available for comparison, a significant number of patients can be medically managed in their own place of residence. More than 80% of patients did not require hospital admission whilst mortality rates were encouraging. Further future re-evaluation of our service performance and its value is required.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Should we reconsider lung transplantation through uncontrolled donation after circulatory death?

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 h of ex vivo lung perfusion. The postoperative course was uneventful, and the recipient was discharged home on day 9. While this case represents a "best-case scenario," it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

Donor-derived disease transmission events in the United States: data reviewed by the OPTN/UNOS Disease Transmission Advisory Committee

Donor-derived disease transmission is increasingly recognized as a source of morbidity and mortality among transplant recipients. Policy 4.7 of the Organ Procurement and Transplantation Network (OPTN) currently requires reporting of donor-derived events. All potential donor-derived transmission events (PDDTE) reported to OPTN/UNOS were reviewed by the Disease Transmission Advisory Committee (DTAC). Summary data from January 1, 2005-December 31, 2007, were prepared for presentation. Reports of PDDTE have increased from 7 in 2005, the first full year data were collected, to 60 in 2006 and to 97 in 2007. More detailed information is available for 2007; a classification system for determining likelihood of donor-derived transmission was utilized. In 2007, there were four proven and one possible donor-derived malignancy transmissions and four proven, two probable and six possible donor-derived infectious diseases transmissions. There were nine reported recipient deaths attributable to proven donor transmissions events arising from eight donors during 2007. Although recognized transmission events resulted in significant morbidity and mortality, transmission was reported in only 0.96% of deceased donor donations overall. Improved reporting, through enhanced recognition and communication, will be critical to better estimate the transmission risk of infection and malignancy through organ transplantation.

Effects of eye size on adults' aesthetic ratings of faces and 5-month-olds' looking times

In two experiments, we investigated the influence of eye size on adults' ratings of faces' attractiveness and 5-month-olds' looking times. Subjects viewed four pairs of female faces that were identical except for the size of the eyes. Whether they saw black-and-white drawings (experiment 1) or coloured photographs (experiment 2), adults rated the faces with larger eyes as more attractive than the faces with smaller eyes. Babies looked equally long at the drawn faces with larger and smaller eyes (experiment 1), but with the more realistic photographed faces, they looked slightly but significantly longer at the versions with larger eyes (experiment 2). Overall, our results suggest that a modest preference for larger eyes that has emerged by 5 months of age may contribute to the development of adult aesthetic preferences.

Development of the Rural-Urban Demand Indicator (RUDI)

In this article we describe development of RUDI (Rural-Urban Demand Indicator), a multivariate interval level measure of demand for health services. RUDI ranks counties by population and purchasing power and was developed for use in a wide variety of health-related research and for policy analyses. RUDI is based on microeconomic theory and Grossman's (1972) extension of the theory, that the family produces health and that the family's demand for health services is derived from the demand for health. Two factors define RUDI: DEMOS (demographics) and EWB (economic well-being). These two factors accounted for 66.2% of the variance observed in 1990 census data. A variety of other analyses offer evidence of known- groups, convergent, factorial, and predictive validity.

Developing a managed care mindset: getting staff on the managed care bandwagon

A managed care mindset involves understanding how managed care works and what managed care organizations will expect when they work with home care providers. To gain that mindset, once managers understand the concept, they need to take steps to educate their staff members and bring about a new perspective.

Wayside Hospice--a shared program model

Two home care agencies came together to bring hospice to their local communities. By pooling their resources and personnel under one umbrella program, they were able to expand their service offerings, knowledge, and expertise, yet keep costs down. The result is the personification of the saying, "Caring is sharing."

Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: results of a prospective trial of operative correction and dynamic extension splinting

In a prospective study, 23 proximal interphalangeal joints that were severely contracted (> or = 45 degrees) as a result of Dupuytren's disease underwent operative correction and 6 months of dynamic extension splinting. Proximal interphalangeal joint extension was measured preoperatively and postoperatively at 3-month intervals for 1 year and at 6-month intervals thereafter. Mean follow-up was 2 years (minimum, 1 year). Overall, at 2 years, 44% improvement in proximal interphalangeal joint extension was noted. Mean improvement of 59% in proximal interphalangeal joint extension was noted in patients who complied with the postoperative dynamic extension splinting program. Patients who were noncomplaint demonstrated a 25% improvement in proximal interphalangeal joint extension. The difference in values between patients who were compliant and those who were not was statistically significant. Other factors--severity of contracture, digit involved, and the necessity for capsular release--were not significantly related to outcome. This study suggests that soft tissue responds to continuous dynamic extension stresses and can be remodeled over time.

Home blood anticoagulant monitoring--a physician alliance result

Developing relationships with physicians can yield more than just a better relationship; it can directly impact an agency's ability to expand into new service areas. The alliance between the Visiting Nurse Association of Central Massachusetts and Dr. Jack Ansell led to the creation of the agency's highly successful home blood anticoagulant monitoring, a service that the growing number of cardiac patients in the United States will demand.

Economics of hospice care

As an institution providing care for patients who are dying, hospice has expanded significantly since the opening of the first hospice in the United States in 1974. Many changes have occurred in that time, including the maturation of hospices and the introduction of third-party reimbursement under Medicare. This article examines literature on hospice from an economic perspective; the focus is on the characteristics of the hospice "industry," demand for hospice care, hospice as a supplier of care, and the cost of hospice care. Two major gaps in the research are the failure to categorize hospices by the type of reimbursement received and the emphasis on expenditures for care to the exclusion of consideration of the cost of producing hospice care.

Hospice: a design for home care for the terminally ill

Hospice may appropriately be understood as a model of holistic care. As a model of holistic care, hospice provides numerous insights suitable for adoption in other health care settings. In addition, hospice provides a preeminent opportunity for nurses to practice within a nursing model; at the present time, nursing goals may be pursued more freely within hospice than in any other setting.

Hospice costs and medicare reimbursement: an application of break-even analysis

The adequacy of Medicare reimbursement to cover hospice costs is examined using break-even analysis. Since hospice costs are high during the first few days after enrollment, a long period of enrollment is required for per diem reimbursement to cover costs. Under a variety of specifications, the length of stay required for the hospice to break even is greater than the median length of stay.

A reexamination of the role of the RAD52 gene in spontaneous mitotic recombination

The RAD52 gene is required for much of the recombination that occurs in Saccharomyces cerevisiae. One of the two commonly utilized mutant alleles, rad52-2, increases rather than reduces mitotic recombination, yet in other respects appears to be a typical rad52 mutant allele. This raises the question as to whether RAD52 is really necessary for mitotic recombination. Analysis of a deletion/insertion allele created in vitro indicates that the null mutant phenotype is indeed a deficiency in mitotic recombination, especially in gene conversion. The data also indicate that RAD52 is required for crossing-over between at least some chromosomes. Finally, examination of the behavior of a replicating plasmid in rad52-1 strains indicates that the frequency of plasmid integration is substantially reduced from that in wild type, a conclusion consistent with a role for RAD52 in reciprocal crossing-over. Analysis of recombinants arising in rad52-2 strains suggests that this allele may result in the increased activity of a RAD52-independent recombinational pathway.

Radionuclide surveillance of the allografted pancreas

To determine the value of scintigraphy to detect posttransplantation complications of the allografted pancreas, we retrospectively reviewed 209 scintigrams obtained with 99mTc-sulfur colloid (99mTc-SC) and 99mTc-glucoheptonate (99mTc-GH). The scintigraphic studies were performed in 37 recipients of simultaneous renal and pancreatic allografts harvested from the same donor. 99mTc-SC was used as an indicator of thrombotic vasculitis; pancreatic perfusion and blood-pool parameters were monitored with 99mTc-GH. In 11 of the 37 recipients, scintigraphic abnormalities suggested posttransplantation infarction. Recurrent episodes of acute rejection of the pancreatic allograft, which always coincided with acute rejection of the renal allograft, were monitored in 24 recipients. Rejection-induced ischemic pancreatitis was suggested in 12 of the 24 recipients and persisted in 10 recipients for several weeks after improvement of renal allograft rejection. Pancreatic atrophy was suggested scintigraphically in 16 of the 24 recipients with recurrent episodes of rejection. Spontaneous pancreatic-duct obstruction and obstructive pancreatitis were associated with a scintigraphic pattern similar to that of rejection-induced ischemic pancreatitis. We concluded that the specific radionuclides used in this series are useful for the surveillance and assessment of posttransplantation pancreatic infarction, acute rejection, pancreatitis, and atrophy.

Simultaneous cadaver renal and pancreas transplantation in type I diabetes

Between February 1985 and April 1986, we performed 11 simultaneous cadaver kidney and segmental pancreatic transplants in patients with type I diabetes. There were nine men and two women ranging in age from 25 to 47 years (mean, 38.5 years). All pancreatic grafts were extraperitoneal, and the pancreatic duct was managed by pancreaticocystostomy utilizing an internal stent. Three patients died from two to six weeks postoperatively of septic complications. Four pancreatic grafts were functioning at 2, 5, 11, and 14 months after operation, and eight patients had had functioning renal allografts from two to 14 months (mean, 6.8 months) with a mean serum creatinine level of 2.4 mg/dL (210 mumol/L). Graft failure occurred in the other four patients from vascular thrombosis (three patients) or hemorrhagic pancreatitis (one patient). Significant morbidity included an infected arterial anastomosis (two patients), pancreatic fistulas (four patients), and bladder leak (four patients). In conclusion, this procedure is an effective option for selective diabetics with end-stage renal disease. Although technical complications were frequent, no adverse effect on renal allograft function was evident. With technical refinements, this procedure should be applicable to most type I diabetics with renal failure.

Selective posttransplantation bilateral native nephrectomy. Indications and results

Twenty-five patients underwent bilateral native nephrectomy one to 68 months (mean, 15.6 months) following renal transplantation. The indications were erythrocytosis in two patients, recurrent urinary tract infection in three, medically uncontrolled hypertension in 18, and hypertension and urinary tract infection in two. One patient died two months after the nephrectomy, and one allograft was lost because of acute tubular necrosis. Both patients with erythrocytosis had prompt return of the hematocrit level and RBC mass to normal. Native nephrectomy eradicated the infection in each of the five patients with recurrent urinary tract infections. Results of nephrectomy for hypertension were classified as excellent in six patients, good in nine, and poor in four. Native renal-vein renin ratios of patients with excellent or good responses were not statistically different when compared with those of poor responders.

The effects of ATP-MgCl2 and dipyridamole in cold-storage preservation

The effects of ATP-MgCl2 and dipyridamole were evaluated in a canine model. Twenty-five adult mongrel dogs were divided into five equal groups. All dogs underwent left nephrectomy and 30 min of warm ischemia followed by Collins' C-4 flush and 24 hr of cold-storage preservation. Heterotopic autotransplantation and immediate contralateral nephrectomy were then performed. Group A served as controls; Group B was pretreated with intravenous ATP-MgCl2 (2.5 mM); Group C with intravenous dipyridamole (10 mg), and Group D with both ATP-MgCl2 (2.5 mM) and dipyridamole (10 mg). Group E was treated with ATP-MgCl2 (2.5 mM) at the time of transplantation. All kidneys underwent cortical biopsies at the end of preservation and 1 hr after restoration of blood flow for determinations of AMP, ADP, and ATP. In Groups A and E there were no survivors, whereas Groups B, C, and D had 40, 60, and 40% graft survival. In Groups B and D, ATP and energy charge (EC) were greater than that of controls after 24 hr of preservation, with Group D values being significantly greater (P less than 0.01). AMP and ADP levels were significantly greater (P less than 0.02) in Group C when compared to Group A. One hour posttransplantation biopsies demonstrated greater ability to regenerate cortical nucleotides in the surviving animals, but no absolute value could be identified as a predictor of viability. In conclusion, pretreatment with ATP-MgCl2 or dipyridamole maintains intracellular nucleotide levels and has a beneficial effect on graft survival in ischemically injured kidneys undergoing cold-storage preservation.

Peptic ulcer disease following transplantation: the role of cimetidine

Of 253 consecutive renal transplants performed in 209 patients between January 1971 and December 1980, symptomatic gastroduodenal ulcerations developed in 22 (8.7 percent). Time of presentation ranged from 5 days to 9 years (mean 225 days) following transplantation with 16 of these patients presenting within the first 3 months. Nine (Group I) patients were diagnosed before the administration of H2 antagonist cimetidine. Mode of presentation in this group was upper gastrointestinal bleeding in each instance. Thirteen patients (Group II) were diagnosed after the clinical use of cimetidine was established. The mode of presentation in this group was bleeding in 11 patients and abdominal pain in 2 patients. In Group I, one patient died from liver failure and an ulcer was not contributory. The remaining eight patients were treated with antacids and blood transfusions (mean 12.7 units). Five patients in this group demonstrated ulcer healing, whereas three patients (37.5 percent) required emergency operations with two postoperative deaths. In Group II, one patient died from hemorrhagic shock before therapy could be instituted. In the other 12 patients treatment consisted of antacids, cimetidine, and blood transfusions (mean 6.8 units). Ten patients had relief of symptoms, whereas two patients (16.7 percent) required emergency operations with no deaths. During cimetidine therapy, two patients had rejection episodes that were reversible, and the remaining patients had no significant alterations in renal function. To conclude, cimetidine is a safe and effective adjunct in the treatment of peptic ulceration in renal transplant recipients.

Potentiation of the carotid artery occlusion reflex by a cholinergic system in the posterior hypothalamic nucleus

Bilateral occlusion of the common carotid arteries of urethane-anesthetized rats evoked a pressor response of 14 +/- 1 mm Hg. Injection into the lateral cerebral ventricle of neostigmine (0.2-1.0 microgram) or physostigmine (10-15 microgram) caused a dose-dependent increase in basal blood pressure and in the magnitude of the carotid artery occlusion (CAO) pressor reflex. Neostigmine (1 microgram) and physostigmine (15 microgram) caused nearly maximal and approximately equal degrees of cholinesterase inhibition in several brain regions. The recovery of the cardiovascular parameters and of brain cholinesterase activity was significantly faster following physostigmine compared to neostigmine. Prior intracerebroventricular injection of atropine (0.3 microgram) or hemicholinium-3 (20 microgram) prevented the increases in basal pressure and the CAO pressor response. Potentiation of the CAO reflex also followed injection of physostigmine or neostigmine into the posterior hypothalamic nucleus and of injection of physostigmine intravenously. Injection of atropine bilaterally into ther posterior hypothalamic nucleus prior to intravenous injection of physostigmine prevented the potentiation of the CAO reflex but not the increase in basal blood pressure. These results indicate that acetylcholine in the posterior hypothalamic nucleus serves as a neurotransmitter in a pathway which can potentiate the pressor response to carotid artery occlusion and thus modulate baroreceptor reflexes.

Modulatory effect of brain acetylcholine on reflex-induced bradycardia and tachycardia in conscious rats

The effects of intracerebroventricular (i.c.v.) injection of physostigmine and hemicholinium-3 (HC-3) on reflex bradycardia and tachycardia have been studied in unanesthetized rats. The reflex increases and decreases in heart rate were elicited by i.v. injection of norepinephrine and sodium nitroprusside, respectively. Physostigmine (5-10 micrograms) increased basal mean arterial pressure (MAP), reduced basal heart rate (HR), enhanced the reflex bradycardia and reduced reflex tachycardia. Physostigmine did not modify either the pressor effect of norepinephrine, the depressor effect of sodium nitroprusside or the responsiveness of peripheral muscarinic receptors. Pretreatment (i.c.v.) with atropine (0.3 micrograms) completely abolished the effect of physostigmine on MAP, HR, reflex bradycardia and reflex tachycardia. Pretreatment (i.c.v.) with mecamylamine (50 micrograms) did not modify the effect of the cholinesterase inhibitor on MAP, HR and reflex tachycardia, but inverted its effect on reflex bradycardia. Injection of HC-3 (20 micrograms i.c.v.) did not modify MAP, but reduced HR and inhibited both reflex bradycardia and reflex tachycardia. The HC-3 bradycardic effect started within minutes and lasted for about 1 hr, while the depressor effect on the reflexes began only after 15 min and continued for several hours. In addition, i.c.v. pretreatment with HC-3 completely abolished all the effects of physostigmine on MAP, HR, reflex bradycardia and reflex tachycardia. These results suggest that brain acetylcholine has a modulatory effect on baroreceptor reflexes. This modulation operates through muscarinic receptors in reflex tachycardia and through both muscarinic and nicotinic receptors in reflex bradycardia.