Telephone assessment of new hernia referrals-is it possible?

PURPOSE

Utilisation of remote clinics is increasing in healthcare settings worldwide. During the height of the COVID pandemic, our UK-based teaching hospital has trialled telephone assessment for new patients presenting with primary hernias. Selected cases are listed for elective repair of primary hernia direct from telephone clinic assessment. In March 2021, after this process had been in place for 13 months, departmental triage criteria were introduced, allocating patients to initial assessment in Face to Face or Telephone Clinics. Here, we evaluate the effectiveness of telephone assessment, with specific attention to 'Day of Surgery' cancellation. We also assess the effect of our triage criteria on rate of 'Day of Surgery' cancellation.

METHODS

Departmental diaries were studied retrospectively to identify patients listed for hernia repair between February 2020 and February 2022. Data were obtained from clinic letters, discharge paperwork and operating lists, as well as from management teams. Fishers Exact test was used to compare groups seen either face to face or remotely as well and pre- and post-intervention.

RESULTS

325 patients were listed for hernia repair, 56 after telephone assessment. 6 (11%) of those listed from telephone clinic were cancelled on the day of surgery, compared with 34 (13%) of those seen face to face. With triage criteria in place, listing from telephone clinic increased significantly from 14 to 27%. Overall day of surgery cancellations reduced from 13 to 9%. Rate of day of surgery cancellation in those assessed in telephone clinic reduced from 12 to 9%.

CONCLUSIONS

There is no significant difference between day of surgery cancellations after face to face or telephone clinic assessment. Triage criteria for telephone assessment appear to increase the numbers being listed after remote clinics. This did not significantly impact the number of day of surgery cancellations.

Pancreatoduodenectomy for suspected malignancy: nonmalignant histology confers increased risk of serious morbidity

BACKGROUND/AIMS

A tissue diagnosis is not always obtained prior to pancreatoduodenectomy (PD) and a proportion of patients are found to have noncancerous histology postoperatively. It is unknown if these patients have different outcomes when compared with those who have malignancy confirmed.

METHODS

A retrospective paired case matched control study was undertaken. Patients who underwent PD for suspected malignancy but ultimately had nonmalignant histology were identified. Each was matched to a confirmed malignant control using the following criteria: age, gender, body mass index, American Society of Anesthesiologists grade, neoadjuvant treatment, preoperative serum bilirubin, preoperative biliary stenting and type of pancreatic anastomosis. Matching was blinded to the measured outcomes, which included perioperative morbidity and mortality.

RESULTS

Forty-five cases were compared with 45 well-matched controls. There was no difference in 30- or 90-day mortality, or length of stay. While overall morbidity rates were the same, patients with nonmalignant disease were more likely to experience major (Clavien-Dindo grade III-IV) morbidity (40.0% versus 17.8%, p = 0.0352). Independently, rates of clinically relevant pancreatic fistula (CR-POPF) were higher in the nonmalignant group (22.2% versus 4.44%, p = 0.0131).

CONCLUSIONS

In our study, PD patients with nonmalignant histology had significantly higher incidence of major morbidity and CR-POPF when compared with those who had malignancy confirmed. This should be considered when planning the management of patients with known or presumed benign/premalignant disease.

Delivery of an Incidental Appendiceal Mucinous Neoplasm

Low-grade appendiceal mucinous neoplasms (LAMNs) are rare and non-invasive tumors of the appendix, and their unexpected discovery during surgery can pose challenges to management. To date, only two cases pertaining to LAMNs without peritoneal spread in pregnancy exist in the literature. Here, we present a literature review of appendiceal mucinous neoplasms and discuss our management and operative approach to a large, incidental appendiceal mucinous neoplasm discovered during an emergency cesarean section of a 38-year-old female.

The epidemiology and outcomes of vascular trauma in Gold Coast, Australia: Institutional experience at a level 1 trauma centre

BACKGROUND

Vascular trauma is a complex and evolving area. Unlike internationally, the epidemiology of vascular trauma is not well documented in Australia; the most recent study was published in 2013. Gold Coast University Hospital (GCUH) is a level 1 trauma centre in Queensland, Australia. The aim of this study was to describe the epidemiology and outcomes of vascular trauma at a level 1 trauma centre, and compare these with the Australian and international literature.

METHODS

All individuals who presented to GCUH between January 2014 and December 2019 with vascular injury were retrieved from the GCUH prospective trauma database. A descriptive analysis was undertaken on this cohort.

RESULTS

The incidence of vascular trauma as a percentage of total trauma remained stable over the study period. The study included 5454 trauma admissions to GCUH, of which 213 sustained vascular injuries. Males were more likely to be injured and blunt trauma was more common than penetrating. Blunt trauma was associated with increased injury complexity. The mortality rate was 8.5% and 10 patients required amputation.

CONCLUSIONS

The proportion of vascular injuries as a percentage of total trauma in Australia is higher than in previous studies. Vascular trauma causes significant injuries and has a higher mortality rate than general trauma.

Low thrombin tissue sealant ARTISS (Baxter), in complex primary closure after Fournier's gangrene

The following case report describes the reconstruction of Fournier's gangrene (FG) which failed initial conventional primary closure due to issues with wound edge friability, large dead spaces, and significant tension and shearing forces created by excess adipose tissue in the patient's groin. In the first reported case that could be found in the literature ARTISS (Baxter), a low thrombin concentration fibrin sealant was used as a tissue adhesive to close the large post FG debridement wound flaps and ensure enough working time to allow for precise wound edge approximation. Employing Artiss in the closure of the large wound allowed for successful healing where simple primary closure had failed, aided an expedient recovery and reduced post reconstructive morbidity.

Reproductive issues in HIV-seropositive women: a survey regarding counseling, contraception, safer sex, and pregnancy choices

Sixty-nine HIV-seropositive women were surveyed with regard to the reproductive counseling they had received, contraception, safer sex practices, pregnancy histories, and pregnancy plans. Of the women surveyed, 84% and 90%, respectively, felt that they had access to the birth control and safer sex methods of their choice. Less than half felt that their physician had adequately counseled them about birth control. Women primarily cited social workers (46.4%) or nurses (34.8%) as the counseling source for birth control and safer sex. When informed about the reduced risk of vertical transmission with zidovudine (AZT), 33 women indicated that information regarding AZT would affect their future pregnancy decisions. Health care professionals need to be aware of this and counsel patients accordingly.

Chronic pancreatitis and neoplasia: correlation or coincidence

Any link between pancreatic carcinoma and chronic pancreatitis could reflect the malignant potential of a chronic inflammatory process. Four patients with ductal adenocarcinomas had a long history of pancreatic pain (median duration 5 years) and showed clear-cut evidence of chronic pancreatitis "downstream" of the tumour. Four were alcoholics and two heavy smokers. These four cases arose within a surgical series of approximately 250 patients with chronic pancreatitis, giving an incidence of 1.6 per cent. The incidence and anatomical distribution of carcinoma and chronic pancreatitis could possibly be consistent with a casual relationship.

Clinical and postmortem outcome of "no-reflow' phenomenon in a patient treated with rotational atherectomy

In the 77-year-old woman described, atherectomy of a circumflex artery with the Rotablator device was complicated by "no reflow." Ten days later, a 75% right coronary artery stenosis was successfully managed by balloon angioplasty. On the following day, acute closure of this vessel resulted in death. Gross examination of the heart showed features of recent posterior infarction, and microscopic study revealed atheroemboli in myocardial arterioles. We conclude that high-speed pulverization of atherosclerotic plaque can cause clinically significant emboli.

Comparison of paraquat-specific murine monoclonal antibodies produced by in vitro and in vivo immunization

The techniques of in vitro and in vivo immunization have been used to produce murine hybridomas secreting anti-paraquat IgM and IgG antibodies, respectively. The monoclonal antibodies from these IgM-secreting and IgG-secreting cell lines have been purified by HPLC and characterized by ELISA for their affinities to eliciting antigen and cross-reactivity. Both antibody preparations exhibited high selectivity and similar affinities for paraquat. There was only a minor degree of interaction with a range of paraquat analogs that differed in the nature and position of group substituents.

Large scale production and purification of paraquat and desipramine monoclonal antibodies and their Fab fragments

We describe the rapid, large scale purification of Fab fragments from mouse monoclonal antibodies. Antibodies against two clinically important and often fatal toxins, paraquat and desipramine, were isolated from mouse ascites fluid by preparative high performance hydroxylapatite (HPHT) or ion exchange (DEAE) high performance liquid chromatography. A competitive inhibition ELISA was used to determine the cross-reactivity of the antibody with analogs of the antigens. Papain digests of the IgGs were subjected to further HPHT followed by Sephadex G-100 chromatography to yield homogeneous Fab fragment preparations. The high purity of these preparations, demonstrated by SDS polyacrylamide gel electrophoresis, has only been achieved previously by affinity chromatography. Intrinsic association constants for the intact IgG and the Fab fragment--antigen interactions, determined by competitive inhibition ELISA, were similar. This indicates that antigen-binding activity was conserved during the production and purification of the Fab fragments.

Repeated hemoperfusion and continuous arteriovenous hemofiltration in a paraquat poisoned patient

Prompt hemodialysis or hemoperfusion can be of value during the first 24 hours after paraquat ingestion particularly when the patient has developed acute renal failure. However, many cases of paraquat poisoning occur in areas where hemoperfusion facilities are unavailable. In contrast, continuous arteriovenous hemofiltration (CAVH) could be instituted easily. We have measured the removal of paraquat from the body by CAVH in a 46 year old male cane farmer who ingested 70 ml, 20% paraquat and died twelve days later from pulmonary fibrosis. Renal failure developed rapidly. Concentrations of paraquat were measured by an indirect competitive ELISA using a murine paraquat monoclonal IgG antibody. Hemoperfusion was performed daily for five days, beginning 78 hours post-ingestion. By 180 hours, when the patient was in respiratory failure, hemoperfusion was replaced with CAVH which was continued for 46 hours. During this time interval, 1.1 mg paraquat was recovered in the hemofiltrate and 1.56 mg paraquat in the urine. The extraction of paraquat by the hemofilter was close to 100%. The plasma clearance of paraquat across the hemofilter was 6.1 ml/min and the renal clearance was 8.2 ml/min. The mean hemoperfusion clearance of paraquat was 50 ml/min and the total amount of paraquat removed by the 34 hours of hemoperfusion was 9 mg. Because of the relative ease with which CAVH can be performed, its low cost, compared to that of hemoperfusion or hemodialysis, and the continuous nature of the procedure, CAVH may be worth considering in paraquat poisoning. It could be used particularly in those patients who have developed renal failure or while patients are being prepared for hemoperfusion.

Long-term antianginal action of verapamil assessed with quantitated serial treadmill stress testing

The long-term efficacy of verapamil in a dose of 360 mg daily in patients with chronic stable angina pectoris was assessed by quantitated serial treadmill exercise tests. Twenty-eight patients were investigated with a placebo-controlled, double-blind, crossover protocol of 2 weeks each and afterward all patients were put on long-term therapy. Exercise tests were performed at the end of the placebo period and after 2, 4, 8, 16, 24 and 52 weeks of verapamil therapy. All 28 experienced angina during treadmill tests on placebo and the mean (+/- standard error of the mean) exercise time was 6.6 +/- 0.5 minutes. This increased to 9.2 +/- 0.8 minutes at 2 weeks and 50 11.2 +/- 0.8 minutes at 4 weeks. Fifteen and 20 of the 28 patients became angina-free during treadmill exercise at 2 and 4 weeks, respectively. The consumption of nitroglycerin showed a similar improvement. The improvement was maintained at 1 year of follow-up. The on-line computer-analyzed S-T segment changes showed a statistically significant improvement at all follow-up periods. Withdrawal of verapamil produced a return to pretreatment levels. The adverse effects noted were constipation in seven patients and reversible P-R interval prolongation in two. No heart failure occurred in any patient. These findings suggest that verapamil possesses a powerful and sustained antianginal action and, in a dose of 360 mg daily, merits a place as a primary therapeutic agent in the management of chronic stable angina.