1308 VIRTUAL FRAILTY WARD - POST DISCHARGE FRAILTY SUPPORT

Background

In response to the COVID pandemic when new robust discharge criteria were introduced to facilitate early discharge to optimise hospital capacity, Virtual Frailty Ward (VFW) was established. VFW provides nurse-led telephone follow-up for patients discharged primarily from the Emergency Department (ED) and the Acute Frailty unit (AFU).

Objectives

We aim to provide continuity of care by following up frail elderly patients at home, reviewing their medical, functional and social progress post discharge and ensuring they received adequate support to avoid hospital re-admission.

Methods

The service is overseen by the Lead Frailty Practitioner, supported by Consultant Geriatricians. Calls are made Monday to Friday by a team of Advanced Specialist Nurses. The case load is split up into 3 categories with different levels of priorities – 1: at least weekly calls; 2: Fortnightly calls; 3: Monthly calls. This service engages closely with community partners such as community frailty service, social care, district nurses and general practitioners.

Results

In year 1 (1/4/2020-31/3/2021), we had 598 patients on this VFW. 93 patients were referred to therapy team for urgent equipment to maintain safety, 73 patients were referred to community frailty and 112 patients had urgent discussions with GP to avoid hospital admissions. The 30 days readmissions rate was 14%. 547 patients were discharged. In year 2 (1/4/2021 – 31/3/2022), we had 297 patients. 49 patients were referred to therapy team, 32 patients were referred to community frailty team, and 41 patients required input from GP. The 30-day readmission rate was 11%. 224 patients were discharged.

Conclusion

VFW is a cost- effective service that has helped to reduce length of stay of frail elderly patients in an acute hospital setting, maintaining patient safety and prevent hospital re-admission, co-ordinated with community services. Our service has been highlighted in the recent GIRFT report on improving clinical practice.

Double Whammy: Rare Case of Infected Chronic Seroma Due to Bacterial Translocation From Biliary Sepsis

We present a case of infected chronic seroma post ventral hernia repair using the Rives-Stoppa technique likely from bacterial translocation from ascending cholangitis. After definitive treatment with endoscopic retrograde cholangiopancreatography (ERCP) and drainage of obstructed gallstones, she continued to show signs of sepsis. Percutaneous drainage of seroma was diagnostic for infection, where Escherichia coli (E. coli) was cultured and coupled with IV antibiotics, her infection was treated. To the best of our knowledge, this is the first case of seroma infection from biliary sepsis, and there are no cases of infected seroma from a secondary infection in the literature.

Small bowel obstruction with situs inversus abdominalis: A case report

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Intestinal obstruction in an adult with situs inversus abdominalis is extremely rare.

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Management requires early investigation & a lower threshold for surgical intervention.

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Detailed pre-operative planning & surgical experience is essential.

Introduction

Situs inversus abdominalis (SIA) is an uncommon condition that causes intestinal malrotation in the paediatric population as its primary complication (Brown, 2017). Presentations of acute surgical emergencies in adults secondary to SIA are extremely rare (Brown, 2017).

Presentation of case

A 38-year-old female with situs inversus abdominalis (SIA) presented with small bowel obstruction (SBO). The patient had a history of a paediatric omphalocele repair.

The patient failed conservative management and required surgical intervention including a laparotomy and adhesiolysis without intestinal resection for resolution of her symptoms.

Discussion

Only 2 cases of SBO secondary to SIA have been documented in the literature; both resulting in bowel resection with a 50 % mortality rate (Mallick, 2006). This is the third reported case and the only case to avoid bowel ischemia. We attribute this to early presentation by the patient, prompt imaging, careful surgical planning with consultant led surgical intervention and a multidisciplinary team approach to recovery.

Conclusion

Acute surgical emergencies in patients with congenital anomalies should have a low threshold for imaging and intervention with detailed pre-operative planning and a senior surgeon led approach.

Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen

BACKGROUND

Acute abdomen is a time-critical condition, which requires prompt diagnosis, initiation of first-line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies.

METHODS

Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post-operative outcomes were obtained from review of operative medical records data over a 1-year duration.

RESULTS

There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target '4-hour' rule, and 41.7% seen within 1-h from triage. Despite this, in cases of intra-abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1-h recommendation in the Sepsis Kills pathway. There was non-significant trend in faster overall time performances with successive higher triage category allocation.

CONCLUSION

This study highlights an opportunity to consider alternative triage methods or fast-track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.

Management of alternative pathology detected using CT KUB in suspected ureteric colic

Acute flank pain is a common presentation to the emergency department (ED), and imaging studies play an important role in establishing an accurate diagnosis. Computed Tomography of Kidneys, Ureters, Bladder (CT KUB) has surpassed all other imaging modalities to become the gold standard in detection of ureteric calculi. The purpose of this study is to identify the range and management of alternative diagnoses established by CT KUB in patients with suspected ureteric colic. Two hundred and fifteen consecutive CT KUB examinations ordered in the ED of a tertiary-care centre for suspected ureteric colic were retrospectively reviewed. This comprised of 134 male (62.3%) and 81 female (37.7%) patients with a mean age of 53 years old. The positive detection rate for ureteric calculi in males was 43.3% compared to a lower rate for females of 29.6% (p < 0.05). Almost two-thirds of patients were discharged following CT KUB imaging, and admission rates were significantly higher in those with alternative radiological findings (p < 0.04) Alternative radiological findings occurred in 72 patients (33.5%), including 15 patients (7.0%) who had clinically important alternative pathology. The rate of clinically important alternative findings was significantly higher in males than females, 9.7% versus 2.5% respectively (p = 0.04). Surgical intervention was more common in patients with alternative radiological findings classified as gastrointestinal (18.2%) compared to non-gastrointestinal (3.6%), however this did not reach statistical significance (p = 0.07). In conclusion, significant alternative pathology was identified using CT KUB in 7% of patients with suspected ureteric colic. The low rates of detection of ureteric calculi and significant alternative pathology in female patients suggests a more thorough clinical assessment is warranted to improve their management, prior to ordering investigations with exposure to radiation.

Large retroperitoneal isolated fibrous cyst in absence of preceding trauma or acute pancreatitis

BACKGROUND

Isolated retroperitoneal cystic masses are uncommon with an estimated incidence of 1/5750 to 1/250,000. The majority present with size related symptoms, complications, or a mass. Approximately a third of patients are asymptomatic and are diagnosed incidentally. Aetiologies of retroperitoneal cystic masses (RPC) include mesenteric, omental, splenic and enteric duplication cysts. Neoplastic RPCs can be divided into epithelial (mucinous or serous cystadenoma), mesothelial (mesothelioma), germ cell (cystic teratoma) and cystic changes in a solid neoplasm (paraganglioma, neurilemmoma, sarcoma).

CASE PRESENTATION

A 53 year-old man presented to us with abdominal pain related to a large mass in his left upper quadrant with associated anorexia and weight loss. He gave no history of previous trauma and denied having symptoms or a history of pancreatitis. He said he had felt this mass increasing in size over the course of several years. Clinical examination of his abdomen revealed a large firm left sided mass extending to his left upper quadrant. Imaging with computed tomography (CT) and magnetic resonance imaging cholangio-pancreatogram (MRCP) revealed a 13.7 cm × 12.2 cm × 10.9 cm cystic lesion in the retroperitoneum which was separate from the kidney, pancreas, spleen and bowel. At laparotomy, this mass was easily dissected from the surrounding viscera and was excised completely intact. Histopathological assessment found the mass to be a large fibrous pseudocyst with no epithelial lining.

CONCLUSION

We present a rare case of an isolated large retroperitoneal fibrous pseudocyst unrelated to previous pancreatitis which was successfully managed with surgery.

Associations between ethnicity, body composition, and bone mineral density in a Southeast Asian population

CONTEXT AND OBJECTIVE

Chinese men in Singapore have a higher incidence of hip fractures than Malay and Indian men. We investigated whether there were corresponding ethnic differences in peak bone mineral density (BMD) in young men and whether differences in body composition influenced peak BMD.

DESIGN AND SETTING

This was a cross-sectional study of healthy volunteers in a tertiary medical center.

PARTICIPANTS

A total of 100 Chinese, 82 Malay, and 80 Indian men aged 21 to 40 years, with body mass index between 18 and 30 kg/m(2) underwent dual-energy x-ray absorptiometry to assess BMD, lean mass (LM) and fat mass (FM), and magnetic resonance imaging to quantify abdominal subcutaneous and visceral adipose tissue. Multiple linear regression models, with adjustment for age and height (as a proxy for skeletal size), were used.

RESULTS

Malay and Indian men had significantly higher BMD than Chinese men at the lumbar spine (Malay: B, 0.06 ± 0.02, P = .001; Indian: B, 0.03 ± 0.02, P = .049), femoral neck (Malay: B 0.04 ± 0.02, P = .034; Indian: B, 0.04 ± 0.02, P = .041), hip (Malay: B, 0.05 ± 0.02, P = .016; Indian: B, 0.06 ± 0.02, P = .001), and ultradistal radius (Malay: B, 0.03 ± 0.01, P < .001; Indian: B, 0.02 ± 0.01, P = .029), and this difference was retained after adjustment for LM and FM, except in Malay men at the femoral neck and in Indian men at the ultradistal radius. LM was an important independent determinant of BMD at all sites, whereas FM, subcutaneous adipose tissue, and visceral adipose tissue were not significantly associated with BMD at any site.

CONCLUSIONS

Lower peak BMD in Chinese men may partly explain the higher fracture incidence in this ethnic group. Further studies are needed to elucidate the reasons for these ethnic differences in bone accumulation.

Activin/Nodal signaling controls divergent transcriptional networks in human embryonic stem cells and in endoderm progenitors

Activin/Nodal signaling is necessary to maintain pluripotency of human embryonic stem cells (hESCs) and to induce their differentiation toward endoderm. However, the mechanisms by which Activin/Nodal signaling achieves these opposite functions remain unclear. To unravel these mechanisms, we examined the transcriptional network controlled in hESCs by Smad2 and Smad3, which represent the direct effectors of Activin/Nodal signaling. These analyses reveal that Smad2/3 participate in the control of the core transcriptional network characterizing pluripotency, which includes Oct-4, Nanog, FoxD3, Dppa4, Tert, Myc, and UTF1. In addition, similar experiments performed on endoderm cells confirm that a broad part of the transcriptional network directing differentiation is downstream of Smad2/3. Therefore, Activin/Nodal signaling appears to control divergent transcriptional networks in hESCs and in endoderm. Importantly, we observed an overlap between the transcriptional network downstream of Nanog and Smad2/3 in hESCs; whereas, functional studies showed that both factors cooperate to control the expression of pluripotency genes. Therefore, the effect of Activin/Nodal signaling on pluripotency and differentiation could be dictated by tissue specific Smad2/3 partners such as Nanog, explaining the mechanisms by which signaling pathways can orchestrate divergent cell fate decisions.

SIP1 mediates cell-fate decisions between neuroectoderm and mesendoderm in human pluripotent stem cells

Human embryonic stem cells (hESCs) rely on fibroblast growth factor and Activin-Nodal signaling to maintain their pluripotency. However, Activin-Nodal signaling is also known to induce mesendoderm differentiation. The mechanisms by which Activin-Nodal signaling can achieve these contradictory functions remain unknown. Here, we demonstrate that Smad-interacting protein 1 (SIP1) limits the mesendoderm-inducing effects of Activin-Nodal signaling without inhibiting the pluripotency-maintaining effects exerted by SMAD2/3. In turn, Activin-Nodal signaling cooperates with NANOG, OCT4, and SOX2 to control the expression of SIP1 in hESCs, thereby limiting the neuroectoderm-promoting effects of SIP1. Similar results were obtained with mouse epiblast stem cells, implying that these mechanisms are evolutionarily conserved and may operate in vivo during mammalian development. Overall, our results reveal the mechanisms by which Activin-Nodal signaling acts through SIP1 to regulate the cell-fate decision between neuroectoderm and mesendoderm in the progression from pluripotency to primary germ layer differentiation.

Clinical and physiological effects of transcranial electrical stimulation position on motor evoked potentials in scoliosis surgery

Background

During intraoperative monitoring for scoliosis surgery, we have previously elicited ipsilateral and contralateral motor evoked potentials (MEP) with cross scalp stimulation. Ipsilateral MEPs, which may have comprised summation of early ipsilaterally conducted components and transcallosally or deep white matter stimulated components, can show larger amplitudes than those derived purely from contralateral motor cortex stimulation. We tested this hypothesis using two stimulating positions. We compared intraoperative MEPs in 14 neurologically normal subjects undergoing scoliosis surgery using total intravenous anesthetic regimens.

Methods

Trancranial electrical stimulation was applied with both cross scalp (C3C4 or C4C3) or midline (C3Cz or C4Cz) positions. The latter was assumed to be more focal and result in little transcallosal/deep white matter stimulation. A train of 5 square wave stimuli 0.5 ms in duration at up to 200 mA was delivered with 4 ms (250 Hz) interstimulus intervals. Averaged supramaximal MEPs were obtained from the tibialis anterior bilaterally.

Results

The cross scalp stimulating position resulted in supramaximal MEPs that were of significantly higher amplitude, shorter latency and required lower stimulating intensity to elicit overall (Wilcoxon Signed Rank test, p < 0.05 for all), as compared to the midline stimulating position. However, no significant differences were found for all 3 parameters comparing ipsilaterally and contralaterally recorded MEPs (p > 0.05 for all), seen for both stimulating positions individually.

Conclusions

Our findings suggest that cross scalp stimulation resulted in MEPs obtained ipsilaterally and contralaterally which may be contributed to by summation of ipsilateral and simultaneous transcallosally or deep white matter conducted stimulation of the opposite motor cortex. Use of this stimulating position is advocated to elicit MEPs under operative circumstances where anesthetic agents may cause suppression of cortical and spinal excitability. Although less focal in nature, cross scalp stimulation would be most suitable for infratentorial or spinal surgery, in contrast to supratentorial neurosurgical procedures.

Activin/Nodal signalling maintains pluripotency by controlling Nanog expression

The pluripotent status of embryonic stem cells (ESCs) confers upon them the capacity to differentiate into the three primary germ layers, ectoderm, mesoderm and endoderm, from which all the cells of the adult body are derived. An understanding of the mechanisms controlling pluripotency is thus essential for driving the differentiation of human pluripotent cells into cell types useful for clinical applications. The Activin/Nodal signalling pathway is necessary to maintain pluripotency in human ESCs and in mouse epiblast stem cells (EpiSCs), but the molecular mechanisms by which it achieves this effect remain obscure. Here, we demonstrate that Activin/Nodal signalling controls expression of the key pluripotency factor Nanog in human ESCs and in mouse EpiSCs. Nanog in turn prevents neuroectoderm differentiation induced by FGF signalling and limits the transcriptional activity of the Smad2/3 cascade, blocking progression along the endoderm lineage. This negative-feedback loop imposes stasis in neuroectoderm and mesendoderm differentiation, thereby maintaining the pluripotent status of human ESCs and mouse EpiSCs.

The value of bilateral ipsilateral and contralateral motor evoked potential monitoring in scoliosis surgery

Intraoperative monitoring (IOM) of the motor pathways is a routine procedure for ensuring integrity of corticospinal tracts during scoliosis surgery. We have previously demonstrated presence of ipsilateral motor evoked potentials (MEPs) during IOM for scoliosis surgery, but its significance was uncertain. In this case series, we show concurrent ipsilateral and contralateral MEP amplitude changes obtained with cortical stimulation are of value in reducing false positive observations during IOM. The use of this easily recordable MEP is thus advocated as a diagnostic adjunct to contralateral MEPs for scoliosis and spinal surgery.

Gastric irradiation for MALT lymphoma: reducing the target volume, fast!

A case of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma treated with radiotherapy alone is reported here. This case highlights treatment issues related to the variability in size and position of the stomach, and the substantial reduction in the size of the irradiated volume achieved by treating the patient in a fasting state.