454 Impact Of COVID-19 Pandemic on Elective Theatre Productivity in Otolaryngology

Aim

COVID-19 has had a significant impact on otolaryngology surgery. There are new requirements to prepare patients for theatre however the impact on theatre productivity is unknown. This study aims to evaluate the impact of COVID-19 on elective theatre productivity.

Method

We conducted a retrospective evaluation of elective otolaryngology theatre lists. Ten consecutive theatre lists beginning on the final week of November 2019 and November 2020 were analysed. Dedicated emergency operation lists were excluded.

Results

There were fewer operating lists per working day in 2020 (0.9) compared to 2019 (2.0) and a higher percentage of operations cancelled (2020: 15.4%, 2019: 8.6%). Theatre lists finished significantly earlier in 2020 than in 2019 (2020 median: 97.5 minutes, 2019 median: 15.5 minutes; p = 0.00018). The percentage of theatre lists finishing over 60 minutes early was substantially greater than the national average of 23% (2020: 75%, 2019: 30%). The median pre-list delay was higher in 2020 than 2019 (2019: 20.5 minutes, 2020: 31.5 minutes; p = 0.14) whilst the median total delay was higher in 2019 compared to 2020 (2019: 20.5 minutes, 2020: 18 minutes; p = 0.21). Both results were not statistically significant. The commonest reason for delay in 2020 were COVID-19 related reasons such as awaiting test results, in 2019 the commonest reason was patient not being ready for theatre such as consent not completed.

Conclusions

COVID-19 has had a significant impact on theatre productivity and is currently the commonest cause of theatre list delay. The early theatre finishing time suggest that improvements can be made to improve theatre productivity.

Are core surgical trainees being trained to operate?

A national prospective study of tonsil and adenoid surgery between 2004 and 2015.

An animal tissue simulation assessing three directional displacement forces on five common tracheostomy securing techniques

Introduction Several methods of securing a tracheostomy tube have been described in the literature including using ties or tapes around the neck and suturing the plastic flange to the neck in various ways. However, there are no wet lab-based studies to objectively determine the force required to displace the tracheostomy tube using different securing techniques. Ours is the first animal tissue simulation study published in the literature. Methods A simulated tracheostomy stoma was created on a sheep neck model. A tracheostomy tube was inserted into the stoma and secured using various methods. Tension tests were conducted to significantly displace the tube from the stoma. Each technique was repeated six times on different sheep necks. All results were analysed using SPSS®. Results Repeat measurements indicated that the largest displacement forces come from an oblique direction while the lowest force values were found at the lateral angle. Averages of displacement showed that medially placed sutures required the largest forces in comparison with other securing methods. Wilcoxon signed-rank testing indicated that medial and continuous suture security resists displacement at forces that otherwise displace flange and interrupted sutures. Conclusions This study has shown that any type of securing suture requires a greater displacement force than the strap of the tracheostomy tube holder alone. Medially placed sutures require a greater displacement force than those placed laterally. Displacement in the lateral direction requires the least force in comparison with movement at perpendicular or oblique angles.

Pharmacokinetics of Recombinant Factor VIII (Recombinate) Using One-stage Clotting and Chromogenic Factor VIII Assay

In a study designed to demonstrate the safety and pharmacokinetics of a recombinant factor VIII (Recombinate) manufactured in Andover, MA and Thousand Oaks, CA, two different methods of factor VIII assay (one-stage clotting and Chromogenic substrate) were compared in vivo. The study was performed in four centres in the UK: London, Oxford, Cardiff and Manchester. Two pharmacokinetic studies, at least one week apart, were performed in 30 patients with severe haemophilia A (VIII:C < 2 IU/dl). A dose of 50 IU/kg was administered with sampling pre-infusion, and +0.25, 0.5, 1, 3, 6, 9, 12 and 24 h post-infusion. The aggregate 60 pharmacokinetic study showed a half-life of 12.7 and 13.0 h (p = 0.28) and recovery of 127 and 161 IU/dl (p = 0.0001) using one-stage clotting or chromogenic substrate respectively. In a supplementary experiment, 20 post-infusion samples were re-assayed by 1-stage and chromogenic assay using two plasma (20th British plasma standard and an “in-house” pooled normal plasma) and two concentrate standards, derived from the same type, but different batch of infused concentrate (Recombinate) and pre-diluted in either individual pre-infusion sample or in pooled commercial haemophilic plasma. The use of the Recombinate concentrate standard overcame the significant difference in FVIII levels between 1-stage and chromogenic assay methods when a plasma standard was used (p <0.0001). It is concluded that where potency dosing designation is carried out by an assay system different to that used in the clinical situation, the use of the recombinant concentrate as a standard in post-infusion plasma samples is likely to give more reliable and reproducible results.

Blood Meal Source Characterization Using Illumina Sequencing in the Chagas Disease Vector Rhodnius pallescens (Hemiptera: Reduviidae) in Panamá

Accurate blood meal identification is critical to understand hematophagous vector-host relationships. This study describes a customizable Next-Generation Sequencing (NGS) approach to identify blood meals from Rhodnius pallescens (Hemiptera: Reduviidae) triatomines using multiple barcoded primers and existing software to pick operational taxonomic units and match sequences for blood meal identification. We precisely identified all positive control samples using this method and further examined 74 wild-caught R. pallescens samples. With this novel blood meal identification method, we detected 13 vertebrate species in the blood meals, as well as single and multiple blood meals in individual bugs. Our results demonstrate the reliability and descriptive uses of our method.

Temporal trends in thyroid-stimulating hormone (TSH) and thyroid peroxidase antibody (ATPO) testing across two phases of iodine fortification in Tasmania (1995-2013)

CONTEXT

Tasmania is an island state of the Australian Commonwealth with a well-documented history of mild iodine deficiency. Between 2001 and 2009, Tasmania experienced two incremental phases of iodine fortification.

OBJECTIVE

To examine trends in thyroid-stimulating hormone (TSH) and thyroid peroxidase antibody (ATPO) testing and their relationship to different phases of iodine nutrition in the Tasmanian population between 1995 and 2013.

DESIGN

Retrospective longitudinal study.

SETTING AND PARTICIPANTS

The major primary care and largest public hospital pathology providers in Tasmania submitted data for all TSH and ATPO tests performed between 1995 and 2013. Data linkage methodology was used to determine trends in TSH and ATPO testing.

RESULTS

A total of 1.66 million TSH assessments, involving 389,910 individual patients, were performed in Tasmania between 1995 and 2013. There was approximately a fourfold increase in the overall rate of TSH testing during this period with the rate of incident TSH assessment remaining relatively stable over the study period. The incidence of overt suppression and elevation of TSH (TSH≤0.1 mIU/L and ≥10 mIU/L) declined 62.3% and 59.7%, respectively, with a trend for increased incidence of borderline TSH elevation ≥4.0 mIU/L. The incidence of thyroid autoimmunity as determined by the proportion of abnormal ATPO results remained stable, with the absolute number of positive test results increasing during the study period.

CONCLUSION

Iodine supplementation of this mildly iodine-deficient population was not associated with an obvious increase in incidence of overt thyroid dysfunction or autoimmunity. Whilst the volume of TSH testing increased over the study period, the increase was driven by patients undergoing follow-up TSH assessments.

Attraction, Oviposition Preferences, and Olfactory Responses of Corn-Infesting Ulidiidae (Diptera) to Various Host-Based Substrates

Fresh market sweet corn (Zea mays L., convar. saccharata var. rugosa, Poales: Poaceae) ears produced in Florida are damaged by the larvae of Euxesta stigmatias Loew, Euxesta eluta Loew, and Chaetopsis massyla Walker (Diptera: Ulidiidae) that renders ears unmarketable. No standard lure exists for monitoring these pests. Oviposition substrate and attractant bioassays were designed to identify attractive substrates for further semiochemical investigation. Frass from the fall armyworm, Spodoptera frugiperda J.E. Smith (Lepidoptera: Noctuidae), was more attractive than other ovipositional substrates tested for E. eluta and C. massyla, and resulted in greater ovipositional output. Tassel-derived armyworm frass was more attractive than leaf-derived frass for oviposition. Frass also resulted in greater oviposition output by two species. In attraction bioassays, frass was generally preferred over the corresponding corn tissue, and only C. massyla demonstrated a preference for silk-frass over tassel-frass. The most promising substrates were then evaluated by electroantennography (EAG) to quantify olfactory responses. Frass volatiles also elicited greater antennal responses than corn volatiles. With tassel-frass, greater amplitude EAG responses were recorded from immature E. eluta female antennae, while mature female E. stigmatias exhibited greater responses. Equivalent antennal response to silk-frass was observed from E. eluta. Overall, silk-frass elicited the greatest EAG responses among all three fly species. Our results indicate that armyworm frass is an important resource in the chemical ecology of corn-infesting silk flies, and this substrate warrants further investigation for potential attractants that may facilitate development of novel management tools for these pests.

Evaluation of Lure Combinations Containing Essential Oils and Volatile Spiroketals for Detection of Host-Seeking Xyleborus glabratus (Coleoptera: Curculionidae: Scolytinae)

The invasive redbay ambrosia beetle, Xyleborus glabratus Eichhoff (Coleoptera: Curculionidae: Scolytinae), vectors the fungal pathogen (Raffaelea lauricola) that causes laurel wilt, a disease responsible for widespread mortality of trees in the Lauraceae in the southeastern United States. Early detection of incipient vector populations may allow for management practices that could successfully mitigate damage. Developing new, highly effective attractants is a priority for improving sensitivity of early detection efforts. In this study, two field tests were conducted to evaluate combinations of commercially available bark and ambrosia beetle lures for enhanced attraction of host-seeking female X. glabratus. In addition, lures were compared for capture of nontarget scolytine beetles. In the first experiment, traps baited with a combination of cubeb oil, conophthorin, chalcogran, and ethanol captured greater numbers of X. glabratus than cubeb oil alone, the current standard attractant. However, this combination lure resulted in higher nontarget scolytine captures than with the cubeb lure. In the second field test, an oil enriched in the sesquiterpene α-copaene caught significantly more X. glabratus than other lures currently available for monitoring this pest. There were no differences in efficacy between cubeb oil lures produced by two different manufacturers, and a combination lure containing copaiba and cubeb oils did not increase captures over the cubeb lure alone. Results of these two tests suggest that increased sensitivity for detection of X. glabratus may be achieved with a multicomponent lure that incorporates α-copaene, spiroketals, and low release of ethanol.

Diabetes and dyslipidemia: characterizing lipoprotein metabolism

Premature atherosclerosis in diabetes accounts for much of the decreased life span. New treatments have reduced this risk considerably. This review explores the relationship among the disturbances in glucose, lipid, and bile salt metabolic pathways that occur in diabetes. In particular, excess nutrient intake and starvation have major metabolic effects, which have allowed us new insights into the disturbance that occurs in diabetes. Metabolic regulators such as the forkhead transcription factors, the farnesyl X transcription factors, and the fibroblast growth factors have become important players in our understanding of the dysregulation of metabolism in diabetes and overnutrition. The disturbed regulation of lipoprotein metabolism in both the intestine and the liver has been more clearly defined over the past few years, and the atherogenicity of the triglyceride-rich lipoproteins, and - in tandem - low levels of high-density lipoproteins, is seen now as very important. New information on the apolipoproteins that control lipoprotein lipase activity has been obtained. This is an exciting time in the battle to defeat diabetic atherosclerosis.

Tonsillectomy is not a procedure of limited value - the unseen costs of tonsillitis and quinsy on hospital bed consumption

OBJECTIVES

To assess the impact of the introduction of the SIGN Clinical guidelines in 1999 and subsequent revision in 2005 on tonsillectomy, hospital admission with tonsillitis and peritonsillar abscess rates in four countries.

METHODS

Retrospective analysis using English, Welsh, Australian and New Zealand National healthcare hospital admission databases between 2000 and 2013. Primary outcomes measures included tonsillectomy rates and hospital admission rates for tonsillitis and peritonsillar abscess. Secondary outcome measures included bed-day usage in England and Wales. Linear forecasting was used to identify the potential impact of any trends.

RESULTS

Following guideline introduction for tonsillectomy, a significant decline in tonsillectomy rates in England (P < 0.01) and Wales (P < 0.05) was seen. Hospital admissions for acute tonsil infections increased in England (P < 0.01) and Wales (P < 0.01). In Australia and New Zealand, tonsillectomy and admission for tonsillitis rates both increased (P < 0.01). During this time, the increased rate of admission for tonsillitis in England and Wales was significantly greater than Australasia (P < 0.01).

CONCLUSIONS

Following the introduction of these Clinical guidelines, there was a decrease in the rate of tonsillectomy in England and Wales and a presumed associated increase in admissions with tonsillitis. This did not occur in Australasia where tonsillectomy rates rose over time. If these trends continue, it is likely that they will have a significant deleterious impact on healthcare spending in the future.

The uptake of day-case septoplasty in England and Wales

Is there a relationship between daycase rates and waiting list times?

Variable Pyrethroid Susceptibility Among the Sweet Corn-Infesting Ulidiidae (Diptera) in Florida and New Baseline Susceptibilities

Florida sweet corn is intensively treated to prevent infestation from the corn-infesting picture-winged fly complex (hereafter referred to as silk flies, Diptera: Ulidiidae). Previous bioassays performed on Euxesta stigmatias Loew demonstrated some pyrethroids performed weakly, while others were more efficacious and with longer-lasting residual activity. Since the last published bioassays, new active ingredients have been made available, other species in the complex discovered, and label restrictions increased for some products. For these reasons, topical bioassays were performed on the three most common species to assess insecticide efficacy of current commercial products labeled for either silk fly or fall armyworm ( Spodoptera frugiperda (J.E. Smith), Lepidoptera: Noctuidae) control. Bioassays were conducted using formulated product mixed in water and applied using a Generation III Research Spray Booth. The median lethal concentration ratio (LC 50 ) of beta-cyfluthrin with and without the pyrethroid synergist piperonyl butoxide was investigated. Acetamiprid, chlorantraniliprole, carbaryl, and flubendiamide did not result in high mortality to any species tested. Euxesta eluta Loew was susceptible to all other insecticides tested, and exhibited the lowest LC 50 to beta-cyfluthrin. Both Chaetopsis massyla Walker and E. stigmatias recovered from several pyrethroid treatments. Euxesta stigmatias also had the highest beta-cyfluthrin LC 50 , and piperonyl butoxide restored beta-cyfluthrin efficacy and lowered the LC 50 s of all three species.

A decade of change in the uptake of parathyroidectomy in England and Wales

INTRODUCTION

Since the late 1990s, a number of factors have reduced the threshold for parathyroidectomy in patients with primary hyperparathyroidism. This study examined whether this has translated into increased numbers of parathyroid operations over the last decade.

METHODS

A retrospective analysis was performed of the Patient Episode Database for Wales and English Hospital Episode Statistics annual data from 2000 to 2010 for parathyroidectomy admissions per 100,000 population. Statistical analysis was by linear regression.

RESULTS

Between 2000 and 2010 there were 24,247 parathyroid operations in England and Wales (0.005% of the population), with 3 times as many women treated as men. Overall, incidence of parathyroidectomy rose from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010 (p<0.0001). In England, it increased from 3.3/100,000 population to 5.8/100,000 and in Wales, it increased from 2.4/100,000 population to 4.6/100,000. Despite similar population demographics, the difference in the rate of change between England and Wales was significant (p<0.05). Uptake also varied according to age; in those aged 0-14 years, incidence of parathyroidectomy remained static whereas in all other age groups, uptake of parathyroidectomy increased significantly from 2000 to 2010. Most notably, surgical intervention in those aged 60-74 and >75 years nearly doubled over the decade (p<0.0001).

CONCLUSIONS

The incidence of parathyroidectomy in adults has increased significantly in the last decade in England and Wales. This likely reflects changes in population demography, available guidelines, lower threshold for referral, changing surgical approach and the realisation that surgical morbidity is now infrequent.

Residual dysglycemia when at target HbA(1c) of 7% (53mmol/mol) in persons with type 2 diabetes

AIMS

To understand the composition of the residual dysglycemia when HbA1c is between 6.5% (48mmol/mol) and 7% (53mmol/mol), representing the definition of diabetes and the recommended treatment goal, respectively.

METHODS

One hundred persons with type 2 diabetes and a HbA1c<7% (53mmol/mol), treated with diet alone and/or oral hypoglycemic agents underwent continuous glucose monitoring (CGM) and were further divided into two subgroups 1 (n=50) and 2 (n=50) according to whether the HbA1c was <6.5% (48mmol/mol) or 6.5-6.9% (48-52mmol/mol), respectively. A similar analysis was performed in those on diet alone: subgroups A (n=34, HbA1c<6.5%, 48mmol/mol) and B (n=10, HbA1c 6.5-6.9%, 48-52mmol/mol). The residual dysglycemia determined from the CGM was assessed using glucose exposures defined as areas under curves (AUCs) and mean glucose values.

RESULTS

Averaged 2-h postprandial glucose value (averaged PPG, mmol/L, mean±SD) and postprandial glucose exposure (AUCpp, mean±SD, mmol·L(-1)·h) were significantly higher in subgroup 2 (mean HbA1c=6.7%, 50mmol/mol) than in subgroup 1 (mean HbA1c=6.0%, 42mmol/mol): averaged PPG=8.1±1.3 versus 7.3±1.3mmol/L (p<0.002); AUCpp=23.5±8.6 versus 16.2±8.6 (p<0.0001). The percentages of persons with averaged PPG≥7.8mmol/L were 52% and 24% (p<0.01) in subgroups 2 and 1, respectively. Similar results were observed in those (subgroups A and B) who were on diet alone.

CONCLUSIONS

The residual dysglycemia in type 2 diabetes with HbA1c between 6.5 and 6.9% (48-52mmol/mol) inclusive is mainly due to remnant abnormal postprandial glucose excursions. Consequently, HbA1c<6.5% (48mmol/mol) is an achievable goal with therapeutic measures aimed at reducing postmeal glucose when the HbA1c is at 7% (53mmol/mol).

Insulin and atherosclerosis: how are they related?

The relationship between insulin and atherosclerosis is complex. People with type 2 diabetes are affected by three main glycaemic disorders: chronic hyperglycaemia; glycaemic variability; and iatrogenic hypoglycaemia. In addition to this triumvirate, the diabetic condition is characterized by lipid disorders, chronic low-grade inflammation and activation of oxidative stress. All these associated disorders reflect the insulin-resistant nature of type 2 diabetes and contribute to the development and progression of cardiovascular (CV) diseases. By both lowering plasma glucose and improving the lipid profile, insulin exerts beneficial effects on CV outcomes. In addition, insulin has several pleiotropic effects such as anti-inflammatory, antithrombotic and antioxidant properties. Insulin per se exerts an inhibitory effect on the activation of oxidative stress and seems able to counteract the pro-oxidant effects of ambient hyperglycaemia and glycaemic variability. However, insulin actions remain a subject of debate with respect to the risk of adverse CV events, which can increase in individuals exposed to high insulin doses. Evidence from the large-scale, long-term ORIGIN trial suggests that early implementation of insulin supplementation therapy in the course of glycaemic disorders, including type 2 diabetes, has a neutral impact on CV outcomes compared with standard management. Thus, the answer to the question "What impact does insulin have on atherosclerosis?" remains unclear, even though it is logical to deduce that insulin should be initiated as soon as possible and that small doses of insulin early on are better than higher doses later in the disease process.

Muckle-Wells syndrome: a treatable cause of congenital sensorineural hearing loss

Muckle-Wells syndrome (MWS) is a rare autosomal dominant condition with variable expression. It is a subset of auto-inflammatory diseases characterised by recurrent inflammatory crises and is associated with chronic recurrent urticaria, sensorineural deafness, periodic arthritis and secondary amyloidosis. The diagnosis of MWS is a clinical one with sufferers classically presenting in childhood with a moderate fever and non-pruiginous urticaria. We describe a case of a six-year-old girl who was successfully diagnosed and treated with Anakinra. Muckle and Wells originally described this syndrome in 1962; however, only recently was it discovered to be genetically linked to chromosome 1q44 and subsequently to missense mutations in the CIAS1/NALP3/PYPAF1 gene. Since then, treatment has evolved and it remains one of few treatable causes of congenital profound sensorineural hearing loss.

'Valve-stabilised' rhinospirometry can predict the benefit of septal surgery: a pre- and post-operative correlation study

Septoplasty is a procedure often associated with high levels of patient dissatisfaction post-operatively. This study examined whether rhinospirometry and a modified 'valve-stabilised' technique could pre-operatively predict the outcome of septal surgery and therefore have a role as an objective tool for selection of patients suffering from nasal obstruction due to septal deformity for the procedure of septoplasty. A prospective study was performed of patients attending Singleton Hospital, Swansea, for surgical treatment of nasal obstruction due to septal deformity. Participants were asked to undertake decongested visual analogue scoring (VAS) and rhinospirometric assessment of their nasal obstruction in both normal 'resting' and 'valve-stabilised' nasal positioning. These investigations were undertaken on the day of surgery and 6 weeks post-operatively. Results were converted into nasal partition ratio scores and were assessed statistically for difference, correlation and accuracy. A total of 29 individual participants were included in the study. Septal surgery produced a statistically significant improvement in nasal airflow symmetry in the normal 'resting' nasal position using rhinospirometry (Wilcoxon ranked p > 0.5). This difference was not seen between evaluations in 'valve-stabilised' position (Wilcoxon p < 0.001). No statistical difference was evident between pre-operative 'valve-stabilised' testing and post-operative 'resting position'. The finding was also apparent on VAS nasal assessment. Correlation studies showed a strong relationship between pre-operative 'valve-stabilised' and post-operative 'resting' rhinospirometry results (Spearman's rho = 0. 586, p < 0.002). The strength of this relationship between VAS assessments was less pronounced (Spearman's rho = 0.386 p = 0.07). 'Valve-stabilised' rhinospirometry and VAS appear to be useful pre-operatively to predict the outcome of septal surgery, in terms of airflow symmetry, for nasal obstruction due to septal deformity, with pre-operative 'valve-stabilised' results correlating well with the post-operative standard 'resting' outcomes. Valve-stabilised rhinospirometry may have a role in pre-operatively predicting of likely post-operative patient satisfaction, although further studies are required in this area.

Comparison between a basal-bolus and a premixed insulin regimen in individuals with type 2 diabetes-results of the GINGER study

AIM

To compare the efficacy and safety of an intensified insulin regimen, using insulin glargine (glargine) once daily and pre-meal insulin glulisine (glulisine) (basal-bolus), with a conventional therapy, using premixed insulin (premix) twice daily.

METHODS

This 52-week, open-label, randomized, multinational, multicentre trial included 310 subjects with type 2 diabetes (T2D) on premix, with or without metformin, who were randomized to a basal-bolus regimen with glargine and glulisine (n = 153; mean +/- s.d. age 60.2 +/- 7.5 years; HbA1c 8.6 +/- 0.8%; weight 87.0 +/- 15.1 kg; T2D duration 12.8 +/- 5.8 years) or twice-daily premix (n = 157; age 60.9 +/- 7.8 years; HbA1c 8.5 +/- 0.9%; weight 84.3 +/- 15.0 kg; T2D duration 12.5 +/- 6.8 years). The primary endpoint was change in HbA1c from baseline to endpoint.

RESULTS

Mean decrease in baseline-to-endpoint HbA1c for basal-bolus vs. premix was -1.31 vs. -0.80% (difference: -0.476%; 95% Cl: -0.714, -0.238; p = 0.0001, ancova). More subjects reached HbA1c < or = 7.0% in the basal-bolus group than in the premix group [68 (46.6%) vs. 43 (27.9%); p = 0.0004], while they also experienced significantly lower mean +/- s.d. daytime (-2.7 +/- 2.3 vs. -2.3 +/- 2.5 mmol/l; p = 0.0033) and postprandial (-3.1 +/- 2.6 vs. -2.5 +/- 2.8 mmol/l; p < 0.0001) blood glucose. Endpoint daily insulin doses were 98.0 +/- 48.7 vs. 91.3 +/- 44.3 IU (p = 0.2104); mean weight gain was +3.6 +/- 4.0 vs. +2.2 +/- 4.5 kg (p = 0.0073). Mean number of overall hypoglycaemic events with basal-bolus and premix was 13.99 and 18.54 events/patient year, respectively (difference: -3.90; 95% CI: -10.40, 2.60; p = 0.2385).

CONCLUSIONS

An intensified basal-bolus regimen using glargine/glulisine results in a significantly superior glycaemic control vs. premix therapy in a population with long-standing insulin-treated T2D, with no increase in the rates of hypoglycaemia.