Impact of the COVID-19 pandemic on management and outcomes in acute appendicitis: Should these new practices be the norm?

Background

In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period.

Methods

All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison.

Results

There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P < 0.001). This decrease was most pronounced in uncomplicated cases, whose operative rates dropped from 90.32% to 62.5% (P = 0.009). Post-operative histology confirmed appendicitis in 73.9% in 2019, compared to 97.5% in 2020 (P = 0.001). Normal appendiceal pathology was reported for 17 cases (24.64%) in 2019, compared to none in 2020 (P < 0.001) – a 0% negative appendicectomy rate (NAR).

Discussion

The 0% NAR in 2020 is due to a combination of increased CT imaging, a higher threshold to operate, and is impacted by increased disease severity due to delayed patient presentation. This study adds to growing literature promoting routine use of radiological imaging to confirm appendicitis diagnosis. As we enter a second lockdown, patients should be encouraged to avoid late presentations, and surgical departments should continue using radiological imaging more liberally in guiding appendicitis management.

A strategy for reducing maternal and newborn deaths by 2015 and beyond

Background

Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.

Discussion

The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.

Summary

Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

p53 protein accumulation and genetic alterations in human giant cell tumors of bone (osteoclastomas)

Inactivation of tumor suppressor genes represents a critical determinant in the development of a large proportion of human cancers. The tumor suppressor gene p53 is the most frequently altered gene in human cancers. In the present study, p53 protein accumulation, gene mutation and the association between p53 alteration and clinicopathological parameters was analyzed in 29 giant cell tumors of bone. p53 overexpression was detected by immunohistochemistry in 23 of 29 (79%) primary tumors but not in adjacent bone tissue. p53 gene mutations in exons 5-8 were detected in 15 of 29 (52%) of the tumors by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) analysis. In 15 (52%) of 29 patient specimens, p53 immunostaining and mutations in exons 5-8 were concordant. Eleven (38%) of 29 tumors overexpressed p53 in the absence of mutations in exons 5-8. No significant association between p53 alterations and clinicopathological parameters was found. The present study represents the first report to assess p53 protein content and gene mutation in a substantial number of giant cell tumors of bone and suggests that p53 alterations play an important role in the development of this neoplasm.

Analysis of antibody reactivity in paired cerebrospinal fluid and serum of a relapsing remitting multiple sclerosis patient

Increasing evidence indicates an involvement of B cells in multiple sclerosis (MS). However, little is known about antigenic targets recognized by antibodies present in blood and cerebrospinal fluid (CSF) of MS patients. This study was therefore aimed at identifying the antigen reactivity of antibodies present in CSF and compares the identified antibody profile with that of the serum of the same patient using cDNA phage display. Selection rounds on paired CSF and serum of this patient identified 13 antigenic targets of which 5 were enriched by serum antibodies and 2 were identified by CSF antibodies. Interestingly, the six remaining antigenic targets were shown to be recognized by both CSF and serum antibodies. These findings point towards both common as well as distinct antibody profiles in CSF and serum of MS patients.

Exploring cDNA Phage Display for Autoantibody Profiling in the Serum of Multiple Sclerosis Patients: Optimization of the Selection Procedure

We applied a cDNA phage display method called serological antigen selection (SAS) to identify immunogenic targets that evoke an autoantibody response in the serum of multiple sclerosis (MS) patients. This method involves the display of a cDNA expression library, in this study a MS brain library, on filamentous phage and subsequent selection using patient immunoglobulin G (IgG). To apply the SAS technology for autoantibodies in the serum of MS patients, an optimization was necessary to deplete cDNA products that encode IgG fragments derived from B cells present in the MS brain plaques. We describe a differential screening procedure in which positive selection rounds on MS serum and negative selection rounds on healthy control serum were alternated to optimize the selection procedure. As a result, a substantial decrease of IgG-displaying phage clones was observed after each negative selection round, thereby preventing an overgrowth of IgG-displaying phage clones. Our depletion strategy was therefore successful in preventing the enrichment of IgG-displaying phage clones. This approach will facilitate the identification of possible MS-related antigens.

Laparoscopic mesh and staple Burch colposuspension

Our objective was to describe our experience with laparoscopic Burch colposuspension and to relate our results to traditional open Burch procedures for the treatment of genuine stress incontinence. Retrospective case series were compared to historical controls. Forty-six women found to have only genuine stress incontinence by history, examination and clinical urodynamics, underwent a mesh and staple laparoscopic Burch procedure. Follow-up ranged from 3 to 50 months. Thirty-seven women were dry, 6 were improved and 3 showed no improvement. This compared to between 75% and 90% of women cured of stress incontinence by the traditional open Burch procedure. We concluded that the results of a mesh and staple laparoscopic Burch procedure in a carefully selected population of women with genuine stress incontinence appears comparable to that reported in the literature for an open Burch procedure.

Female gender is a risk factor for drug-induced long QT and cardiac arrhythmias in an in vivo rabbit model

INTRODUCTION

Clinical observations and in vitro experimental data indicate that females have a longer QT interval than males, which is associated with a higher risk of drug-induced cardiac arrhythmias. Little is known about this gender difference in anesthetized animals, which may affect the outcome of in vivo drug tests.

METHODS AND RESULTS

We evaluated potential gender differences in ventricular repolarization (QT, QTc, JT, and JTc interval) and its dispersion, as well as in its response to dofetilide, an IKr blocker, in anesthetized rabbits challenged with the alpha1-adrenoceptor agonist methoxamine. A 12-lead ECG was recorded during the experiments. At baseline, there were no significant gender differences in ventricular repolarization values in male and female rabbits under anesthesia. Dofetilide (0.04 mg/kg/min IV for 60 min; n = 10 per gender) produced marked prolongation of the ventricular repolarization time and its dispersion, associated with a high incidence of polymorphic ventricular tachycardia (PVT; 100% in females vs 80% in males) and ventricular fibrillation (VF; 80% in females vs 50% in males; P > 0.05). QT and JT interval at 2 minutes as well as QT and JT dispersion at 10 and 30 minutes during dofetilide infusion were significantly higher in female than in male rabbits. After 30 minutes of dofetilide infusion, 10 of 10 female rabbits had severe cardiac arrhythmias (complete AV block, PVT, or VF), so ECG parameters were impossible to assess (vs 3/10 males with severe cardiac arrhythmias; P < 0.05). During dofetilide infusion, female rabbits developed complete AV block, PVT, or VF at doses about 50% lower than those given to males.

CONCLUSION

The present study indicates that female rabbits are more susceptible to drug-induced long QT and cardiac arrhythmias than are male rabbits; therefore, female rabbits are more appropriate for testing drug-induced cardiac arrhythmias.

The MEN-1 gene is rarely down-regulated in pituitary adenomas

The gene for multiple endocrine neoplasia type 1 (MEN-1) has recently been cloned and encodes a putative tumor suppressor protein named menin. We have previously reported inactivating MEN-1 gene mutations associated with loss of heterozygosity (LOH) of the normal allele in tumors of patients with MEN-1 and in some sporadic pituitary tumors. These genetic alterations, however, are noted in no more than 10% of sporadic adenomas. To investigate whether other mechanisms may result in down-regulation of menin gene expression in pituitary adenomas, we examined menin gene expression by semiquantitative RT-PCR in 60 sporadic pituitary adenomas. Ribonucleic acid (RNA) was extracted from surgically resected, morphologically characterized tumors. Primers were designed to amplify a 257-bp fragment spanning exons 4-6 of the MEN-1 gene. A product of the predicted size was amplified from normal pituitary samples as well as from adenomas. Competitive PCR was performed with the housekeeping gene PGK-1 to quantitate menin gene expression. A comparable ratio of menin/PGK-1 messenger RNA was identified in all but three samples; in two tumors with LOH, menin expression was weak, and in one tumor, menin messenger RNA was undetectable, associated with LOH and mutation of the other allele. Reduced expression of menin in some sporadic adenomas is consistent with a putative tumor suppressor role for this gene product. However, lack of menin down-regulation in the majority of these tumors, which exhibit LOH at 11q13 in up to 20% of cases, provides compelling evidence for an additional tumor suppressor gene at this locus, which is more commonly involved in the pathogenesis of pituitary neoplasms.

Endomyocardial fibrosis and eosinophilia

Absolute eosinophil counts were assessed in 15 African patients with proven endomyocardial fibrosis. Though the mean eosinophil count in patients with endomyocardial fibrosis was higher compared with the normals reported from Kampala (1-13 vs 0.72X10(9)/1), the absolute range was comparable. A high percentage of patients with endomyocardial fibrosis had malarial parasites, high malarial antibody titres, hookworms, or strongyloides, but the correlation of eosinophilia to various parasitic infections was poor. Both eosinophilia and parasitic infections are common in the tropics and they effect patients with endomyocardial fibrosis no more than the population at large. Other aetiological factors, genetic, environmental, and immunological, are felt to be important in the causation of endomyocardial fibrosis in Uganda and evidence for this is reviewed. Though there is a similarity in pathological features, African endomyocardial fibrosis is a distinct entity from Löffler's endocarditis and cardiac lesions seen in eosinophilic leukaemia or reactive eosinophilia. There is no hard evidence to suggest that African endomyocardial fibrosis is a variant of Löffler's endocarditis caused by parasitic infections via eosinophilia.

Altered microfilament structure in cells transformed with a temperature-sensitive transformation mutant of murine sarcoma virus

The structure and distribution of microfilaments were examined by electron microscopy in uninfected normal rat kidney (NRK) cells, murine sarcoma virus (MSV)-transformed NRK cells, and NRK cells infected with a cold-sensitive transformation mutant of MSV, i.e., NRK (MSV-1b) cells, grown at both permissive (39 degrees) and nonpermissive (33 degrees) temperature. The uninfected cells contained numerous microfilaments which were especially prominent at sites of intercellular adherens junctions. In contrast, the MSV-transformed cells contained few microfilaments and did not form adherens junctions. At 33 degrees, the NRK (MSV-1b) cells appeared normal but formed an altered form of adherens junction with disorganized microfilaments. At 39 degrees, these cells resembled NRK cells transformed by wild-type MSV but still formed a few of the altered type of adherens junctions. Disorganized adherens junction microfilaments were also found in cells newly infected with wild-type MSV. These results suggest that the perturbed assembly of microfilaments at adherens junctions may be an intermediate stage in the loss of adherens junctions during viral transformation.

The sick-sinus syndrome in Africans

Fifteen cases of the sick-sinus syndrome in young Negroes are presented. The etiology was unknown in all cases; organic heart disease was absent. The very high default rate suggests that the prognosis may be grave. This disorder is by no means uncommon in young persons in tropical countries and the dangers of a mistaken diagnosis of epilepsy or a psychiatric illness have been emphasized. In the absence of an artificial pacemaker, it is suggested that sympathomimetic drugs, while not affecting the heart rate, may be useful in reducing the frequency of syncopal attacks.

Temperature-dependent expression of transformation by cold-sensitive mutant of murine sarcoma virus

Morphological transformation of normal rat kidney cells by a murine sarcoma virus was found to be cold-sensitive. Cells transformed by the virus expressed their transformed phenotype at the permissive temperature (39 degrees ) but not at the nonpermissive temperature (33 degrees ), as judged by the criteria of morphological changes and colony-forming ability on monolayers of normal rat kidney cells. Cold-sensitive expression of transformation was specific for focus-derived normal rat kidney cells transformed by the virus, readily reversible, and not lost during serial propagation of the cells. The genome of the murine sarcoma virus can be rescued by superinfection with Moloney leukemia virus at the permissive or nonpermissive temperature, and the rescued virus exhibited the same cold-sensitive properties as the original transforming virus. These results suggest that maintenance of the transformed state is continuously dependent on a cold-sensitive viral function.

Effect of prostaglandins A 1 , A 2 , B 1 , E 2 and F 2 on forearm arterial bed and superficial hand veins in man

1. The effects of local infusions of prostaglandins (PG) A1, A2, B1, E2 and F2α have been studied in the forearm arterial bed and superficial hand veins of man.

2. Prostaglandins A1, A2, B1, E2 and F2α all gave rise to a dose-dependent increase in forearm blood flow when infused into the brachial artery. At dosages just below the dilator range, PGF2α caused a transient fall in forearm flow, but this was not seen with any of the other prostaglandins.

3. Prostaglandins A1, A2 and E2 had no effect when infused locally into relaxed veins but caused dose-dependent dilatation when given into veins preconstricted with either noradrenaline or 5-hydroxytryptamine. Prostaglandins B1 and F2α caused dose-dependent constriction when given into relaxed veins and had no dilator effect when infused into preconstricted veins.

4. The results suggest that there are at least two types of receptors mediating responses to prostaglandins in peripheral blood vessels.

Pathology of infective endocarditis. A postmortem evaluation

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A survey for cardiovascular disease in middle-aged Ugandans

A study of 412 persons aged at least 45 years showed that cardiovascular disease, especially hypertension, was common. Cardiac enlargement was the most frequent complication of hypertension; cerebrovascular accidents were rare. Cardiomegaly without hypertension or valvular disease was found in 29 persons. Valvular disease was present in 17 persons, but was symptomless in all but 3 cases.