Where are our patients? Retrospective cohort study of acute medical unit admissions during and prior to the COVID-19 pandemic

Admissions to hospital have declined markedly during the COVID‐19 pandemic in Australia. This may be due to patients not presenting with acute illness or managing their chronic illness at home. We reviewed a cohort admitted to the Acute Medical Unit of the Royal Melbourne Hospital during and before the pandemic and found admissions were more acutely unwell and more comorbid. This may lead to worse outcomes for those not presenting, as well as those presenting late. We recommend a public health campaign to encourage Australians to present to hospital if unwell.

A Novel Use of Embryonic Gut Organoid Culture to Investigate Duodenal Atresia

BACKGROUND

The cause of duodenal atresia (DA) is not known. Tandler's "solid cord" hypothesis conflicts with current biological evidence. In humans, a genetic aetiology is supported by the association with Trisomy 21. Interruption of Fgf10 is the strongest genetic link to DA in mice, demonstrating an increased incidence and severity as embryos mature. This project aimed to develop an organoid model to facilitate ex vivo DA research on the FGF10/FGFR2b signalling pathway. We hypothesised that DA morphology represents an evolving spectrum of disease and that Fgf10 knockout organoids would vary in growth pattern compared to wild-type.

METHODS

Organoids were cultured from the duodenum of E12.5 Fgf10 knockout, heterozygous and wild-type embryos, using an air-liquid interface with Growth Factor reduced Matrigel. Organoids were photographed every 48 h to observe growth. Organoids were isolated and fixed after 14 days, then stained with DAPI, KI-67, and cytokeratin to demonstrate proliferation and differentiation.

RESULTS

Wild-type duodenum developed into crypt-forming organoids. Fgf10 heterozygous duodenum failed to progress beyond the development stage of spheroids. Fgf10 knockout duodenum failed to demonstrate any growth. Wholemount staining showed the greatest cell proliferation and differentiation in wild-type tissue.

CONCLUSION

This research presents a novel concept for the growth of embryonic gastrointestinal tissue to inform normal biology. The small sample numbers and restricted culture duration limit longer-term growth analysis. While this model serves as a potential ex vivo setting for future research, that research should consider organoid models with greater standardisation and other gastrointestinal regions.

LEVEL OF EVIDENCE

Animal/laboratory study.

Managing Acute Esophageal Necrosis Secondary to Diabetic Ketoacidosis in a Rural Centre: A Case Report and Proposed Algorithm for Management

Acute esophageal necrosis (AEN) is a rare phenomenon, usually presenting with hematemesis or melena in patients who are already unwell with concurrent pathology. We present a case of AEN in an acutely unwell 82-year-old man who presented in diabetic ketoacidosis (DKA). He was successfully managed in our rural centre with remote guidance from a tertiary centre. We propose an evidence-informed management algorithm to guide and assist clinicians caring for patients with AEN in resource-limited settings. Initial management of AEN should prioritize resuscitation and correction of any underlying pathology, such as DKA. Early endoscopic assessment is required for the diagnosis of AEN and quantification of the extent of necrosis. Early repeat endoscopy (48-72 h) is recommended to assess healing and is useful in guiding ongoing management. In resource-limited settings, early referral and transfer for patients with AEN is recommended in the absence of intensive care support, endoscopy, or limited blood products.

Upfront Thoracic Magnetic Resonance Imaging for the Evaluation of Thymic Lesions to Reduce Non-Therapeutic Diagnostic Thymectomy: A Narrative Review

Background: Thymic pathologies represent the most common lesions of the anterior mediastinum. They may be classified as malignant or benign. Current diagnostic pathways recommend an initial assessment with computed tomography (CT) imaging to delineate potentially malignant thymic lesions. Despite this, high rates of non-therapeutic thymectomy continue to be observed. This carries with it significant anaesthetic, operative, and post-operative risks, in addition to healthcare costs. Consequently, there is a growing interest in magnetic resonance imaging (MRI) as a primary diagnostic modality for lesions of the anterior mediastinum. This narrative review outlines the current approaches to the evaluation of thymic lesions, with a discussion of the strengths and limitations of CT and MRI imaging modalities. It also evaluates the current discourse on the use of upfront MRI for thymic and anterior mediastinal lesion assessment. Methods: A narrative review was performed following a search on the Medline database. Articles that were evaluated had explored the role of MRI on the evaluation of thymic and anterior mediastinal lesions. Results: Current work-up for thymic and anterior mediastinal lesions are highly variable and centre around the use of CT. Upfront MRI demonstrates a similar accuracy to CT for various thymic and anterior mediastinal pathologies; however, the efforts to integrate this approach into routine practice remain in their infancy, with no standardised guidelines that exist. Conclusions: This narrative review demonstrates that there is a paucity of evidence relating to the sensitivity and specificity of MRI compared to CT for thymic lesion analysis and their subsequent relationship with non-therapeutic thymectomy. Future prospective trials to assess the role of MRI in thymic lesion determination are required to understand whether MRI can more accurately characterise these lesions to reduce non-therapeutic thymectomy. Additionally, further research efforts are required to characterise best-practice methods for integrating MRI into diagnostic pathways for these lesions in a cost-effective and resource-conscious manner.

Reviving the poppy seed test for the diagnosis of colovesical fistula: A case report from a single rural center experience

Key Clinical Message

The poppy seed test is a valuable, cost-effective, and sensitive initial diagnostic investigation to identify the presence of colovesical fistula, particularly for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support. The poppy seed test therefore may act as a bridge toward the commencement of appropriate referral pathways for the management of colovesical fistula.

Abstract

The diagnosis of colovesical fistula is resource intensive, often requiring a combination of radiological investigation and endoscopy. The poppy seed test is a non-invasive and cost-effective alternative that has been demonstrated to identify presence of colovesical fistula with high sensitivity. There is however a noticeable paucity of recommendations for the poppy seed test in the diagnostic approach to colovesical fistula due to significant advancements in alternative radiologic and endoscopic technologies. Despite this, in resource-challenged areas with lack of specialist support, the poppy seed test is a cost-effective, accessible and safe test that can be performed to confirm the presence of colovesical fistula. We report a case of a 79-year-old man with a past history of colorectal cancer managed surgically with adjuvant chemoradiotherapy who develops noisy micturition, pneumaturia, and fecaluria 22 years after treatment. Given the suspicion of colovesical fistula, computed tomography imaging and cystoscopy were performed which was unable to demonstrate an overt fistula. The poppy seed test was utilized and demonstrated presence of poppy seeds in the urine, confirming the presence of a fistula. The patient was referred to a specialist surgical center for consideration of further management. The poppy seed test is a valuable initial diagnostic investigation for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support in confirming the presence of a colovesical fistula and initiating referral pathways for the management of this condition.

A Scoping Review of the Clinical Utility of Laparoscopic Vasectomy

Vasectomy is a common procedure performed for family planning. Traditionally, this has been via a scrotal approach. In contrast, laparoscopic vasectomy is a documented but rarely described procedure that may minimise anaesthetic risk, surgical risk, and healthcare expenditure in patients undergoing elective laparoscopic procedures for concurrent pathology such as hernia repair. This scoping review evaluates the clinical utility of laparoscopic vasectomy. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Articles were identified with keywords related to laparoscopy and vasectomy. Six peer-reviewed, full-text articles published in English were included in this review. These studies encompass eight individual patient cases of laparoscopic vasectomy performed in the 1990s and early 2000s. All the cases included laparoscopy for concurrent pathology, the most common of which was inguinal hernia. There were no complications associated with laparoscopic vasectomy. For patients requiring laparoscopic surgery for alternate pathologies, synchronous laparoscopic vasectomy improves surgical efficiency by minimising anaesthetic time, operative time, and risk, in addition to lower associated healthcare costs. However, consideration is given to the limitations of this approach, and a note is made of the lack of evidence regarding safety and efficacy given the paucity of cases described in the literature.