Balancing scarce hospital resources during the COVID-19 pandemic using discrete-event simulation.

COVID-19 has disrupted healthcare operations and resulted in large-scale cancellations of elective surgery. Hospitals throughout the world made life-altering resource allocation decisions and prioritised the care of COVID-19 patients. Without effective models to evaluate resource allocation strategies encompassing COVID-19 and non-COVID-19 care, hospitals face the risk of making sub-optimal local resource allocation decisions. A discrete-event-simulation model is proposed in this paper to describe COVID-19, elective surgery, and emergency surgery patient flows. COVID-19-specific patient flows and a surgical patient flow network were constructed based on data of 475 COVID-19 patients and 28,831 non-COVID-19 patients in Addenbrooke's hospital in the UK. The model enabled the evaluation of three resource allocation strategies, for two COVID-19 wave scenarios: proactive cancellation of elective surgery, reactive cancellation of elective surgery, and ring-fencing operating theatre capacity. The results suggest that a ring-fencing strategy outperforms the other strategies, regardless of the COVID-19 scenario, in terms of total direct deaths and the number of surgeries performed. However, this does come at the cost of 50% more critical care rejections. In terms of aggregate hospital performance, a reactive cancellation strategy prioritising COVID-19 is no longer favourable if more than 7.3% of elective surgeries can be considered life-saving. Additionally, the model demonstrates the impact of timely hospital preparation and staff availability, on the ability to treat patients during a pandemic. The model can aid hospitals worldwide during pandemics and disasters, to evaluate their resource allocation strategies and identify the effect of redefining the prioritisation of patients.

Endoscopy and implantable electronic devices.

The increasing use of implantable electronic devices such as cardiac pacemakers and neurostimulators means that they are being increasingly encountered in endoscopy departments. The electromagnetic fields generated during electrosurgery and with magnetic imaging systems have the potential to interfere with such devices. The authors present a case that highlights some of the steps necessary for minimising risk, review the evidence and summarise the currently available guidance.

Colorectal cancer detection: time to abandon barium enema?

OBJECTIVES: To assess the sensitivity of double contrast barium enema (DCBE) for diagnosing colorectal cancer (CRC). DESIGN: Retrospective evaluation of DCBE performed in the 2 years prior to diagnosis of CRC. SETTING: Teaching hospital in Cambridge, UK. PATIENTS: 1310 consecutive cases of CRC identified from cancer registry data. INTERVENTIONS: DCBE and colonoscopy. MAIN OUTCOME MEASURES: Sensitivity of DCBE for diagnosing CRC. RESULTS: 215 patients had undergone a DCBE within the 2 years prior to diagnosis with CRC. After excluding those reported as inadequate, 37 of these were reported as normal, giving a sensitivity of 83% (81-85%). CONCLUSIONS: The performance of DCBE is inadequate for the exclusion of CRC. Expansion of colonoscopy and CT colonography capacity is urgently required nationally so that DCBE can finally be abandoned as a firstline test in patients at risk of CRC.

MGEA5-14 polymorphism and type 2 diabetes in Mexico City.

A family-based study has recently reported that a variant located in intron 10 of the gene MGEA5 increases susceptibility to Type 2 Diabetes (T2D). We evaluated the distribution of this SNP in a sample of T2D patients (N = 271) and controls (N = 244) from Mexico City. The frequency of the T allele was higher in the cases (2.6%) than in the controls (1.8%). After adjusting for age, sex, BMI, education, and individual ancestry the odds ratio was 1.60 but the 95% confidence interval was wide and overlapped 1 (0.52-4.86, P-value : 0.404). In order to characterize the distribution of the MGEA5-14 polymorphism in the relevant parental populations, we genotyped this variant in European (and European Americans), West African, and Native American samples. The T-allele was present at a frequency of 2.3% in Spain, 4.2% in European Americans, and 13% in Western Africans, but was absent in two Native American samples from Mexico and Peru. Given the low frequency of the T-allele, further studies using large sample sizes will be required to confirm the role of this variant in T2D.

Long-term study of re-infection following successful eradication of Helicobacter pylori infection.

BACKGROUND: 'Re-infection' with Helicobacter pylori after eradication has been estimated to occur in 0-14% of patients, although most so-called 're-infections' occur within the first year following 'eradication' and many may actually be due to recrudescence of a temporarily suppressed infection. AIM: To study the true re-infection rate, we have studied re-infection rates after eradication therapy by excluding the first year's data, minimizing the possible confounding effect of recrudescence. METHODS: All patients tested for H. pylori infection following eradication therapy between 1987 and 2004 were evaluated. Testing was carried out by urea breath test and gastric biopsy. Patients were included if they were found to be negative for H. pylori infection by testing at least 1 year following eradication and underwent at least one further test for H. pylori. RESULTS: 1162 patients met the inclusion criteria with median post-eradication follow-up of 3 years (1.5-14) including 4668 tests; 3319 years of follow-up were analysed. Thirteen cases of re-infection occurred (re-infection rate 0.4% per year). CONCLUSIONS: This large study of H. pylori re-infection avoided cases of recrudescence by excluding the first post-eradication year. True re-infection is probably less common than previously thought.

Oral prednisolone metasulphobenzoate in the treatment of active ulcerative colitis.

BACKGROUND: Corticosteroids are one of the mainstays of treatment for active ulcerative colitis, but they are associated with numerous side effects. The sparingly absorbed corticosteroid prednisolone metasulphobenzoate is used topically in the treatment of distal disease. A targeted-release oral preparation (Predocol) has been developed to allow delivery of this drug to the whole colon. We have studied the effect of oral Predocol on inflammation as measured by 99Tc(m)-HMPAO leucocyte scintigraphy in patients with symptomatic and sigmoidoscopic relapse of known extensive ulcerative colitis. METHODS: Fourteen patients were recruited and received Predocol 47.1 mg twice daily, 8 for 7 days and 6 for 14 days. Scintigraphy was performed prior to and at the end of treatment. Each segment of colon was graded (0-4) and individual scores summed to give a total scintigraphic score. RESULTS: Total scintigraphic score improved by a mean of 2.5 (P = 0.027). Mean individual scores improved in the rectum by 0.7 (P = 0.038) and in the descending colon by 0.8 (P = 0.033). CONCLUSIONS: Predocol is an oral preparation of a poorly absorbed salt of prednisolone that is effective in reducing inflammation over short treatment periods in patients with active ulcerative colitis.

Adult small intestinal transplantation in England and Wales.

BACKGROUND: In 1996 two transplantation centres in the UK were commissioned by the National Specialist Commissioning Advisory Group for England and Wales to assess small intestinal transplantation in adults. The joint experience of the two centres is presented. METHODS: Patients with irreversible small intestinal failure and complications of parenteral nutrition, and those with abdominal disease requiring extensive visceral resection, were assessed as candidates and where appropriate listed for surgery. RESULTS: Thirty-six patients were assessed for small intestinal transplantation and, of these, 14 underwent surgery. Twelve patients survived the transplantation procedure. Of these, seven patients were alive at 1 year, five at 3 years and three at 5 years. Three patients remain alive. Patient and graft survival improved with experience; the 1-year survival rate improved in the last 4 years of this experience from 43 to 57 per cent, and the 3-year survival rate from 29 to 43 per cent. CONCLUSION: Small intestinal transplantation is associated with a high mortality rate but may benefit carefully selected patients in whom conservative management is likely to carry a greater mortality rate.

Rupture of the pectoralis major: a meta-analysis of 112 cases.

Of about 150 cases reported in the literature on pectoralis major ruptures, 108 were selected as presenting enough data to be analyzed for cause, rupture site, injury mechanism, and treatment outcome. We added data on four of our own cases reported here. All patients yet reported have been men. Rupture of the PM occurs most commonly in sports during weight training, weight lifting, or wrestling when the arm is externally rotated and abducted. Most reported ruptures are complete and are located at the insertion to the humerus. Work-related injuries occur more often at the musculo-tendinous junction. The prognosis is related neither to the age of the patient nor to the location of the rupture. Surgical treatment, preferably within the first 8 weeks after the injury, has a significantly better outcome than conservative treatment or delayed repair.

Heterorhabditis bacteriophora: seasonal dynamics and distribution in a stand of sugar maple, Acer saccharum.

The seasonal dynamics of an indigenous entomopathogenic nematode, a new strain of Heterorhabditis bacteriophora, "Nittany strain," in a stand of sugar maple, Acer saccharum, were examined utilizing a Galleria mellonella bait method. Seasonal dynamics are described in relation to soil temperature; occurrence is related to distance from a tree bole. A correlation between soil temperature and the number of infected G. mellonella was observed. Soil temperature had a significant effect on the number of positive samples, i.e., soil samples containing infected G. mellonella, obtained. In addition, seasonality had a significant effect on whether positive samples were obtained on a given date. There was no significant difference in the abundance of positive samples among three distances from a tree bole, namely, at the base of the tree, 2 m from the bole, or at the dripline.