Safety of maintaining elective and emergency surgery during the COVID-19 pandemic with the introduction of a Protected Elective Surgical Unit (PESU): A cross-specialty evaluation of 30-day outcomes in 9,925 patients undergoing surgery in a University Health Board.

Background: The COVID-19 pandemic has caused unprecedented health care challenges mandating surgical service reconfiguration. Within our hospital, emergency and elective streams were separated and self-contained Protected Elective Surgical Units were developed to mitigate against infection-related morbidity. Aims of this study were to determine the risk of COVID-19 transmission and mortality and whether the development of Protected Elective Surgical Units can result in significant reduction in risk. Methods: A retrospective observational study of consecutive patients from 18 specialties undergoing elective or emergency surgery under general, spinal, or epidural anaesthetic over a 12-month study period was undertaken. Primary outcome measures were 30-day postoperative COVID-19 transmission rate and mortality. Secondary adjusted analyses were performed to ascertain hospital and Protected Elective Surgical Unit transmission rates. Results: Between 15 March 2020 and 14 March 2021, 9,925 patients underwent surgery: 6,464 (65.1%) elective, 5,116 (51.5%) female, and median age 57 (39-70). A total of 69.5% of all procedures were performed in Protected Elective Surgical Units. Overall, 30-day postoperative COVID-19 transmission was 2.8% (3.4% emergency vs 1.2% elective P < .001). Protected Elective Surgical Unit postoperative transmission was significantly lower than non-Protected Elective Surgical Unit (0.42% vs 3.2% P < .001), with an adjusted likely in-hospital Protected Elective Surgical Unit transmission of 0.04%. The 30-day all-cause mortality was 1.7% and was 14.6% in COVID-19-positive patients. COVID-19 infection, age > 70, male sex, American Society of Anesthesiologists grade > 2, and emergency surgery were all independently associated with mortality. Conclusion: This study has demonstrated that Protected Elective Surgical Units can facilitate high-volume elective surgical services throughout peaks of the COVID-19 pandemic while minimising viral transmission and mortality. However, mortality risk associated with perioperative COVID-19 infection remains high.

Genome Sequences of 14 Siphophages That Infect Serratia marcescens.

We announce the complete genome sequences of 14 Serratia bacteriophages isolated from wastewater treatment plants. These phages define two previously undescribed types which we call the Carrot-like phage cluster (phages Carrot, BigDog, LittleDog, Niamh, Opt-148, Opt-169, PhooPhighters, Rovert, Serratianator, Stoker, Swain, and Ulliraptor) and Tlacuache-like phage cluster (Tlacuache and Opt-155).

Past, present, and future of nitrous oxide.

Introduction: For a drug that has been omnipresent for nearly 200 years, nitrous oxide's (N2O) future seems less certain than its illustrious past. Environmental concerns are coming to the fore and may yet outweigh important clinical benefits. Sources of data: After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered. Areas of agreement: The analgesic and anaesthetic advantages of N2O remain despite a plethora of newer agents. Areas of controversy: N2O greenhouse gas effect and its inhibition of key enzymes involved in protein and DNA synthesis have provided further fuel for those intent on eliminating its further clinical use. Growing points: The use of N2O for treatment-resistant depression has gained traction. Areas timely for developing research: Comparative studies for N2O role in combatting the prescription opioid analgesic epidemic may well provide further clinical impetus.

Adjuvant lipiodol I-131 after curative resection/ablation of hepatocellular carcinoma.

AIM: A total of 329 patients with hepatocellular carcinoma have been treated at our unit since 1990. Following the randomized controlled trial in Hong Kong by Lau et al. in 1999, patients have been offered adjuvant lipiodol I-131. The aim of this study was to determine the effectiveness of adjuvant lipiodol I-131, following potentially curative surgery with resection and/or ablation, on overall and disease-free survival rates. MATERIAL AND METHODS: The prospectively updated hepatocellular carcinoma database was analysed retrospectively. A total of 34 patients were identified to have received adjuvant lipiodol I-131 post-curative treatment with surgical resection and/or ablation. Patient demographics, clinical, surgical, pathology, and survival data were collected and analysed. RESULTS: Three patients received ablation alone, 24 resection, and 7 resection and ablation. Of the 34 patients treated, there were 2 possible cases of treatment-related fatality (pneumonitis and liver failure). Potential prognostic factors studied for effect on survival included age, gender, serum AFP concentration, Child-Pugh score, cirrhosis, tumor size, portal vein tumor thrombus, tumor rupture, and vascular and margin involvement. The median follow-up duration was 23.3 months. The overall median survival was 40.1 months, while the overall survival rates at 1, 2, 3, and 4 years were 87.1%, 71.7%, 60.7%, and 49.6%, respectively. Median duration to recurrence was 22.3 months. CONCLUSION: Administration of adjuvant lipiodol I-131 is associated with good overall survival.

Validation of a semi-automated scintigraphic technique for detecting episodic, real-time colonic flow.

The relationships between the movement of colonic content and regional pressures have only been partially defined. During the analysis of a combined colonic scintigraphic and manometric study, a quantitative technique for determining discrete, episodic, real-time colonic flow was developed. Our aim was to validate this technique through the construction of a computer-generated phantom model of known antegrade and retrograde motility. The anthropoid phantom was rasterized into a 6-mm voxel model to create a 3D voxel phantom of the colon with four distinct colonic segments. Associating a time/activity curve with each segment simulated dynamic behaviour. Activity in the model was based on data obtained from human colonic scintigraphic recordings using 30 MBq of (99m)Tc sulphur colloid. The flow was simulated by modifying the input time/activity functions to represent episodes of net flow of 2%, 5% or 10% of segmental content. Our quantitative technique was applied to the phantom model to measure the accuracy with which simulated flows were detected. Our quantitative technique proved to be a sensitive and specific means of detecting the presence and the magnitude of discrete episodes of colonic flow and therefore, should improve our ability to correlate colonic flow and motor patterns.

Oropharyngeal scintigraphy: a reliable technique for the quantitative evaluation of oral-pharyngeal swallowing.

A valid and reliable technique to quantify the efficiency of the oral-pharyngeal phase of swallowing is needed to measure objectively the severity of dysphagia and longitudinal changes in swallowing in response to intervention. The objective of this study was to develop and validate a scintigraphic technique to quantify the efficiency of bolus clearance during the oral-pharyngeal swallow and assess its diagnostic accuracy. To accomplish this, postswallow oral and pharyngeal counts of residual for technetium-labeled 5- and 10-ml water boluses and regional transit times were measured in 3 separate healthy control groups and in a group of patients with proven oral-pharyngeal dysphagia. Repeat measures were obtained in one group of aged (> 55yr) controls to establish test-retest reliability. Scintigraphic transit measures were validated by comparison with radiographic temporal measures. Scintigraphic measures in those with proven dysphagia were compared with radiographic classification of oral vs. pharyngeal dysfunction to establish their diagnostic accuracy. We found that oral ( p = 0.04), but not pharyngeal, isotope clearance is swallowed bolus-dependently. Scintigraphic transit times do not differ from times derived radiographically. All scintigraphic measures have extremely good test-retest reliability. The mean difference between test and retest for oral residual was -1% (95% CI -3%-1%) and for pharyngeal residual it was -2% (95% CI -5%-1%). Scintigraphic transit times have very poor diagnostic accuracy for regional dysfunction. Abnormal oral and pharyngeal residuals have positive predictive values of 100% and 92%, respectively, for regional dysfunction. We conclude that oral-pharyngeal scintigraphic clearance is highly reliable, bolus volume-dependent, and has a high predictive value for regional dysfunction. It may prove useful in assessment of dysphagia severity and longitudinal change.

Treating vulvar vestibulitis with electromyographic biofeedback of pelvic floor musculature.

OBJECTIVE: To evaluate the effectiveness of electromyographic biofeedback of pelvic floor musculature in the management of patients with moderate to severe vulvar vestibulitis syndrome. STUDY DESIGN: Twenty-nine patients with moderate to severe vulvar vestibulitis syndrome were included in this study. Each patient was given a computerized electromyographic assessment of pelvic floor muscles. She was then provided with a portable electromyographic home trainer biofeedback device, and specific instructions were given to perform biofeedback-assisted pelvic floor muscle rehabilitation exercises. The patients received monthly evaluations of the pelvic floor muscles to ensure and motivate compliance and to monitor improvement and symptom changes. Patients were evaluated on a monthly basis for vestibulodynia and dyspareunia. RESULTS: Fifteen of the 29 treated patients (51.7%) demonstrated markedly decreased introital tenderness, and 14 of them (93.3%) were able to resume sexual activity without discomfort. Nine patients (31.0%) demonstrated a significant decrease in introital tenderness and pain, and six of the nine (66.7%) resumed sexual activity. Thus, 20 of the 29 women (69%) became sexually active. Following completion of treatment, 24 (88.9%) reported negligible or mild pain. Five of the 29 did not show any significant improvement, and none of them were able to resume sexual activity. Within six months of the start of therapy, 90% ultimately resuming sexual activity had done so. CONCLUSION: Electromyographic biofeedback of pelvic floor musculature is an effective approach to vulvar vestibulitis.

Measurement of cognitive performance in computer programming concept acquisition: interactive effects of visual metaphors and the cognitive style construct.

An innovative research program was devised to investigate the interactive effect of instructional strategies enhanced with text-plus-textual metaphors or text-plus-graphical metaphors, and cognitive style on the acquisition of programming concepts. The Cognitive Styles Analysis (CSA) program (Riding,1991) was used to establish the participants' cognitive style. The QUEST Interactive Test Analysis System (Adams and Khoo,1996) provided the cognitive performance measuring tool, which ensured an absence of error measurement in the programming knowledge testing instruments. Therefore, reliability of the instrumentation was assured through the calibration techniques utilized by the QUEST estimate; providing predictability of the research design. A means analysis of the QUEST data, using the Cohen (1977) approach to size effect and statistical power further quantified the significance of the findings. The experimental methodology adopted for this research links the disciplines of instructional science, cognitive psychology, and objective measurement to provide reliable mechanisms for beneficial use in the evaluation of cognitive performance by the education, training and development sectors. Furthermore, the research outcomes will be of interest to educators, cognitive psychologists, communications engineers, and computer scientists specializing in computer-human interactions.

An assessment of the sensitivity of the Cedars-Sinai quantitative gated SPECT software to changes in the reconstruction of the short-axis slices.

OBJECTIVE: This study assessed whether variations in count density, reconstruction filtering parameters and the short-axis orientation selected for reconstructions of myocardial short-axis slices significantly influenced the left ventricular ejection fraction (LVEF) calculated from a gated myocardial perfusion SPECT study. METHODS: The Cedars-Sinai quantitative gated SPECT software package was used to estimate the LVEF from gated 99mTc-sestamibi and 201TI gated SPECT studies in 20 patients. Oblique slices were reconstructed 12 times for each study, independently varying the filter cutoff and the orientation of the short axis each time. RESULTS: There were no clinically significant changes in the LVEF over the range of cutoff frequencies or orientation for either the 201TI or 99mTc-sestamibi studies. There was excellent agreement between the LVEF calculated from the 201TI and 99mTc-sestamibi studies on the same patients using the default filter (mean difference = 0.25% points). CONCLUSIONS: The Cedars-Sinai quantitative gated SPECT software package for parallel-hole collimators can be used with confidence to obtain an LVEF, and is not sensitive to variations in count density, filtering parameters or short-axis orientation.

Pertussis encephalopathy with high cerebrospinal fluid antibody titers to pertussis toxin and filamentous hemagglutinin.

A 7-year-old unimmunized girl with pertussis presented with respiratory failure and electroencephalographic evidence of an encephalopathy. The cerebrospinal fluid (CSF)/serum ratio of antibodies to pertussis toxin and filamentous hemagglutinin were 11- and ninefold higher than the CSF/serum ratio of total immunoglobulin G. The CSF/serum ratio of albumin was normal. These findings indicate production of antibodies in the central nervous system to Bordetella pertussis antigens and imply, therefore, that the pertussis encephalopathy in this girl was associated with the entry of pertussis antigens into the central nervous system.

Reproducibility study of left ventricular measurements with breath-hold cine MRI using a semiautomated volumetric image analysis program.

The reproducibility of a semiautomated method of volumetric analysis allowing estimates of left ventricular (LV) parameters in approximately 5 minutes of analysis time is reported. Twenty normal volunteers underwent cine breath-hold cardiac MRI on two occasions with two observers using this new semiautomated method to estimate LV parameters. Reproducibility of this technique was comparable to published data with a variability of less than approximately 10% for all LV parameters calculated. Using this technique, the 95% confidence limits for change for left ventricular end diastolic volume (LVEDV) = +/-15 ml, left ventricular end systolic volume (LVESV) = +/-8 ml, LV mass = +/-24 g, and left ventricular ejection fraction (LVEF) = +/-6%. This new method also compared favorably to established manual methods. This new method permits estimation of LV parameters with acceptable reproducibility in a time that may permit routine quantitation of cardiac MR studies.

The effect of human anticardiolipin antibodies on murine pregnancy.

Anticardiolipin antibodies (aCL) were affinity purified or isolated in the IgG fraction of serum from 6 patients with antiphospholipid antibody syndrome. Anticardiolipin antibodies from one patient consistently compromised murine pregnancy. However in 92% (45 of 49) of cases injection of human anticardiolipin antibodies had no adverse effect on murine pregnancy, regardless of whether affinity purified aCL or IgG fractions were used. It is concluded that in most cases human anticardiolipin antibodies alone do not induce murine fetal loss.

Comparison of tests for the lupus anticoagulant and antiphospholipid antibodies in systemic lupus erythematosus.

A variety of laboratory assays are used to screen for the presence of the lupus anticoagulant. Six commonly used coagulation tests, and the ELISA assay for antiphospholipid antibody using three different substrate phospholipids, have been evaluated in 110 patients with systemic lupus erythematosus or lupus-like disease. One or more coagulation assays was abnormal in 41% (45/110) of the patients. No individual test detected more than 78% of these abnormalities, indicating that a single phospholipid based coagulation test cannot be used to screen for a possible lupus anticoagulant. A combination of Actin FSL, DTTA and DRVVT detected all the abnormalities. The most sensitive two-test combination was Actin FSL and DRVVT. Approximately half (56%) of the patients with a positive clotting test had an abnormal antiphospholipid antibody assay. A similar proportion (58%) of the aPL positive patients had a prolonged coagulation test. The marked discordance between the coagulation assays and a positive antiphospholipid antibody test further complicates the laboratory definition of this abnormality, at least in patients with systemic lupus erythematosus.

Influence of aging on oral-pharyngeal bolus transit and clearance during swallowing: scintigraphic study.

The aim of the study was to determine the influence of normal aging on regional transit and the efficiency of bolus clearance during the oral and pharyngeal phases of swallowing. We compared scintigraphically derived oral-pharyngeal transit times and isotope clearance during swallowing in 21 healthy aged volunteers (mean age 68 +/- 8 yr) and 9 young controls (mean age 28 +/- 7.5 yr). Subjects swallowed 5- and 10-ml water boluses mixed with 30 MBq 99mtechnetium tin colloid. Oral and pharyngeal transit times, pharyngeal clearance time, and postswallow residual counts in each region were derived from time-activity curves. Pharyngeal residual counts were significantly greater in the aged than in controls (P = 0.0008), but age did not influence oral residual. Aging significantly prolonged oral transit time (P = 0.02), pharyngeal transit time (P = 0.0004), and pharyngeal clearance time (P = 0.0001). We conclude that normal impairs the efficiency of pharyngeal clearance during swallowing, prolongs scintigraphic measures of oral-pharyngeal transit, and increases the exposure time of the glottis to the swallowed bolus.

Effects of publicity and a warning letter on illegal cigarette sales to minors.

The study aimed to assess rates of illegal cigarette sales to children and the impact on these rates of publicity and a warning letter threatening prosecution. Children aged 12 and 13 made two repeat purchasing attempts, three months apart, at 255 randomly selected tobacco retail outlets in Sydney. A randomly selected 50 per cent of retail outlets which sold cigarettes illegally at the first attempt were sent warning letters threatening prosecution. Publicity about the undercover buying operation was organised between the attempts. At the first attempts, 39 per cent of shops sold cigarettes to the children and 32 per cent sold them at the second attempt. Shops which sold on the first occasion and received warning letters reduced selling by 69 per cent compared to the 40 per cent reduction in shops which sold cigarettes on the first attempt and were not sent warning letters, a net reduction of 29 per cent seemingly attributable to the warning letters (95 per cent confidence interval 8 per cent to 50 per cent). It is extremely easy for children as young as 12 to buy cigarettes. The combined effects of publicity about undercover buying operations and warning letters threatening prosecution seem capable of reducing selling by about 29 per cent. Because of inconsistencies in selling or refusals, future attempts to measure selling rates to children should use repeat purchasing attempts and classify outlets as 'selling', 'not selling' or 'sometimes selling'.

Elution of anticardiolipin antibodies and their cofactor beta 2-glycoprotein 1 from the placentae of patients with a poor obstetric history.

Anticardiolipin antibodies (aCL) were eluted from the placentae of four women with elevated serum levels of aCL, demonstrating that these antibodies are bound to affected placentae. Anticardiolipin antibodies bound to affected placentae were only of the IgG isotype and the level of aCL in placental eluates did not reflect serum levels. Anticardiolipin antibodies were not isolated from placental eluates of control normal pregnancies. beta 2-Glycoprotein 1, the anticardiolipin antibody cofactor, was present in the placental eluates from both control and antiphospholipid antibody (aPL) affected pregnancies and was localised in the syncytiotrophoblast by immunohistochemical analysis. Antinuclear antibodies were present in the placental eluates of 3 of the 4 patients with antiphospholipid antibody syndrome and were absent from the placental eluates of control pregnancies. The authors propose that anticardiolipin antibody binds directly to placental tissue, disrupting uteroplacental blood flow and/or transport through the villi.

The herpes simplex virus type 1 strain 17 open reading frame RL1 encodes a polypeptide of apparent M(r) 37K equivalent to ICP34.5 of herpes simplex virus type 1 strain F.

The region between the 'a' sequence and the 5' end of the IE1 gene within the long repeat sequence of the herpes simplex virus (HSV) genome plays an important role in the neurovirulence of both HSV-1 strain F and HSV-1 strain 17. However, there has been controversy over the protein-coding potential of this region. Although an open reading frame (ORF) was predicted in HSV-1(F) and shown to encode a polypeptide called ICP34.5, only recently has a corresponding ORF, designated RL1, been recognized in HSV-1(17). To determine whether the HSV-1(17) ORF is expressed, we raised antipeptide sera against predicted amino acid sequences from RL1; one serum specifically recognized a 37K protein in HSV-1(17)-infected cell extracts. Compared with the corresponding HSV-1(F) polypeptide the HSV-1(17) protein has a lower apparent M(r), shows similar kinetics of accumulation and intracellular localization but may accumulate to lower levels than the HSV-1(F) protein. The non-neurovirulent HSV-1(17) deletion variant 1716 fails to synthesize detectable levels of ICP34.5. Thus we have established that HSV-1(17), like HSV-1(F), expresses ICP34.5, a protein important for HSV neurovirulence.