Utility of overnight oximetry indices in the evaluation of children with snoring and suspected obstructive sleep apnea.

STUDY OBJECTIVES: Optimal cutoff values of oximetry indices that differentiate obstructive sleep apnea (OSA) from primary snoring (PS) is not well established. Our study aimed to assess the utility of overnight oximetry indices in differentiating PS from OSA and assessing OSA severity, compared to polysomnography (PSG), in children with suspected OSA. METHODS: This was a retrospective study of children (1-18 years) with snoring who underwent PSG. Patients with Down syndrome, craniofacial anomalies, known genetic syndromes, neuromuscular conditions and central apnea index ≥ 5 were excluded. Demographic data, PSG variables and oximetry indices (e.g. oxygen desaturation index [ODI3, defined as number of ≥ 3% desaturation episodes/hour of artifact free recording time and SpO2 nadir]) were collected. RESULTS: Of 1,203 children (mean age 9.1±3.9 years, 67.7% males), 91.8% (847/923) ≤ 12 years and 84.3% (236/280) > 12 years had OSA. Optimal cutoff of ODI3 for differentiating PS from OSA was 2.4 [Se: 78.8% (75.9%-81.6%), Sp: 80.5% (69.9%-88.7%)] in ≤ 12 years and 3.6 [Se: 71.1% (64.8%-76.8%), Sp: 91.1% (78.8%-97.5%)] in > 12 years. The optimal cutoff of ODI3 for differentiating PS from mild, moderate and severe OSA categories were 2.0 [Se: 70.1% (65.3%-74.5%), Sp: 70.1% (58.6%-80.0%)]; 3.7 [Se: 82.3% (76.6%-87.1%), Sp: 94.8% (87.2%-98.6%)] and 4.3 [Se: 99.1% (96.8%-99.9%), Sp: 98.7% (93.0%-100.0%)] in ≤ 12 years; and 1.9 [Se: 78.8% (75.9%-81.6%), Sp: 80.5% (69.9%-88.7%)]; 4.1 [Se: 85.4% (72.2%-93.9%), Sp: 91.1% (78.8%-97.5%)] and 6.9 [Se: 98.4% (91.2%-100.0%), Sp: 97.8% (88.2%-99.9%)] in > 12 years, respectively. CONCLUSIONS: This study provides optimal cutoff values for ODI3 in differentiating PS from OSA and assessing OSA severity in children. As oximetry is cheaper and widely available, ODI3 has the potential to be incorporated into cost-effective clinical decision-making algorithms, especially in resource limited settings.

"Connect Local": protocol for the evaluation of a codesigned whole of community approach to promote social connection in older adults.

Background: There is wide acknowledgement in the literature that social connection is protective against loneliness and depression. More robust research, however, is needed to evaluate interventions that promote social connection. This protocol paper outlines the evaluation of a community-wide social connection program, Connect Local, in metropolitan Melbourne, Australia to support people 65 years and older to increase access to local community services/activities; and to ascertain impact on social connection, loneliness, depressive symptoms, physical and mental wellbeing, and use of health services. Methods: A Type 1 Hybrid design, including program effectiveness, cost-effectiveness, and implementation evaluation of the Connect Local program, will be undertaken. Eighty-eight participants aged ≥65 years with one or more chronic health condition, who are also either experiencing or at risk of loneliness, social isolation and depressive symptoms will be invited to participate in the evaluation. Outcomes, measured at baseline, 3, 6 and 12 months, include loneliness, social isolation, depressive symptoms, social anxiety, goal attainment, wellbeing, quality of life and health care utilisation. A gender and age matched comparator group of 88 individuals will be recruited from outside the intervention local government area. Impact of the intervention on community service providers in the target region will be evaluated using mixed methods, where triangulation will be used to combine the qualitative and quantitative data using a deductive-simultaneous design. Changes in wellbeing and quality of life of community volunteers will also be measured. All groups will be interviewed to ascertain their experience and perceptions of the program. The economic evaluation will use a Social Return on Investment (SROI) approach, to include outcomes at the individual, community, and system levels. Implementation outcomes will consider Reach, Adoption, Feasibility, Acceptability, Appropriateness, Fidelity, and Sustainability of the intervention. Discussion: This study will provide a better understanding of the impacts of a community-wide social connection approach in older adults, the community and broader system. Clinical trial registration: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385192; Identifier ACTRN12623000968673.

Salvage neck surgery in recurrent nodal NPC: Do all patients require a comprehensive neck dissection in the modern MRI era?

OBJECTIVE: The standard treatment for regional failure in nasopharyngeal carcinoma (NPC) is the radical neck dissection (RND). Our study sought to determine if magnetic resonance imaging (MRI) may accurately predict nodal involvement to allow selected levels of neck dissection to be preserved. STUDY DESIGN AND SETTING: We analysed retrospectively all NPC patients in our centre undergoing neck dissections as salvage therapy for nodal recurrence. Nodal involvement based on the preoperative MRI was assessed and compared with postoperative histopathology. METHODS: This is a retrospective study conducted on patients in our centre with recurrent NPC from February 2002 to February 2017. Patients were identified from the database of the otolaryngology oncology division at our institution. Of these, 28 patients met all our inclusion and exclusion criteria. We calculated sensitivity and specificity as well as average number of nodes per patient. RESULTS: In our study, we calculated the false negative and false positive rates of preoperative MRI neck by levels. Overall sensitivity of MRI picking up disease by level was 76% and specificity was 86%. CONCLUSION: Based on our study, we will be missing a total of 10 (7.1%) diseased neck levels in eight (28.5%) patients. MRI alone, therefore, does not provide enough information to allow safe selective preservation of neck levels in surgical salvage of neck recurrences in NPC.

Retaining dermatology patients in primary care through dialogue with secondary care providers: A service evaluation.

BACKGROUND: There are long patient waiting lists for specialist care. A dermatology dialogue service between primary and secondary care (DDPS) was developed in eastern England. Primary care referrers uploaded patient images of skin conditions for review by and dialogue with consultant dermatologists in an attempt to retain patients in primary care rather than refer them to secondary care. METHODS: Evaluation of service performance against specific targets, including reduction in secondary care waiting list growth over the period April 2021-March 2022 inclusive. Service activity was summarized in terms of speed of resolution, case numbers, and dispositions. Clinician and patient satisfaction were assessed using structured questionnaires. Actual numbers of new referrals were compared to projections based on historical data. Waiting list growth was compared to other specialties and other commissioning areas. Waiting times to initial treatment were monitored. RESULTS: Over 3300 patients were enrolled and > 90% of dialogues were resolved within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Waiting list growth for dermatology patients in the commissioning area was smaller than for other major specialties, and generally smaller than growth for dermatology waiting lists commissioned by other NHS commissioners. There was no negative impact on the urgent priority (cancer pathway) waiting list. CONCLUSION: The DDPS was satisfactory for clinicians and patients and coincided with lower growth in dermatology waiting lists than might otherwise have been expected.

Effect of water calcium, copper, and silver on branchial Na+ permeability in a characid and cichlid fish.

We tested the hypothesis that water Ca2+ is involved in control of branchial Na+ permeability in low pH tolerant convict cichlids and black neon tetras. We measured Na+ efflux in water with different Ca2+ concentrations during exposure to low pH, silver, and copper, at levels which are known to stimulate Na+ efflux. For convict cichlids at pH 7.5 exposure to 0 µmol L-1 Ca2+caused Na+ efflux to rise 2.5 times above controls at 100 µmol L-1 Ca2+. However, raising [Ca2+] to 500 µmol L-1 had no effect. Upon exposure to pH 3.5 (control [Ca2+]) Na+ efflux rose almost 5× and increasing the [Ca2+] 5-fold did not reduce the magnitude of stimulation. Exposure to 1 µmol L-1 silver and 25 µmol L-1 copper stimulated Na+ efflux 7×, and 2×, respectively. Raising [Ca2+] concentration during metal exposure halved the stimulation of Na+ efflux caused by silver, and eliminated the stimulation elicited by copper. For black neon tetras raising or lowering water [Ca2+] had no effect on Na+ efflux at pH 7.5. Exposure to pH 3.5 caused Na+ efflux to rise 2.5× but changing [Ca2+] had no effect. Exposure to 1 µmol L-1 silver, or 25 µmol L-1 copper caused Na+ efflux of tetras to rise 4-fold and 3-fold, respectively. Raising [Ca2+] during silver exposure reduced the stimulation of Na+ efflux by about 50%, but during copper exposure increased [Ca2+] had no effect on stimulation of Na+ efflux. These results suggest water Ca2+ plays a role in control of branchial Na+ permeability in cichlids, but perhaps not tetras. In addition, the silver and copper concentrations required to inhibit Na+ uptake and stimulate Na+ efflux were higher than the concentrations used on non-characids and non-cichlids, which indicates that our fish are much more tolerant of these metals.

Evaluation of high dose N- Acetylcysteine on airway inflammation and quality of life outcomes in adults with bronchiectasis: A randomised placebo-controlled pilot study.

BACKGROUND: High dose N acetylcysteine (NAC), a mucolytic, anti-inflammatory and antioxidant agent has been shown to significantly reduce exacerbations, and improve quality of life in placebo controlled, double blind randomised (RCT) studies in patients with COPD, and in an open, randomised study in bronchiectasis. In this pilot, randomised, double-blind, placebo-controlled study, we wished to investigate the feasibility of a larger clinical trial, and the anti-inflammatory and clinical benefits of high dose NAC in bronchiectasis. AIMS: Primary outcome: to assess the efficacy of NAC 2400 mg/day at 6 weeks on sputum neutrophil elastase (NE), a surrogate marker for exacerbations. Secondary aims included assessing the efficacy of NAC on sputum MUC5B, IL-8, lung function, quality of life, and adverse effects. METHODS: Participants were randomised to receive 2400 mg or placebo for 6 weeks. They underwent 3 visits: at baseline, week 3 and week 6 where clinical and sputum measurements were assessed. RESULTS: The study was stopped early due to the COVID pandemic. In total 24/30 patients were recruited, of which 17 completed all aspects of the study. Given this, a per protocol analysis was undertaken: NAC (n = 9) vs placebo (n = 8): mean age 72 vs 62 years; male gender: 44% vs 50%; baseline median FEV11.56 L (mean 71.5 % predicted) vs 2.29L (mean 82.2% predicted). At 6 weeks, sputum NE fell by 47% in the NAC group relative to placebo (mean fold difference (95%CI: 0.53 (0.12,2.42); MUC5B increased by 48% with NAC compared with placebo. Lung function, FVC improved significantly with NAC compared with placebo at 6 weeks (mean fold difference (95%CI): 1.10 (1.00, 1.20), p = 0.045. Bronchiectasis Quality of life measures within the respiratory and social functioning domains demonstrated clinically meaningful improvements, with social functioning reaching statistical significance. Adverse effects were similar in both groups. CONCLUSION: High dose NAC exhibits anti-inflammatory benefits, and improvements in aspects of quality of life and lung function measures. It is safe and well tolerated. Further larger placebo controlled RCT's are now warranted examining its role in reducing exacerbations.

openFrame: A modular, sustainable, open microscopy platform with single-shot, dual-axis optical autofocus module providing high precision and long range of operation.

'openFrame' is a modular, low-cost, open-hardware microscopy platform that can be configured or adapted to most light microscopy techniques and is easily upgradeable or expandable to multiple modalities. The ability to freely mix and interchange both open-source and proprietary hardware components or software enables low-cost, yet research-grade instruments to be assembled and maintained. It also enables rapid prototyping of advanced or novel microscope systems. For long-term time-lapse image data acquisition, slide-scanning or high content analysis, we have developed a novel optical autofocus incorporating orthogonal cylindrical optics to provide robust single-shot closed-loop focus lock, which we have demonstrated to accommodate defocus up to ±37 µm with <200 nm accuracy, and a two-step autofocus mode which we have shown can operate with defocus up to ±68 µm. We have used this to implement automated single molecule localisation microscopy (SMLM) in a relatively low-cost openFrame-based instrument using multimode diode lasers for excitation and cooled CMOS cameras.

Cauda equina thickening: an approach to MRI findings.

There are many causes of cauda equina (CE) thickening on neuroimaging of the lumbar spine. The imaging features of CE thickening for the various conditions often overlap and are non-specific to clinch a definite diagnosis. Hence, the imaging findings have to be discerned in accordance with the patient's presenting history, clinical examination findings, and results from electrophysiology and laboratory studies. In this review, the authors aim to supplement the existing literature on imaging findings of CE thickening with a diagnostic framework for clinical workup. The authors also aim to familiarise readers with the interpretation of CE thickening on magnetic resonance imaging (MRI) and would like to illustrate the normal variants and pitfalls that could be mistaken for abnormal results.

Is it a judgment of representativeness? Re-examining the birth sequence problem.

Although all birth orders in the "birth sequence problem" are equiprobable, most participants judge the less representative order as less likely than the more representative order. But this well-known problem confounds representativeness with the direction in which birth orders are compared. We hypothesized and corroborated in three experiments (total N = 1,136) that participants pragmatically infer the birth orders' relative prevalence from the direction of comparison. Experiment 1 found that participants judged the less representative sequence as more common when we reversed the comparison. Experiment 2 reproduced these results despite removing representativeness as a cue. In Experiment 3, participants preferred to place the relatively common sequence as the referent in an inverted "speaker" problem. Our results turn the iconic problem's interpretation on its head: Rather than indicating flawed human cognition, the birth sequence problem illustrates people's ability to adaptively extract subtle linguistic meaning beyond the literal content.

Macroprolactin screening in 464 patients with hyperprolactinaemia.

INTRODUCTION: Macroprolactinaemia is usually detected by polyethylene glycol (PEG) precipitation in clinical laboratories. Laboratory data on prolactin and macroprolactin screening by PEG precipitation in a tertiary hospital were reviewed in order to revise the local policy for reflex screening and reporting of macroprolactin in patients with hyperprolactinaemia. MATERIALS AND METHODS: Paired prolactin results from 464 patients before and after PEG precipitation, either requested by a clinician or performed as a reflex test, were retrieved and reviewed. RESULTS: Recovery of prolactin after PEG treatment was highly variable (3.7 to 97.7%). The distribution of prolactin recovery percentages after PEG precipitation in patients with true hyperprolactinaemia was markedly different from that in patients without true hyperprolactinaemia. The proportion of patients with true hyperprolactinaemia increased gradually with increasing pre-PEG prolactin concentrations; the reverse was true with macroprolactinaemia. Five patients (1.1%) were found to have co-existing macroprolactinaemia and true hyperprolactinaemia. CONCLUSION: Results from this retrospective study indicate that macroprolactinaemia is common and can be present even in patients with very high serum prolactin concentrations. There is no cut-off limit for pre-PEG serum prolactin concentration that can totally exclude macroprolactinaemia. Moreover, co-existence of true hyperprolactinaemia and macroprolactinaemia in the same patient is not a rare phenomenon. Post-PEG prolactin concentration and percentage recovery should be reported together to guide the interpretation and management of hyperprolactinaemia.

A cross-cultural comparison of sleep patterns between typically developing children and children with ASD living in Saudi Arabia and the United Kingdom.

BACKGROUND: Sleep is crucial for child development, especially for children with ASD. While it is known that children with ASD experience more severe sleep problems and that these problems tend to persist compared to their typically developing counterparts, these findings tend to come from only Western countries. A cross-cultural study is important to understand if the prevailing understanding of sleep in children with ASD can be extended to different cultural backgrounds. AIM: A cross-cultural study is conducted, involving typically developing children and children with ASD aged 5-12 across two countries: Saudi Arabia and the United Kingdom. METHODS AND PROCEDURES: Using a combination of questionnaires measuring ASD severity (CARS-2), sleep quality (CSHQ), sociodemographic and lifestyle variables and sleep diaries, 244 children were sampled using a mixture of snowball and convenience sampling methods. OUTCOMES AND RESULTS: Children with ASD experience more sleep problems compared to typically developing children in Saudi Arabia, and these problems similarly persist across time. Specifically, it was found that children with ASD in Saudi Arabia experience greater sleep onset latency and a greater number of night awakenings. Additionally, across the ASD groups, it was found that children from Saudi Arabia generally experienced poorer sleep than children in the United Kingdom in terms of shorter sleep duration, although children in the United Kingdom tended to report more instances of sleep anxiety and parasomnias. CONCLUSIONS AND IMPLICATIONS: Several reasons such as parental education about sleep hygiene, cultural influences and social hours were put forward as potential explanations for cross-cultural differences. Findings served to emphasise the importance of culturally-appropriate interventions and public education regarding child sleep.

Evaluate the safety and efficacy of dura sealant patch in reducing cerebrospinal fluid leakage following elective cranial surgery (ENCASE II): study protocol for a randomized, two-arm, multicenter trial.

BACKGROUND: Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants. METHODS: We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H2O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control. DISCUSSION: This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019.

Evaluation of N-acetylcysteine dose for the treatment of massive acetaminophen ingestion.

METHODS: The use of N-acetylcysteine (NAC) remains the standard of care for treatment of acetaminophen (APAP) toxicity and overdose. Currently, there is growing evidence to suggest that massive acetaminophen overdose is associated with increased hepatotoxicity despite timely administration of NAC. This raises the question as to whether an increased dose of intravenous (IV) NAC should be used in the setting of massive APAP ingestion. This study aimed to evaluate the rate of hepatotoxicity after massive APAP overdose treated with 3 different NAC treatment regimens. METHODS: This was a retrospective cohort study conducted by electronic medical record review of cases reported to a statewide poison control system between 2007 and 2020. Inclusion criteria were single APAP or APAP combination-medication ingestion; acute massive acetaminophen (APAP) ingestion (defined as APAP concentration ≥ 2 times above the Rumack-Matthew 150 nomogram); received one of the three NAC regimens: standard dose IV NAC, oral (PO) NAC, or high dose IV NAC. The risk of hepatotoxicity was evaluated using a multivariate logistic regression model with standard dose IV NAC as the base variable for comparison. RESULTS: A total of 373 patients met inclusion for the study. Of those, 135 cases were treated with standard dose IV NAC, 121 cases treated with PO NAC, and 117 cases treated with high dose IV NAC. The risk of developing hepatotoxicity was not statistically significant between the high dose IV NAC (OR 1.05, 95% CI 0.52 - 2.09) or oral NAC (OR 0.69, 95% CI 0.33 - 1.46) when compared to standard dose IV NAC. When adjusted for APAP combination medications, initial APAP ratio, initial elevated AST/ALT, and treatment within 8 h, there remained no difference between treatment regimens. CONCLUSION: This study was unable to detect a large absolute reduction in the rate of hepatotoxicity after massive APAP ingestion in patients treated with high dose IV NAC or PO NAC when compared to standard dose IV NAC; even when treatment was initiated within 8 h of ingestion.

Specialist Networks Influence Clinician Willingness to Treat Individuals with Special Needs.

BACKGROUND: The South Australian Dental Service's Special Needs Network was established to support oral health professionals working within their statewide government-funded dental service to treat patients with special needs. This study aimed to investigate how a structured network relationship with specialists in special needs dentistry influenced the willingness of dentists to treat this group of patients. METHODS: Semi-structured interviews were used to explore the views of specialists and dentists involved in the South Australian Dental Service's Special Needs Network. Inductive thematic analysis identified emerging themes enabling completion of a SWOT (strengths, weaknesses, opportunities, threats) analysis. RESULTS: Dentists felt that a strength of the Network was a greater sense of collegiality, particularly for those working in rural areas. Although the inability to get immediate advice was seen as a weakness, dentists felt a more structured relationship with specialists improved communication pathways and resulted in more timely care. The aging workforce, systemic barriers in the public dental system, such as productivity pressures and infrastructure, and the lack of support from other health professionals were seen as ongoing barriers and threats. Regardless, dentists identified the use of telehealth and visiting specialists as future opportunities. Specialists felt that the Network was a valuable resource but were skeptical about its effectiveness, feeling that a limitation was the ability of dentists to recognize the complexity of cases. CONCLUSIONS: Ongoing support from and communication with specialists in special needs dentistry through a structured network improved the perceived ability and willingness of dentists to treat patients with special needs. KNOWLEDGE TRANSFER STATEMENT: This research suggests that providing support to dentists through a hub-and-spoke network that facilitates additional training, professional interaction, and improved communication with specialists in special needs dentistry may help overcome some of the current barriers to access to care experienced by individuals with special needs, particularly those associated with the willingness and capability of clinicians treat them.

Characterizing the features and course of psychiatric symptoms in children and adolescents with autoimmune encephalitis.

Autoimmune encephalitis (AE) can present like a psychiatric disorder. We aimed to illustrate the psychiatric manifestations, course and management of AE in a paediatric cohort. Neuropsychiatric symptoms, investigations and treatment were retrospectively retrieved in 16 patients (mean age 11.31, SD 2.98) with an AE diagnosis at the liaison psychiatry services in two UK tertiary paediatric centres. Psychiatric presentation was characterised by an acute polysymptomatic (predominantly agitation, anger outbursts/aggressiveness, hallucinations, and emotional lability) onset. Antipsychotics produced side effects and significant worsening of symptoms in four cases, and benzodiazepines were commonly used. This psychiatric phenotype should make clinicians suspect the diagnosis of AE and carefully consider use of treatments.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE: Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect. METHODS: This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect. RESULTS: Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49). CONCLUSIONS: Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

COVID-19, circuit breaker and safe reopening - perspective from an ENT practice at a tertiary hospital in Singapore.

COVID-19 has affected every walk of life, including the healthcare sector. In this article, we discuss how an Otolaryngology department in a tertiary hospital in Singapore had to adapt to the pandemic in areas of outpatient care, elective surgeries, personal protection, residency training, education and research. Documenting our experience has helped us to understand the areas of work which can be affected in a pandemic and the factors that have helped to mitigate disruption. This will prove useful in our approach to subsequent pandemics.