Anaesthetists' current practice and perceptions of aerosol-generating procedures: a mixed-methods study.

The evidence base surrounding the transmission risk of 'aerosol-generating procedures' has evolved primarily through quantification of aerosol concentrations during clinical practice. Consequently, infection prevention and control guidelines are undergoing continual reassessment. This mixed-methods study aimed to explore the perceptions of practicing anaesthetists regarding aerosol-generating procedures. An online survey was distributed to the Membership Engagement Group of the Royal College of Anaesthetists during November 2021. The survey included five clinical scenarios to identify the personal approach of respondents to precautions, their hospital's policies and the associated impact on healthcare provision. A purposive sample was selected for interviews to explore the reasoning behind their perceptions and behaviours in greater depth. A total of 333 survey responses were analysed quantitatively. Transcripts from 18 interviews were coded and analysed thematically. The sample was broadly representative of the UK anaesthetic workforce. Most respondents and their hospitals were aware of, supported and adhered to UK guidance. However, there were examples of substantial divergence from these guidelines at both individual and hospital level. For example, 40 (12%) requested respiratory protective equipment and 63 (20%) worked in hospitals that required it to be worn whilst performing tracheal intubation in SARS-CoV-2 negative patients. Additionally, 173 (52%) wore respiratory protective equipment whilst inserting supraglottic airway devices. Regarding the use of respiratory protective equipment and fallow times in the operating theatre: 305 (92%) perceived reduced efficiency; 376 (83%) perceived a negative impact on teamworking; 201 (64%) were worried about environmental impact; and 255 (77%) reported significant problems with communication. However, 269 (63%) felt the negative impacts of respiratory protection equipment were appropriately balanced against the risks of SARS-CoV-2 transmission. Attitudes were polarised about the prospect of moving away from using respiratory protective equipment. Participants' perceived risk from COVID-19 correlated with concern regarding stepdown (Spearman's test, R = 0.36, p < 0.001). Attitudes towards aerosol-generating procedures and the need for respiratory protective equipment are evolving and this information can be used to inform strategies to facilitate successful adoption of revised guidelines.

Quantitative evaluation of aerosol generation from upper airway suctioning assessed during tracheal intubation and extubation sequences in anaesthetized patients.

BACKGROUND: Open respiratory suctioning is defined as an aerosol generating procedure (AGP). Laryngopharyngeal suctioning, used to clear secretions during anaesthesia, is widely managed as an AGP. However, it is uncertain whether upper airway suctioning should be designated as an AGP due to the lack of both aerosol and epidemiological evidence. AIM: To assess the relative risk of aerosol generation by upper airway suctioning during tracheal intubation and extubation in anaesthetized patients. METHODS: This prospective environmental monitoring study was undertaken in an ultraclean operating theatre setting to assay aerosol concentrations during intubation and extubation sequences, including upper airway suctioning, for patients undergoing surgery (N=19). An optical particle sizer (particle size 0.3-10 µm) sampled aerosol 20 cm above the patient's mouth. Baseline recordings (background, tidal breathing and volitional coughs) were followed by intravenous induction of anaesthesia with neuromuscular blockade. Four periods of laryngopharyngeal suctioning were performed with a Yankauer sucker: pre-laryngoscopy, post-intubation, pre-extubation and post-extubation. FINDINGS: Aerosol was reliably detected {median 65 [interquartile range (IQR) 39-259] particles/L} above background [median 4.8 (IQR 1-7) particles/L, P<0.0001] when sampling in close proximity to the patient's mouth during tidal breathing. Upper airway suctioning was associated with a much lower average aerosol concentration than breathing [median 6.0 (IQR 0-12) particles/L, P=0.0007], and was indistinguishable from background (P>0.99). Peak aerosol concentrations recorded during suctioning [median 45 (IQR 30-75) particles/L] were much lower than during volitional coughs [median 1520 (IQR 600-4363) particles/L, P<0.0001] and tidal breathing [median 540 (IQR 300-1826) particles/L, P<0.0001]. CONCLUSION: Upper airway suctioning during airway management was not associated with a higher aerosol concentration compared with background, and was associated with a much lower aerosol concentration compared with breathing and coughing. Upper airway suctioning should not be designated as a high-risk AGP.

Cover crops and carbon stocks: How under-vine management influences SOC inputs and turnover in two vineyards.

There is a growing awareness surrounding the importance of maintaining and increasing soil organic carbon (SOC, henceforth) stocks in vineyard systems. Increasing SOC positively influences numerous soil properties and has the added advantage of removing atmospheric CO2, thereby helping to mitigate the effects of climate change. Cover crops have long been used to influence soil properties in vineyard mid-rows, including increasing SOC content. Few studies, however, have quantified cover crop influence on SOC stocks and composition in the under-vine area, owing to a general reluctance to adopt under-vine cover crop management. This research aims to quantify SOC stocks and dissolved organic carbon (DOC) in soils from four treatments of under-vine management practice including two cover crop combinations, a straw mulch and herbicide-managed control across two vineyard sites established in 2014. We sampled soils under-vine to depths of 0-30 cm (stratified; 0-10 cm and 10-30 cm) and quantified both SOC concentrations and bulk density to ascertain SOC stocks. Further to this, we quantified water extractable organic carbon (WEOC) as a measure of the labile carbon stock, and measured heterotrophic respiration in a laboratory incubation as an indication of SOC turnover. We found that cover crop-managed soil under-vine sequesters up to 23% more soil organic carbon (SOC) as the traditional, herbicide practice over a five-year period of growth. Microbial activity increased by more than double in cover crop soils, owing to an increase in DOC and that there is evidence for more resistant C in cover crop soils. These results suggest that cover crop management under-vine is a viable solution to increase SOC stocks within vineyard systems. Taken together, the results of this study indicate that a shift from bare earth to cover crops in the under-vine region has the potential to sequester carbon in vineyard soils.

Evaluation of urinary chloride dipsticks for the rapid estimation of hydration status in patients receiving artificial nutrition: Feasibility study.

BACKGROUND AND AIMS: The home parenteral nutrition (HPN) population face many challenges, especially with respect to fluid balance management. A low urinary sodium concentration of <20 mmol/L is commonly used as an indicator of dehydration that requires clinical assessment in these patients. The Quantab titrator dipstick measures chloride concentration of a solution and correlates with sodium concentration. We assessed whether it would be feasible to use the Quantab dipstick in the HPN population and explored relationships between Quantab dipstick estimated chloride concentration and quality of life (QOL). METHODS: Patients on HPN were asked to collect urine samples at 5 specific times points (day 0,7,14, 21 and 28) to send to the laboratory for formal electrolyte analysis. The participant and a member of laboratory staff tested these samples with the Quantab dipstick to estimate urinary chloride concentration. Participants were instructed to complete a QOL questionnaire at each of the 5 time-points in addition to a baseline demographic questionnaire and an end-of-study questionnaire. Six participants completed an interview at the end of the study period. The relationship between participant-derived and laboratory-derived data was assessed using rank correlation coefficients. QOL assessment was correlated with urine dipstick measurements. RESULTS: 10 patients on HPN completed the study. Data on chloride concentration as estimated by the dipstick (assessed by participants and by the laboratory) and sodium concentration from the laboratory were available for 47 urine samples. There was a positive relationship between participant dipstick estimated chloride concentration and laboratory sodium (Kendall's τ = 0.45; P < 0.001; Spearman's rs = 0.58 P < 0.001; 47 pairs). There was a strong correlation between chloride concentrations estimated by dipstick in the laboratory and by participants (Kendall 0.58 p < 0.001, Spearman's 0.69 p < 0.001; 47 pairs). In exploratory analyses, there was no relationship between QOL and dipstick estimated chloride concentration. Participants had no issues collecting urine samples but some difficulties were reported with determining the dipstick reading. CONCLUSIONS: Patients on HPN are able to collect urine specimens, complete QOL questionnaires, and are capable of using the Quantab dipstick to estimate urinary chloride concentration. The Quantab dipstick correlates with laboratory measured sodium and chloride concentrations. Further work is required to fully establish whether this point-of-care test could be used to guide fluid balance management in the HPN population.

Quality of life, cognitive, physical and emotional function at diagnosis predicts head and neck cancer survival: analysis of cases from the Head and Neck 5000 study.

PURPOSE: The aim of this paper is to determine whether health-related quality of life (HRQOL) at diagnosis of head and neck cancer (HNC) is associated with overall survival following treatment with curative intent after adjusting for other factors. METHODS: Data were collected from 5511 participants of the Head and Neck 5000 study (HN5000). HRQOL was measured using the EORTC QLQ-C30. Questionnaire and covariate data were available from 2171 participants diagnosed as follows: oral cavity (655), oropharynx HPV+ (723) and HPV- (277), and larynx (516). On average, participants were followed up 3.2 years (SD 1.2) after diagnosis. Data were adjusted for age, gender, co-morbidity, intended treatment, education level, income from benefits, smoking status and alcohol consumption. RESULTS: There was a clinically meaningful difference between Global HRQOL scores at diagnosis and survival in an unadjusted and adjusted model: [HR = 0.86, CI 0.82-0.89, p < 0.001 (unadjusted) and HR = 0.90, CI 0.86-0.94, p < 0.001 (adjusted)]. In analyses stratified by tumour site and HPV status, this association was similarly noted before adjustment and persisted after. There were some tumour sub-site variations: improved survival for people with laryngeal cancer reporting higher levels of physical role or social functioning and people with oral cancer reporting higher levels of role or social functioning. CONCLUSION: As survival is the main priority for most people diagnosed with cancer, pre-treatment HRQOL is an additional factor to be included in risk stratification and case-mix adjustments. There is merit in incorporating HRQOL into routine clinical care as this is a useful facet in patient-clinician decision making, prognostication and recovery.

Recommendation to test limonene hydroperoxides 0·3% and linalool hydroperoxides 1·0% in the British baseline patch test series.

BACKGROUND: There is a significant rate of sensitization worldwide to the oxidized fragrance terpenes limonene and linalool. Patch testing to oxidized terpenes is not routinely carried out; the ideal patch test concentration is unknown. OBJECTIVES: To determine the best test concentrations for limonene and linalool hydroperoxides, added to the British baseline patch test series, to optimize detection of true allergy and to minimize irritant reactions. METHODS: During 2013-2014, 4563 consecutive patients in 12 U.K. centres were tested to hydroperoxides of limonene in petrolatum (pet.) 0·3%, 0·2% and 0·1%, and hydroperoxides of linalool 1·0%, 0·5% and 0·25% pet. Irritant reactions were recorded separately from doubtful reactions. Concomitant reactions to other fragrance markers and clinical relevance were documented. RESULTS: Limonene hydroperoxide 0·3% gave positive reactions in 241 (5·3%) patients, irritant reactions in 93 (2·0%) and doubtful reactions in 110 (2·4%). Linalool hydroperoxide 1·0% gave positive reactions in 352 (7·7%), irritant reactions in 178 (3·9%) and doubtful reactions in 132 (2·9%). A total of 119 patients with crescendo reactions to 0·3% limonene would have been missed if only tested with 0·1% and 131 patients with crescendo reactions to 1·0% linalool would have been missed if only tested with 0·25%. In almost two-thirds of patients with positive patch tests to limonene and linalool the reaction was clinically relevant. The majority of patients did not react to any fragrance marker in the baseline series. CONCLUSIONS: We recommend that limonene hydroperoxides be tested at 0·3% and linalool hydroperoxides at 1·0% in the British baseline patch test series.

Nursing work and sensory experiences of hospital design: A before and after qualitative study following a move to all-single room inpatient accommodation.

The embodied experience of nursing practice is rarely studied. Drawing on data from an internationally relevant larger study conducted in 2013-14, here we explore the sensory dimension of the embodied experiences of nursing staff working on two acute NHS hospital wards before and after a move to all-single room inpatient accommodation. We undertook a secondary analysis of 25 interviews with nursing staff (12 before and 13 after the move with half [13/25] using photographs taken by participants) from a mixed-method before-and-after study. This analysis focused on the sensory dimensions of nursing staff's experiences of their working practices and the effect of the built environment upon these. Drawing on Pallasmaa's theoretocal insights, we report how the all-single room ward design prioritises 'focused vision' and hinders peripheral perception, whilst the open ward environment is rich in contextual and preconscious information. We suggest all-single room accommodation may offer staff an impoverished experience of caring for patients and of working with each other.

Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection.

BACKGROUND: Chewing gum may stimulate gastrointestinal motility, with beneficial effects on postoperative ileus suggested in small studies. The primary aim of this trial was to determine whether chewing gum reduces length of hospital stay (LOS) after colorectal resection. Secondary aims included examining bowel habit symptoms, complications and healthcare costs. METHODS: This clinical trial allocated patients randomly to standard postoperative care with or without chewing gum (sugar-free gum for at least 10 min, four times per day on days 1-5) in five UK hospitals. The primary outcome was LOS. Cox regression was used to calculate hazard ratios for LOS. RESULTS: Data from 402 of 412 patients, of whom 199 (49·5 per cent) were allocated to chewing gum, were available for analysis. Some 40 per cent of patients in both groups had laparoscopic surgery, and all study sites used enhanced recovery programmes. Median (i.q.r.) LOS was 7 (5-11) days in both groups (P = 0·962); the hazard ratio for use of gum was 0·94 (95 per cent c.i. 0·77 to 1·15; P = 0·557). Participants allocated to gum had worse quality of life, measured using the EuroQoL 5D-3L, than controls at 6 and 12 weeks after operation (but not on day 4). They also had more complications graded III or above according to the Dindo-Demartines-Clavien classification (16 versus 6 in the group that received standard care) and deaths (11 versus 0), but none was classed as related to gum. No other differences were observed. CONCLUSION: Chewing gum did not alter the return of bowel function or LOS after colorectal resection. REGISTRATION NUMBER: ISRCTN55784442 (http://www.controlled-trials.com).

Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies.

By reducing energy density, low-energy sweeteners (LES) might be expected to reduce energy intake (EI) and body weight (BW). To assess the totality of the evidence testing the null hypothesis that LES exposure (versus sugars or unsweetened alternatives) has no effect on EI or BW, we conducted a systematic review of relevant studies in animals and humans consuming LES with ad libitum access to food energy. In 62 of 90 animal studies exposure to LES did not affect or decreased BW. Of 28 reporting increased BW, 19 compared LES with glucose exposure using a specific 'learning' paradigm. Twelve prospective cohort studies in humans reported inconsistent associations between LES use and body mass index (-0.002 kg m(-)(2) per year, 95% confidence interval (CI) -0.009 to 0.005). Meta-analysis of short-term randomized controlled trials (129 comparisons) showed reduced total EI for LES versus sugar-sweetened food or beverage consumption before an ad libitum meal (-94 kcal, 95% CI -122 to -66), with no difference versus water (-2 kcal, 95% CI -30 to 26). This was consistent with EI results from sustained intervention randomized controlled trials (10 comparisons). Meta-analysis of sustained intervention randomized controlled trials (4 weeks to 40 months) showed that consumption of LES versus sugar led to relatively reduced BW (nine comparisons; -1.35 kg, 95% CI -2.28 to -0.42), and a similar relative reduction in BW versus water (three comparisons; -1.24 kg, 95% CI -2.22 to -0.26). Most animal studies did not mimic LES consumption by humans, and reverse causation may influence the results of prospective cohort studies. The preponderance of evidence from all human randomized controlled trials indicates that LES do not increase EI or BW, whether compared with caloric or non-caloric (for example, water) control conditions. Overall, the balance of evidence indicates that use of LES in place of sugar, in children and adults, leads to reduced EI and BW, and possibly also when compared with water.

Prefrontal hypoactivation during working memory in bipolar II depression.

BACKGROUND: Patterns of abnormal neural activation have been observed during working memory tasks in bipolar I depression, yet the neural changes associated with bipolar II depression have yet to be explored. METHOD: An n-back working memory task was administered during a 3T functional magnetic resonance imaging scan in age- and gender-matched groups of 19 unmedicated, bipolar II depressed subjects and 19 healthy comparison subjects. Whole-brain and region-of-interest analyses were performed to determine regions of differential activation across memory-load conditions (0-, 1- and 2-back). RESULTS: Accuracy for all subjects decreased with higher memory load, but there was no significant group × memory load interaction. Random-effects analyses of memory load indicated that subjects with bipolar II depression exhibited significantly less activation than healthy subjects in left hemispheric regions of the middle frontal gyrus [Brodmann area (BA) 11], superior frontal gyrus (BA 10), inferior parietal lobule (BA 40), middle temporal gyrus (BA 39) and bilateral occipital regions. There was no evidence of differential activation related to increasing memory load in the dorsolateral prefrontal or anterior cingulate cortex. CONCLUSIONS: Bipolar II depression is associated with hypoactivation of the left medio-frontal and parietal cortex during working memory performance. Our findings suggest that bipolar II depression is associated with disruption of the fronto-parietal circuit that is engaged in working memory tasks, which is a finding reported across bipolar subtypes and mood states.

Effects of native grass cover crops on beneficial and pest invertebrates in Australian vineyards.

Indigenous cover crops have the potential to promote an increase in natural enemies providing fortuitous control of pest species and other ecosystem services. We test this idea in a vineyard in south eastern Australia, where reduced water availability because of drought coupled with increased temperatures has generated interest in sustainable alternatives to the exotic perennial cover crops commonly planted. Three endemic perennial cover crops, comprising the grasses Austrodanthonia richardsonii and Chloris truncata and a mix of two saltbushes (Atriplex semibaccata and Atriplex suberecta) were established as cover crops and compared with introduced oats (Avena sativa). Abundance of a range of predators and parasitoids was higher in vines with native cover crops compared with the oat control. In addition, predation levels of sentinel eggs of a common vineyard pest, light brown apple moth (Epiphyas postvittana), were increased in the native cover crops. However, the native cover crops also increased the abundance of some potential pest species. Native plants therefore have potential to increase abundance of beneficial invertebrates that assist in pest control, but need to be used carefully to ensure that they do not increase local pest problems.

Total mandibular reconstruction for massive osteolysis of the mandible (Gorham-Stout syndrome).

Massive osteolysis (Gorham-Stout syndrome) is a rare condition of unknown aetiology that is thought to result from a localised endothelial proliferation of lymphatic vessels resulting in destruction and absorption of bone. The diagnosis of Gorham-Stout syndrome can be made only after first excluding osteolysis from infection, inflammation, endocrine disease, and cancer. The syndrome is rarely seen in the facial skeleton and has a variable prognosis. Many treatments have been advocated but only surgery and radiotherapy have had some success. We present a case of massive osteolysis of the entire mandible, which was reconstructed with a free vascularised fibular graft and bilateral prosthetic replacements of the temporomandibular (TMJ) joints. Four years later the fibular graft had been absorbed requiring further reconstruction with another fibula graft.

Microvascular free tissue transfer in the management of squamous cell carcinoma of the tongue during pregnancy.

We describe a 36-year-old patient with a stage III carcinoma (pT2N1M0) of the tongue that presented in the second trimester of pregnancy. It was treated by primary excision and reconstruction with a free flap. To our knowledge this is the first reported case of successful microvascular free tissue transfer for oral cancer during pregnancy.

Insertion of percutaneous endoscopic gastrostomy tubes by a maxillofacial surgical team in patients with oropharyngeal cancer.

This study assessed the clinical outcome after insertion of a percutaneous endoscopic gastrostomy tube (PEGT) by a maxillofacial team in a series of 54 patients. The indication for PEG feeding was any patient with oropharyngeal cancer who was unlikely to return to oral feeding within 14 days. Fifty-two patients (96%) had tubes successfully inserted at the time of examination under anaesthesia (n = 19) or definitive operation (n = 33). Feeding was established at a median of 2 days (range 1-6). Median duration of tube feeding was 18 weeks (range 4-70). There were no deaths or major complications and 10 minor complications. No tube was lost or required premature removal. We conclude that insertion of a PEG tube is a procedure that can be done safely by maxillofacial surgeons.

Chronic eosinophilic pneumonia associated with T-cell lymphoma.

A case of a woman presenting with a parotid swelling is described. She had chronic eosinophilic pneumonia (CEP) for approximately 2 years prior to presentation. After further investigation she had biopsy of her parotid, which proved to be T-cell lymphoma. This is a rare association, the diagnosis and the management of this condition is discussed.