Two-year outcomes of conservatively managed appendicitis during the COVID-19 pandemic-a multicentre cohort study.

PURPOSE: During the COVID-19 pandemic, the new RCSEng guidelines resulted in appendicitis being more commonly managed conservatively to avoid aerosol-generating procedures. This resulted in shorter hospital stays without increased short-term complications. The 2-year outcomes of this change, specifically recurrence and re-admission rates remain unknown. METHODS: We conducted a multicentre, prospective, observational study including all adult patients treated as appendicitis after the implementation of the new surgical guidelines during the COVID-19 pandemic. Outcomes included initial management failure, re-admission rate, appendicitis recurrence, and interval appendicectomy. A historical cohort prior to the COVID-19 pandemic was used for comparison. Patients were followed up for 2-years post index admission. Categorical and continuous variables were compared using Fisher's exact test and Student's T or Mann-Whitney U tests as appropriate. RESULTS: Sixty-three and 79 patients with appendicitis were included from four NHS trusts, before (A) and after (B) the new intercollegiate guidelines respectively. Operative management was used less frequently in cohort B (28/79 vs 52/63; p<0.001). More patients re-presented in cohort B (14/79 vs 3/63; p=0.020), but not when comparing only those managed conservatively (2/11 vs 13/52; p=1.000). A similar trend was observed for appendicitis recurrence although without statistical significance (2/63 vs 9/79; p=0.112); with loss of trend when comparing those managed conservatively-only (2/11 vs 9/52; p=1.000). Among all patients, four (2.8%) were found to have underlying neoplasia of which three were initially managed conservatively (3/63; 4.8%). CONCLUSION: Conservative management of appendicitis has previously been shown to have short-term benefits in expedited hospital discharge without early complications. The present study shows it has a higher readmission and appendicitis recurrence rates. The risks of this alongside missed/delayed management of neoplasia needs to be considered alongside the benefits including avoidance of aerosol-generating general anaesthesia and laparoscopy during the COVID-19 pandemic or similar future health crises. Small case numbers limit analysis.

Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study.

PURPOSE: The COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown. METHODS: We performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications. RESULTS: A total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760). CONCLUSION: Introduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients.

Brucellosis-induced autoimmune haemolytic anaemia (AIHA).

Brucellosis is a rare zoonotic infection caused by small, fastidious Gram-negative coccobacilli of the genus Brucella that may be associated with haemolytic complications including thrombotic microangiopathy and haemolytic anaemia. We describe a patient with culture confirmed brucellosis who presented with malaise, high grade fever, hepatosplenomegaly and Coombs-positive autoimmune haemolytic anaemia. The patient was successfully treated with combination of doxycycline and rifampicin with no further episodes of relapses or haemolysis. Although rare, the possibility of brucellosis should always be kept in mind in patients with risk factors who present with haemolysis and endemic area.

Sinonasal inverted papilloma recurrence rates and evaluation of current staging systems.

BACKGROUND: Sinonasal inverted papillomas (SNIPs) are benign epithelial growths with high recurrence rates after surgical management. This study aims to evaluate SNIP recurrence rates after endoscopic surgery and to provide a comparison of published staging systems. METHODS: This chart review evaluated primary and revision SNIP cases from January 2008 to December 2016 at a tertiary sinus centre. Data was collected on patient demographics, origin site, surgical approaches, follow-up duration, recurrence, and smoking history. Each case was staged using Krouse, Oikawa, Cannady, Han, and Kamel systems. RESULTS: 52 primary and 22 revision SNIP patients had a mean follow-up of 42.3 (range:3-55) months. 11 primary cases (21.1%) and 5 revision cases (22.7%) had recurrences. Primary and revision cases had a mean time to recurrence of 24.0 (range:3-55) and 14.6 (range:10-20) months respectively. Smoking history had an OR of 0.63 (CI 95%: 0.18-2.22) for recurrence. The age group of 20-39 years featured the highest rates of recurrence. Patient groups defined by each staging system were compared by Kaplan-Meier survival analyses and logrank tests. Chi-squared values for Krouse, Oikawa, Cannady, Han, and Kamel systems were 6.73, 7.02, 6.19, 8.23 and 3.29, respectively. CONCLUSION: Recurrence rates found in this study are comparable to published literature. No statistical significance was found to associate smoking with recurrence. Han and Cannady staging systems were found to define patient groups that correlated well with recurrence. Staging systems should play a role in the management of SNIPs, especially to identify patients requiring additional post-surgical monitoring.

Severe hypothyroidism presenting with supraventricular tachycardia.

Thyroid disease is common and can have various systemic manifestations including cardiac diseases. Hypothyroidism is commonly associated with sinus bradycardia, low QRS complexes, prolonged QT interval and conduction blocks but rarely may cause arrhythmias. We present a patient who presented with presyncope and supraventricular tachycardia with severe hypothyroidism. Patient responded well to thyroxine replacement with biochemical improvement, the disappearance of arrhythmia after restoration of euthyroidism suggests that hypothyroidism might be the cause of supraventricular tachycardia. The aim of this report is to underline the possible aetiological link between supraventricular tachycardia and hypothyroidism, although supraventricular arrhythmias are ordinary features of hyperthyroidism.

Use of ICSI in IVF cycles in women with tubal ligation does not improve pregnancy or live birth rates.

STUDY QUESTION: Does ICSI improve outcomes in ART cycles without male factor, specifically in couples with a history of tubal ligation as their infertility diagnosis? SUMMARY ANSWER: The use of ICSI showed no significant improvement in fertilization rate and resulted in lower pregnancy and live birth (LB) rates for women with the diagnosis of tubal ligation and no male factor. WHAT IS KNOWN ALREADY: Prior studies have suggested that ICSI use does not improve fertilization, pregnancy or LB rates in couples with non-male factor infertility. However, it is unknown whether couples with tubal ligation only diagnosis and therefore iatrogenic infertility could benefit from the use of ICSI during their ART cycles. STUDY DESIGN, SIZE, DURATION: Longitudinal cohort of nationally reported cycles in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) of ART cycles performed in the USA between 2004 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: There was a total of 8102 first autologous fresh ART cycles from women with the diagnosis of tubal ligation only and no reported male factor in the SART database. Of these, 957 were canceled cycles and were excluded from the final analysis. The remaining cycles were categorized by the use of conventional IVF (IVF, n = 3956 cycles) or ICSI (n = 3189 cycles). The odds of fertilization, clinical intrauterine gestation (CIG) and LB were calculated by logistic regression modeling, and the adjusted odds ratios (AORs) with 95% confidence intervals were calculated by adjusting for the confounders of year of treatment, maternal age, race and ethnicity, gravidity, number of oocytes retrieved, day of embryo transfer and number of embryos transferred. MAIN RESULTS AND THE ROLE OF CHANCE: The main outcome measures of the study were odds of fertilization (2PN/total oocytes), clinical intrauterine gestation (CIG/cycle) and live birth (LB/cycle). The fertilization rate was higher in the ICSI versus IVF group (57.5% vs 49.1%); however, after adjustment this trend was no longer significant (AOR 1.14, 0.97-1.35). Interestingly, both odds of CIG (AOR 0.78, 0.70-0.86), and odds of LB were lower (AOR 0.77, 0.69-0.85) in the ICSI group. Plurality at birth, mean length of gestation and birth weight did not differ between the two groups. LIMITATIONS, REASONS FOR CAUTION: This was a retrospective study, therefore only the available parameters could be included, with parameters of interest such as smoking status not available for inclusion. Smoking status may have led practitioners to use ICSI to improve pregnancy and LB outcomes. WIDER IMPLICATIONS OF THE FINDINGS: Studies have shown that in the USA there is an increasing usage of ICSI for non-male factor infertility despite a lack of evidence-based benefit. Our study corroborates this increasing use over the last 8 years, specifically in the tubal ligation only patient population. Even after adjusting for multiple confounders, the patients who underwent ICSI had no statistically significant improvement in fertilization rate and actually had a lower likelihood of achieving a clinical pregnancy and LB. Therefore, our data suggest that the use of ICSI in tubal ligation patients has no overall benefit. This study contributes to the body of evidence that the use of ICSI for non-male factor diagnosis does not improve ART outcomes over conventional IVF. STUDY FUNDING/COMPETING INTERESTS: None.

Mortality following primary total knee replacement in public hospitals in Hong Kong.

INTRODUCTION: More than 2000 total knee replacements are performed each year in Hong Kong and more than 10 000 patients are on the waiting list. How safe is total knee replacement, however? The aims of the study were to review the mortality of primary total knee replacement in public hospitals in Hong Kong and to identify risk factors for mortality in a high-volume hospital. METHODS: All primary total knee replacements performed in Hospital Authority hospitals and Yan Chai Hospital from October 2011 to September 2014 were reviewed. Case-control analysis was performed for risk factors of total all-cause mortality in total knee replacement at Yan Chai Hospital. RESULTS: There were 6588 patients in Hospital Authority hospitals and 1184 in Yan Chai Hospital (1095 unilateral and 89 bilateral total knee replacement). The mean follow-up time of patients in Yan Chai Hospital was 12.8 months. The mortality at 30 days, 90 days and 1 year was 0%, 0.08%, 0.34% for Yan Chai Hospital; and 0.1%, 0.2%, 0.7% for Hospital Authority hospitals, respectively. For Yan Chai Hospital, the mean operation-to-death interval was 21 months (range, 1-35 months). The mean age at death was 78 years and main causes were malignancy (50%) and pneumonia (21%). Predictors of mortality included age at surgery, American Society of Anesthesiologists class 3, and preoperative range of motion. Hospital surgery volume, preoperative co-morbidities, and postoperative deep vein thrombosis were not significant factors. CONCLUSIONS: Mortality after primary total knee replacement was low in public hospitals in Hong Kong. Patients of older age or poorer general well-being in terms of poor range of motion or American Society of Anesthesiologists class 3 should be in optimal health before surgery and counselled about the higher mortality rate. A citywide joint replacement registry may help monitor and analyse postoperative total knee replacement mortality specific to our locality.

Drug delivery with topically applied nanoparticles: science fiction or reality.

The efficacy of topically applied drugs is determined by their action mechanism and their potential capacity of passing the skin barrier. Nanoparticles are assumed to be efficient carrier systems for drug delivery through the skin barrier. For flexible nanoparticles like liposomes, this effect has been well demonstrated. The penetration properties of solid nanoparticles are currently under intensive investigation. The crucial advantage of nanoparticles over non-particulate substances is their capability to penetrate deeply into the hair follicles where they can be stored for several days. There is no evidence, yet, that solid particles ≥40 nm are capable of passing through the healthy skin barrier. Therefore and in spite of the long-standing research efforts in this field, commercially available solid nanoparticle-based products for drug delivery through the healthy skin are still missing. Nevertheless, the prospects for the clinical use of nanoparticles in drug delivery are tremendous. They can be designed as transport systems delivering drugs efficiently into the hair follicles in the vicinity of specific target structures. Once deposited at these structures, specific signals might trigger the release of the drugs and exert their effects on the target cells. In this article, examples of such triggered drug release are presented.

Suprascapular nerve blockage for painful shoulder pathology - a systematic review and meta-analysis of treatment techniques.

BACKGROUND: Suprascapular nerve blockade (SSNB) through injection (SSNBi) and/or pulsed radiofrequency (PRF) provide options for the management of painful shoulder pathology. Multiple techniques for delivery of SSNB are described but no consensus on optimal symptom control is available. This systematic review and meta-analysis aims to assess patient-focussed outcomes in SSNB and explore the impact of variation in the technical application of this treatment modality. METHODS: MEDLINE, Embase and CINAHL were searched for case series, cohort studies and randomised control trials published from database inception until 28 January 2021. Articles reporting use of SSNBi or PRF for treatment of shoulder pain with a minimum 3 months follow-up were included. Patient-reported outcome measures (PROMs) were extracted and the pooled standardised mean difference (SMD), weighted by study size, was reported. Quality of methodology was assessed using Wylde's nonsummative four-point system. FINDINGS: Of 758 references, 18 studies were included, totalling 704 SSNB. Average pain improvement at 3 months was 52.3%, with meta-analysis demonstrating a SMD of 2.37. Whereas SSNBi combined with PRF shows the greatest SMD of 2.75, this did not differ significantly from SSNBi or PRF when used as monotherapy. Location of treatment and the guidance technique used did not influence outcome. CONCLUSION: SSNBi and PRF provide safe and effective treatment for shoulder pain, as judged by PROMs. This may be of particular value in aging or comorbid patients and with surgical restrictions during the COVID-19 pandemic. Regardless of technique, patients experience a marked improvement in pain that is maintained beyond 3 months.

Coping with challenging behaviours of children with autism: effectiveness of brief training workshop for frontline staff in special education settings.

BACKGROUND: The present study examined the effectiveness of three staff training elements: psychoeducation (PE) on autism, introduction of functional behavioural analysis (FBA) and emotional management (EM), on the reaction of challenging behaviours for frontline staff towards children with autism in Hong Kong special education settings. METHODS: A sample of 311 frontline staff in educational settings was recruited to one of the three conditions: control, PE-FBA and PE-FBA-EM groups. A total of 175 participants completed all three sets of questionnaires during pre-training, immediate post-training and 1-month follow-up. RESULTS: Findings showed that the one-session staff training workshop increased staff knowledge of autism and perceived efficacy but decrease helping behavioural intention. CONCLUSIONS: In spite of the limited effectiveness of a one-session staff training workshop, continued staff training is still necessary for the improvement of service quality. Further exploration on how to change emotion response of staff is important.

Association of the POU class 2 homeobox 1 gene (POU2F1) with susceptibility to Type 2 diabetes in Chinese populations.

AIMS: POU class 2 homeobox 1 (POU2F1), also known as octamer-binding transcription factor-1 (OCT-1), is a ubiquitous transcription factor that plays a key role in the regulation of genes related to inflammation and cell cycles. POU2F1 is located on chromosome 1q24, a region with linkage for Type 2 diabetes in Chinese and other populations. We examined the association of POU2F1 genetic variants with Type 2 diabetes in Hong Kong Chinese using two independent cohorts. METHODS: We genotyped five haplotype-tagging single nucleotide polymorphisms at POU2F1 in 1378 clinic-based patients with Type 2 diabetes and 601 control subjects, as well as 707 members from 179 families with diabetes. RESULTS: We found significant associations of rs4657652, rs7532692, rs10918682 and rs3767434 (OR = 1.26-1.59, 0.0003 < P(unadjusted) < 0.035) with Type 2 diabetes in the clinic-based case-control cohorts. Rs3767434 was also associated with Type 2 diabetes (OR = 1.55, P(unadjusted) = 0.013) in the family-based cohort. Meta-analysis revealed similar associations. In addition, the risk G allele of rs10918682 showed increased usage of insulin treatment during a mean follow-up period of 7 years [hazard ratio = 1.50 (1.05-2.14), P = 0.025]. CONCLUSIONS: Using separate cohorts, we observed consistent results showing the contribution of multiple variants at POU2F1 to the risk of Type 2 diabetes.

Suicidal ideation among HIV+ former blood and/or plasma donors in rural China.

Suicidal ideation is life-threatening and is prevalent among people living with HIV (PLWH). A dearth of such studies was conducted in China. This study investigated the prevalence of suicidal ideation and associated factors among PLWH who were former blood and/or plasma donors (FBPD) in a rural county in central China. Prospective respondents were randomly selected from a local registry; 176 PLWH who were FBPD joined the study. With informed consent, these PLWH and their spouse were interviewed separately and anonymously. Respectively, 34 and 8% of the sampled (index) PLWH self-reported having suicidal ideation and making a suicidal attempt in the last year. The multivariate analyses results showed that the index PLWH's Physical Function subscale score of the Medical Outcomes Study HIV Health Survey scale (Odds ratio (OR)=6.67, 95% CI=1.69-26.27, 75 percentiles), the Depression subscale score of the Depression, Anxiety, and Stress Scales (DASS; OR=9.26, 95% CI=1.32-64.77), and the spouse's Depression subscale score of the DASS (OR=7.64, 95% CI=1.37-42.77) were independently associated with the index PLWH's suicidal ideation. HIV-related variables (e.g., duration of diagnosis, treatment and side effects) and perceived discrimination of the index PLWH, and HIV status of the PLWH's spouse, were not significant factors. Depression is a risk factor for suicides. Moreover, depression may be contagious and the depression status of the spouse also matters. Treatments for depression and prevention intervention for suicides targeting PLWH in rural China are not readily available. Such services are greatly warranted and need to be provided to both the PLWH and his/her spouse.