The impact of elective surgery postponement during COVID-19 on emergency bellwether procedures in a large tertiary centre in Singapore.

The coronavirus disease 2019 (COVID-19) pandemic drove many healthcare systems worldwide to postpone elective surgery to increase healthcare capacity, manpower, and reduce infection risk to staff. The aim of this study was to assess the impact of an elective surgery postponement policy in response to the COVID-19 pandemic on surgical volumes and patient outcomes for three emergency bellwether procedures. A retrospective cohort study of patients who underwent any of the three emergency procedures [Caesarean section (CS), emergency laparotomy (EL), and open fracture (OF) fixation] between 1 January 2018 and 31 December 2021 was conducted using clinical and surgical data from electronic medical records. The volumes and outcomes of each surgery were compared across four time periods: pre-COVID (January 2018-January 2020), elective postponement (February-May 2020), recovery (June-November 2020), and postrecovery (December 2020-December 2021) using Kruskal-Wallis test and segmented negative binomial regression. There was a total of 3886, 1396, and 299 EL, CS, and OF, respectively. There was no change in weekly volumes of CS and OF fixations across the four time periods. However, the volume of EL increased by 47% [95% confidence interval: 26-71%, P = 9.13 × 10-7) and 52% (95% confidence interval: 25-85%, P = 3.80 × 10-5) in the recovery and postrecovery period, respectively. Outcomes did not worsen throughout the four time periods for all three procedures and some actually improved for EL from elective postponement onwards. Elective surgery postponement in the early COVID-19 pandemic did not affect volumes of emergency CS and OF fixations but led to an increase in volume for EL after the postponement without any worsening of outcomes.

Predictive Model for Positive Video Capsule Endoscopy in Iron Deficiency Anemia.

BACKGROUND AND AIMS: Bleeding from the gastrointestinal tract can contribute to the development of iron deficiency anemia (IDA) among individuals without another obvious source of bleeding. In order to identify patients most likely to benefit from examination of the small bowel, our aim was to create a risk score for positive video capsule endoscopy (VCE) in IDA utilizing a multicenter collection of studies. METHODS: We performed a retrospective multicenter study utilizing VCE studies performed for an indication of IDA between 1/1/2005 and 7/31/2018. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. Data were analyzed with Student's t test for continuous variables and the Fisher's exact test for categorical variables. Logistic regression was used to identify independent associations with positive VCE. RESULTS: In total, 765 VCE procedures were included with 355 (46.5%) male subjects and a median age of 63.2 (SD 15.3) years. One hundred ninety studies (24.8%) were positive (P2) for small bowel bleeding. Four variables associated with positive VCE which were incorporated into a point scoring system: (+) 1 for age ≥ 66 years, active smoking and cardiac arrythmia and (-) 1 for preceding hemoglobin level ≥ 8.5. The risk probabilities for positive VCE-assigned scores - 1, 0, 1, and 2 + were 12.3% (95% CI 7.3-17.3%), 20% (14.9-25.1%), 34.8% (28.6-41%), and 39% (30-47.8%). CONCLUSION: In order to improve the diagnostic yield of capsule examinations, risk factors should be applied to clinical decision-making. We created a risk score for positive VCE in IDA, including the risk factors of age, smoking, history of cardiac arrythmia, and preceding hemoglobin level.

Analysis of Speaker Introduction Formality by Gender at the American College of Gastroenterology 2020 Annual Scientific Meeting.

BACKGROUND: Gender-based differences in the use of professional titles during speaker introductions have been described in other medical specialties. AIMS: Our primary aim was to assess gender-based differences in the formality of speaker introductions at the American College of Gastroenterology 2020 Virtual Annual Scientific Meeting. Our secondary aim was to assess gender-based differences in the formality of speaker self-introductions. METHODS: Reviewed presentations from the American College of Gastroenterology Annual Meeting for gender-based differences in professional title use during speaker introductions and self-introductions. RESULTS: Speakers included 29 women (37.2%) and 49 men (62.8%). We found no significant gender differences in the use of professional titles by introducers (t(67) = - 0.775, p = 0.441) or in self-introductions (36.4% of women vs. 41.9% of men, t(63) = 0.422, p = 0.674). CONCLUSION: The lack of gender differences in professional title use may represent a novel advantage of virtual meeting formats or suggest increased attention to gender bias in introductions.

Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists.

BACKGROUND AND AIMS: This study aims to assess current practices and perspectives of gastroenterologists on approaches to code status before inpatient endoscopy. METHODS: Self-reported data were obtained through a voluntary, anonymous survey of gastroenterologists and gastroenterology trainees in the United States. The survey assessed respondents' approach to, beliefs, and knowledge regarding inpatient periprocedural code status discussions. RESULTS: Four hundred thirty-six gastroenterologists and 83 trainees completed the survey. For patients with an existing do not resuscitate (DNR) order, respondents reversed the code status before endoscopy either all (40.8%, n = 212) or most of the time (18.3%, n = 95). When asked their personal opinion, 32.6% (n =169) supported automatic DNR reversal to full resuscitation attempt during a procedure, 18.5% (n = 96) supported that DNR orders could be sustained, and 48.7% (n = 253) supported offering limited resuscitation. Many gastroenterologists were unaware of institutional (40.7%, n = 211) or national (80.7%, n = 419) policies, and a majority reported that a gastroenterology-specific guideline would be helpful (88.6%, n = 460). CONCLUSIONS: Although most of the gastroenterologists reverse DNR orders more than 75% of the time before endoscopy, many also believe patients should be allowed to remain DNR during a procedure and supported a third option for limited resuscitation. Most gastroenterologists were unaware of institutional policies or existing national guidelines. These findings suggest considerable variation in knowledge and current approaches regarding periendoscopic code status reversal.

Celiac Disease and Its Role in the Development of Metabolic Bone Disease.

Celiac disease (CD) is an immune-mediated enteropathy that occurs in genetically susceptible hosts with the ingestion of gluten-containing products. Ongoing gluten consumption leads to intestinal damage, characterized by villous blunting and increased intraepithelial lymphocytes, resulting in malabsorption. Pertinent to the development of bone disease, malabsorption of calcium and vitamin D leads to secondary hyperparathyroidism and metabolic bone disease among individuals with CD. In this article, we review the pathogenesis of CD and the effects of malabsorption on bone health. Imbalances in bone resorption and formation particularly in individuals with CD and persistent disease activity ultimately lead to a state of bone loss and impaired mineralization. Initiation of a gluten-free diet is critical in the management of CD-related metabolic bone disease, demonstrating improvements in bone mineral density within the first year of dietary adherence.

Can reporting more lead to less? The role of metrics in assessing liver transplant program performance.

Appropriate metrics for performance analysis is an active topic of debate within the transplant community. This study explores current proposals on metric expansion as well as potential metrics and prospective collaborations that have not received widespread discussion within the transplant community. The premature introduction of additional, nonvalidated metrics risks behaviors that may undermine donor utilization and patient access to transplantation.

Correction to: Risk Factors for Clostridium difficile Isolation in Inflammatory Bowel Disease: A Prospective Study.

The original version of the article unfortunately contained an error in a percentage value in Results section of Abstract.

Risk Factors for Clostridium difficile Isolation in Inflammatory Bowel Disease: A Prospective Study.

INTRODUCTION: Clostridium difficile is the most commonly isolated stool pathogen in inflammatory bowel disease (IBD). Traditional risk factors for C. difficile may not exist in patients with IBD, and no prior studies have assessed the risk factors for the isolation of C. difficile in both symptomatic and asymptomatic IBD outpatients. METHODS: We prospectively recruited consecutive IBD patients presenting to our outpatient clinic between April 2015 and February 2016. We excluded patients with a diverting ostomy or ileoanal pouch. Demographics, healthcare exposures, medical therapies and disease activity were recorded from medical charts or surveys. A rectal swab was performed from which toxigenic culture and PCR analysis for the presence of toxin and fluorescent PCR ribotyping were performed. The primary outcome of interest was isolation of toxigenic C. difficile. RESULTS: A total of 190 patients were enrolled in this prospective study including 137 (72%) with Crohn's disease and 53 (28%) with ulcerative colitis. At the time of enrollment, 69 (36%) had clinically active disease. Sixteen (8.4%) patients had toxigenic C. difficile isolated on rectal swab at enrollment and four (2.1%) patients had non-toxigenic C. difficile cultured. Mixed infection with more than one toxigenic isolate was present in 5/16 (31.3%) individuals. Patients with CD with a toxin positive isolate were more likely to have a history of CDI in the past 12 months (40 vs. 11.02%, p = 0.027) and an emergency department visit in the past 12 weeks (50 vs. 20.63%, p = 0.048). In UC, individuals with isolation of C. difficile were more likely to be hospitalized within the past 12 months (66.6 vs. 8.51%, p = 0.003). C. difficile isolation at the time of presentation was not associated with a subsequent disease relapse over a 6-month period in CD (p = 0.557) or UC (p = 0.131). CONCLUSION: Healthcare exposures remain a significant risk factor for C. difficile isolation in the IBD population; however, this was not associated with relapse of disease. Further studies assessing the clinical significance of C. difficile isolation is warranted in IBD.

Multiphase Multi-Detector Row Computed Tomography Imaging Characteristics of Large (>5 cm) Focal Hepatocellular Carcinoma.

OBJECTIVE: The aim of this study was to describe the multiphase multi-detector row computed tomography (MDCT) imaging findings of large (>5 cm) focal hepatocellular carcinoma (HCC). METHODS: Following review of the medical records of 321 patients with newly diagnosed HCC who underwent MDCT within the radiology database from January 2007 to November 2014, 27 patients (20 men and 7 women; mean age, 69 [SD, 10.1] years [range, 49-87 years]) with histologically confirmed HCC greater than 5 cm were included in this institutional review board-approved study. Multiphase, dedicated liver MDCT images of these cases were retrospectively reviewed by 2 radiologists in consensus to describe the enhancement characteristics of these lesions. RESULTS: Mean tumor diameter was 8.4 (SD, 2.4) cm (range, 5.2-13.5 cm). Cirrhosis was present in 16 (59%) of 27 patients. Seventeen (85%) of 20 patients with available laboratory data presented with elevated alpha-fetoprotein (median, 97 ng/mL). Twenty-three (85%) of 27 demonstrated either heterogeneous enhancement with gradual fill-in (14/27 [52%]) or peripheral enhancement with centripetal fill-in (9/27 [33%]). Twenty-two (81%) of 27 lacked washout on delayed phase images, and 21 (78%) of 27 demonstrated a pseudocapsule. Twenty-seven of 27 lesions were well defined, 8 (30%) of 27 were exophytic, 15 (56%) of 27 were unifocal, 5 (25%) of 20 cases demonstrated vascular invasion, and 7 (26%) of 27 cases presented with extrahepatic metastases. CONCLUSIONS: Large (>5 cm) focal HCC may present as a dominant mass with a pseudocapsule and initial heterogeneous or peripheral enhancement with gradual or centripetal fill-in without washout on multiphase MDCT. Awareness of this variant is important to allow distinction from other benign (eg, hemangioma) and malignant (eg, cholangiocarcinoma) focal liver lesions.

Thrombin down-regulates tissue factor pathway inhibitor expression in a PI3K/nuclear factor-κB-dependent manner in human pleural mesothelial cells.

Tissue factor pathway inhibitor (TFPI) is the primary inhibitor of the extrinsic coagulation cascade, and its expression is reported to be relatively stable. Various pathophysiologic agents have been shown to influence TFPI activity by regulating its expression or by modifying the protein. It is not clear how TFPI activity is regulated in normal physiology or in injury. Because thrombin and TFPI are locally elaborated in pleural injury, we sought to determine if thrombin could regulate TFPI in human pleural mesothelial cells (HPMCs). Thrombin significantly decreased TFPI mRNA and protein levels by > 70%. Thrombin-mediated down-regulation of TFPI promoted factor X activation by HPMCs. The ability of thrombin to significantly decrease TFPI mRNA and protein levels was maintained at nanomolar concentrations. Protease-activated receptor (PAR)-1, a mediator of thrombin signaling, is detectable in the mesothelium in human and murine pleural injury. PAR-1 silencing blocked thrombin-mediated decrements of TFPI in HPMCs. Thrombin activates PI3K/Akt and nuclear factor κB (NF-κB) signaling in HPMCs. Inhibition of PI3K (by PX-866) and NF-κB (by SN50) prevented thrombin-mediated TFPI mRNA and protein down-regulation. These are the first studies to demonstrate that thrombin decreases TFPI expression in HPMCs. Our findings demonstrate a novel mechanism by which thrombin regulates TFPI expression in HPMCs and promotes an unrestricted procoagulant response, and suggest that interactions between PI3K and NF-κB signaling pathways are linked in HPMCs and control TFPI expression. These findings raise the possibility that targeting this pathway could limit the ability of the mesothelium to support extravascular fibrin deposition and organization associated with pleural injury.

Battling against the great disruption to surgical care in a pandemic: experiences of 11 South and Southeast Asian countries.

OBJECTIVES: The majority of the cancelled elective surgeries caused by the COVID-19 pandemic globally were estimated to occur in low- and middle-income countries (LMICs), where surgical services had long been in short supply even before the pandemic. Therefore, minimising disruption to existing surgical care in LMICs is of crucial importance during a pandemic. This study aimed to explore contributory factors to the continuity of surgical care in LMICs in the face of a pandemic. DESIGN: Semistructured interviews were conducted over zoom with surgical leaders of 25 tertiary hospitals from 11 LMICs in South and Southeast Asia in September to October 2020. Key themes were subsequently identified from the interview transcripts using the Braun and Clarke's method of thematic analysis. RESULTS: The COVID-19 pandemic affected all surgical services of participating institutions to varying degrees. Overall, elective surgeries suffered the gravest disruption, followed by outpatient surgical care, and finally emergency surgeries. Keeping healthcare workers safe and striving for continuity of essential surgical care emerged as notable response strategies observed across all participating institutions. CONCLUSION: This study suggested that four factors are important for the resilience of surgical care against COVID-19: adequate COVID-19 testing capacity and effective institutional infection control measures, designated COVID-19 treatment facilities, whole-system approach to balancing pandemic response and meeting essential surgical needs, and active community engagement. These findings can inform healthcare institutions in other countries, especially LMICs, in their effort to tread a fine line between preserving healthcare capacity for pandemic response and protecting surgical services against pandemic disruption.

Impact of health education on the knowledge of tuberculosis among sputum-positive pulmonary TB patients and their care-givers.

Tuberculosis is a world-wide disease, the chest affliction (pulmonary tuberculosis) being the commonest. Over 14 million persons are estimated to presently suffer from acute tuberculosis. Poverty apart, ignorance about origin, spread and prevention is a major factor in the large scale prevalence of the disease. It was therefore decided to assess the impact of health education among sputum-positive pulmonary tuberculosis patients and their caregivers on all aspects and also to evaluate their knowledge on day of allocation of treatment. Using a structured questionnaire with multiple choices regarding signs & symptoms, causes, transmission of tuberculosis, availability of treatment etc. on 56 patients and 62 care-givers. The study concludes that direct and indirect methods of health education significantly enhance the awareness about the nature, spread and prevention of tuberculosis.

Surveillance Recommendation for Colonoscopy after Polypectomy.

The incidence and mortality of colorectal cancer (CRC) have declined over the past several decades, largely due to improvement and uptake in screening, particularly with colonoscopy. The US Multi-Society Task Force on CRC published guidelines for surveillance after polypectomy in 2012, which were updated in 2020 with some important changes, and this review will provide an updated overview of evidence and outcomes of surveillance after polypectomy. Notable modifications to surveillance guidelines include increasing interval time between colonoscopies from 5 to 7 to 10 years for 1 to 2 low-risk adenomas (<10 mm) and from 3 years to 3 to 5 years when 3 to 4 low-risk adenomas are identified.

The Psychological Well-Being of Southeast Asian Frontline Healthcare Workers during COVID-19: A Multi-Country Study.

OBJECTIVES: This study examined the prevalence of anxiety, depression, and job burnout among frontline healthcare workers (HCWs) across six Southeast Asian countries (Indonesia, Malaysia, Philippines, Singapore, Thailand, Vietnam) during the COVID-19 pandemic in 2021. We also investigated the associated risk and protective factors. METHODS: Frontline HCWs (N = 1381) from the participating countries participated between 4 January and 14 June 2021. The participants completed self-reported surveys on anxiety (GAD-7), depression (PHQ-8), and job burnout (PWLS). Multivariate logistic regressions were performed with anxiety, depression, and job burnout as outcomes and sociodemographic and job characteristics and HCW perceptions as predictors. RESULTS: The average proportion of HCWs reporting moderate anxiety, moderately severe depression, and job burnout across all countries were 10%, 4%, and 20%, respectively. Working longer hours than usual (Odds ratio [OR] = 1.82; 3.51), perceived high job risk (1.98; 2.22), and inadequate personal protective equipment (1.89; 2.11) were associated with increased odds of anxiety and job burnout while working night shifts was associated with increased risk of depression (3.23). Perceived good teamwork was associated with lower odds of anxiety (0.46), depression (0.43), and job burnout (0.39). CONCLUSION: Job burnout remains a foremost issue among HCWs. Potential opportunities to improve HCW wellness are discussed.