Patient Satisfaction in Emergency General Surgery: A Prospective Cross-Sectional Study.

BACKGROUND: The importance of the patient experience is increasingly being recognised. However, there is a dearth of studies regarding factors affecting patient-reported outcomes in emergency general surgery (EGS), including none from the Southern Hemisphere. We aim to prospectively assess factors associated with patient satisfaction in this setting. METHODS: In this prospective cross-sectional study, all consecutive adult patients admitted to an acute surgical unit over four weeks were invited to complete a validated Patient-Reported Experience Measures questionnaire. These were completed either in person when discharge was imminent or by telephone <4 weeks post-discharge. Responses were used to determine factors associated with overall patient satisfaction. RESULTS: From 146 eligible patients, 100 (68%) completed the questionnaire, with a mean overall satisfaction score of 8.3/10. On multivariate analyses, eight factors were significantly associated with increased overall satisfaction. Five of these were similar to those previously prescribed by other like studies, being patient age >50 years, sufficient analgesia, satisfaction with the level of senior medical staff, important questions answered by nurses and confidence in decisions made about treatment. Three identified factors were new: sufficient privacy in the emergency department, sufficient notice prior to discharge and feeling well looked after in hospital. CONCLUSIONS: Factors associated with patient satisfaction were identified at multiple points of the patient journey. While some of these have been reported in similar studies, most differed. Hospitals should assess factors valued by their EGS population prior to implementing initiatives to improve patient satisfaction.

Endoscopically Assisted Intraoral Removal of an Ectopic Third Molar in the Mandibular Subcondylar Region.

The ectopic placement of mandibular third molars in the subcondylar region is an uncommon phenomenon. Most patients are asymptomatic but can present with acute infection or associated pathology necessitating surgical intervention. Surgical approaches have been described utilizing both extraoral and intraoral approaches to the region.This paper presents a clinical report of a patient presenting with acute fascial space infection arising from an ectopic third molar in the mandibular subcondylar region, managed with surgical removal via an endoscopically assisted intraoral approach.

Long-term follow-up of the TRED-HF trial: Implications for therapy in patients with dilated cardiomyopathy and heart failure remission.

AIMS: In TRED-HF, 40% of patients with recovered dilated cardiomyopathy (DCM) relapsed in the short term after therapy withdrawal. This follow-up investigates the longer-term effects of therapy withdrawal. METHODS AND RESULTS: TRED-HF was a randomized trial investigating heart failure therapy withdrawal in patients with recovered DCM over 6 months. Those randomized to continue therapy subsequently withdrew treatment between 6 and 12 months. Participants were recommended to restart therapy post-trial and were followed until May 2023. Clinical outcomes are reported in a non-randomized fashion from enrolment and from the end of the trial. The primary outcome was relapse defined as ≥10% reduction in left ventricular ejection fraction to <50%, doubling in N-terminal pro-B-type natriuretic peptide to >400 ng/L, or clinical features of heart failure. From enrolment to the last follow-up (median 6 years, interquartile range 6-7), 33 of 51 patients (65%) relapsed. The 5-year relapse rate from enrolment was 61% (95% confidence interval [CI] 45-73) and from the end of the trial was 39% (95% CI 19-54). Of 20 patients who relapsed during the trial, nine had a recurrent relapse during follow-up. Thirteen relapsed for the first time after the trial; seven had restarted low intensity therapy, four had not restarted therapy and two did not have therapy withdrawn. The mean intensity of therapy was lower after the trial compared to enrolment (mean difference -6 [-8 to -4]; p < 0.001). One third of relapses during follow-up had identifiable triggers (arrhythmia [n = 4], pregnancy [n = 1], hypertension [n = 1], infection [n = 1]). Corrected atrial fibrillation was associated with reduced risk of relapse (hazard ratio 0.33, 95% CI 0.12-0.96; p = 0.042). CONCLUSIONS: The risk of relapse in the 5 years following the TRED-HF trial remained high. Restarting lower doses of heart failure medications at the end of the trial, external triggers and disease progression are likely to have contributed to relapse.

Sudden Cardiac Death in Athletes: Facts and Fallacies.

The benefits of exercise for cardiovascular and general health are many. However, sudden cardiac death (SCD) may occur in apparently healthy athletes who perform at the highest levels. A diverse spectrum of diseases is implicated in SCD in athletes, and while atherosclerotic coronary artery disease predominates in individuals of >35 years of age, primary cardiomyopathies and ion channelopathies are prevalent in young individuals. Prevention of SCD in athletes relies on the implementation of health policies aimed at the early identification of arrhythmogenic diseases (such as cardiac screening) and successful resuscitation (such as widespread utilization of automatic external defibrillators and training members of the public on cardiopulmonary resuscitation). This review will focus on the epidemiology and aetiologies of SCD in athletes, and examine fallacies in the approach to this controversial field. Furthermore, potential strategies to prevent these tragic events will be discussed, analysing current practice, gaps in knowledge and future directions.

Hyponatraemic seizure secondary to primary polydipsia following urological surgery.

An 82-year-old man presented to the emergency department with delirium, vomiting and an initial hyponatraemia of 112 mmol/L the day after successful transurethral vaporisation of the prostate. He had a tonic-clonic seizure in the acute surgical unit and was managed subsequently in the intensive care unit with a controlled rate of hypertonic saline. Initial work-up for the cause of hyponatraemia revealed a low urine osmolality, suggestive of relative excess water intake. Detailed examination of the operation notes revealed no discrepancy between intraoperative irrigating fluid input and output. Careful collateral history revealed that the patient had drunk 8 L of water in the 24 hours following the operation, after taking advice to 'drink plenty of water' literally. This case highlights the importance of conveying specific advice to patient, the lower incidence of transurethral resection syndrome in resections using saline as an irrigation fluid and outlines the pathway for investigation and management for hyponatraemia.

Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience.

BACKGROUND: Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM. METHODS: A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates. RESULTS: Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001). CONCLUSION: ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

Shortened dual antiplatelet therapy in contemporary percutaneous coronary intervention era.

Percutaneous coronary intervention with stenting is followed by a duration of dual antiplatelet therapy (DAPT) to reduce stent thrombosis and avoid target lesion failure. The period of DAPT recommended in international guidelines following drug-eluting stent implantation is 12 mo for most patients with acute coronary syndrome, and 6 mo for patients with chronic coronary syndrome or high bleeding risk. The new generation of drug-eluting stents have metallic platforms with thinner struts, associated with significantly less stent thrombosis. Shortened DAPT has been investigated with these stents, with evidence from randomised clinical trials for some individual stents showing non-inferior safety and efficacy outcomes. This has to be balanced by the effect of DAPT on secondary prevention of systemic cardiovascular disease especially in high-risk populations. This review will outline the current evidence for individual stents with regards to DAPT duration for both acute coronary syndrome and chronic coronary syndrome and discuss further directions for research and personalised medicine in this contemporary percutaneous coronary intervention era.

Concurrent Large Pericardial Cyst with Giant Thoracic Aortic Aneurysm-Presentation and Natural Evolution.

We report the first case of a patient with large pericardial cyst occurring concurrently with a very large thoracic aortic aneurysm. There have been no patients reported in the literature with this constellation of syndromes. Additionally, this case was followed through a period of 4 years, enabling the natural evolution of both pathologies to be visualised.

Utility of wearable physical activity monitors in cardiovascular disease: a systematic review of 11 464 patients and recommendations for optimal use.

Aims: Physical activity (PA) plays an important role in primary and secondary prevention of cardiovascular disease (CVD), functioning as a marker of disease progression and response to therapy. Real-world measurement of habitual PA is now possible through wearable activity monitors, however, their use in cardiovascular patients is not well described. Methods and results: We performed a systematic review to summarize how wearable activity monitors have been used to measure PA in patients with CVD, with 11 464 patients included across 108 studies. Activity monitors were primarily used in the setting of cardiac rehabilitation (46, 43%). Most often, triaxial accelerometers (70, 65%) were instructed to be worn at the hip (58, 54%) for 7 days (n = 54, 50%). Thirty-nine different activity monitors were used, with a range of accelerometer specific settings for collection and reporting of activity data. Activity was reported most commonly as time spent in metabolic equivalent-defined activity levels (49, 45%), while non-wear time was defined in just 16 (15%) studies. Conclusion: The collecting, processing, and reporting of accelerometer-related outcomes were highly heterogeneous. Most validation studies are limited to healthy young adults, while the paucity of methodological information disclosed renders interpretation of results and cross-study comparison challenging. While accelerometers are promising tools to measure real-world PA, we highlight current challenges facing their use in elderly multimorbid cardiology patients. We suggest recommendations to guide investigators using these devices in cardiovascular research. Future work is required to determine optimal methodology and consensus-based development of meaningful outcomes using raw acceleration data.

Spontaneous Tension Pneumothorax as a Complication of COVID-19.

Key Clinical Message. Tension pneumothorax is an uncommon presentation in patients with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) or COVID-19 pneumonia. We present a case of tension pneumothorax in a patient with COVID-19 pneumonia and myocarditis. This was an unlikely diagnosis in a patient with no known underlying lung condition and no other precipitating factors such as barotrauma. In an acute deterioration of patients with SARS-CoV-2, it is important to always consider alternative diagnoses and repeat imaging.

The acute surgical unit: An updated systematic review and meta-analysis.

OBJECTIVE: To systematically review comparative studies on the acute surgical unit (ASU) model. METHODS: Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis. RESULTS: Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy. CONCLUSION: Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.

Recurrent Infective Endocarditis with Mycotic Aneurysm - Imaging Modalities for the Detection of an Infective Focus.

Staphylococcus aureus bacteremia (SAB) and infective endocarditis (IE) are infections associated with considerable morbidity, requiring prompt accurate diagnosis and treatment. We present a case of a 58-year-old male patient with four episodes of recurrent symptomatic SAB treated for IE, but without positive findings on transthoracic echocardiography, transesophageal echocardiography, and fluorodeoxyglucose-positron emission tomography (FDG-PET). On the last admission, FDG-PET showed increased uptake in the right atrial appendage, and white blood cell single-photon emission computerized tomography (WBC-SPECT) was able to identify the infective focus as IE of the aortic valve. CT of the thorax also identified an associated mycotic aneurysm of the right coronary sinus. He was subsequently treated with mechanical aortic prosthesis and right coronary sinus plasty, and his symptoms did not recur till 2 years postcardiothoracic surgery. This case report demonstrates the emergence of nuclear cardiovascular imaging modalities in the diagnostic workup of IE and the utility of FDG-PET and WBC-SPECT in the identification of the infective focus. Patients with possible IE from the modified Duke criteria should be considered for FDG-PET or WBC-SPECT to enhance sensitivity. Peripheral mycotic aneurysms are a common complication of left-sided IE, which can present late into the disease process, and aortic imaging should be considered in patients with recurrent endocarditis to identify this.

Right sided heart failure secondary to hypereosinophilic cardiomyopathy - clinical manifestation and diagnostic pathway.

Hypereosinophilic cardiomyopathy is a rare restrictive cardiomyopathy which often presents with left-sided heart failure. We present an interesting case of a 58-year-old male patient with known hypereosinophillic syndrome who had presented with congestive cardiac failure with predominant features of right-sided volume overload. Cardiac magnetic resonance imaging confirmed the diagnosis by demonstrating obliteration of the right ventricular apex and endocardial-delayed gadolinium enhancement at the mid-septal and inferior segment, at both the right ventricular and left ventricular apical region, consistent with fibrosis. He was successfully treated with intravenous diuretics to good effect. This case report demonstrates a rare clinical presentation of right ventricle involvement in hypereosinophilic cardiomyopathy and the current pathway for diagnosis with the favoured emergence of cardiac magnetic resonance imaging. All patients with hypereosinophilic syndrome should be closely monitored for signs of cardiac involvement, as early treatment carries a better prognosis.

Emergency general surgery models in Australia: a cross-sectional study.

Objective Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. EGS structures in most Australian hospitals remain unknown. This study aimed to describe the national spectrum of EGS models. Methods A cross-sectional study was performed of all Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). The primary outcome was the incidence of each EGS model. Secondary outcomes were the relationship of the EGS model to objective hospital variables, and qualitative reasons for the choice of model. Results Of the 120 eligible hospitals, 119 (99%) participated. Sixty-four hospitals reported using an ASU (28%) or hybrid EGS model (26%), whereas the remaining 55 (46%) used a traditional model. ASU implementation was significantly more common among hospitals of greater peer group, bed number, surgeon pool and trauma service sophistication. Leading drivers for ASU commencement were aims to improve patient care and decrease after-hours operating, whereas common barriers against uptake were insufficient EGS patient load or surgeon on-call pool. Conclusions ASU or hybrid models of care may be more widespread than currently reported. The introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput. What is known about the topic? Traditionally, general surgical staff were rostered to elective operating and clinic duties, with emergency patients managed on an ad hoc basis. An ASU model, with a surgeon dedicated to EGS patients, has been associated with superior outcomes. However, the Australian uptake of this model is unknown. What does this paper add? This study enrolled 119 of 120 (99%) Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). Uptake of the ASU or hybrid model was more widespread than expected, existing in 64 of 119 (54%) centres. Factors for and against ASU implementation were also assessed. What are the implications for practitioners? Hospitals considering implementing an ASU or hybrid model will be reassured by the common reports of improved patient outcomes and decreased after-hours operating. However, potential hospitals must assess the suitability of the ASU model to their surgeon pool and EGS patient load.

Does emergency general surgery model affect staff satisfaction, training and working hours?

BACKGROUND: Few studies have assessed the relationship between different emergency general surgery models and staff satisfaction, operative experience or working hours. The Royal Australasian College of Surgeons recommends maximum on-call frequency of one-in-four for surgeons and registrars. METHODS: A cross-sectional study was conducted of all medium- to major-sized Australian public hospitals offering elective general surgery. At each site, an on-call general surgery registrar and senior surgeon were invited to participate. Primary outcomes were staff satisfaction and registrar-perceived operative exposure. Secondary outcomes were working hours. RESULTS: Among eligible hospitals, 119/120 (99%) were enrolled. Compared with traditional emergency general surgery models, hybrid or acute surgical unit models were associated with greater surgeon and registrar satisfaction on quantitative (P = 0.012) and qualitative measures. Registrar-perceived operating exposure was unaffected by emergency general surgery model. Longest duration on-duty was higher among traditional structures for both registrars (mean 22 versus 15 h; P = 0.0003) and surgeons (mean 59 versus 41 h; P = 0.020). On-call frequency greater than one-in-four was more common in traditional structures for registrars (51% versus 28%; P = 0.012) but not surgeons (6% versus 0%; P = 0.089). Data on average hours per day off-duty were obtained for registrars only, and were lower in traditional structures (13 versus 15 h; P = 0.00002). CONCLUSION: Hybrid or acute surgical unit models may improve staff satisfaction without sacrificing perceived operative exposure. While average maximum duration on-duty exceeded hazardous thresholds for surgeons regardless of model, unsafe working hours for registrars were more common in traditional structures. General surgical departments should review on-call rostering to optimize staff and patient safety.

Optimisation of dark adaptation time required for mesopic microperimetry.

BACKGROUND: Macular Integrity Assessment (MAIA) microperimetry is increasingly used in clinical and research settings to assess point retinal sensitivity and fixation stability. Testing occurs under mesopic conditions, commonly after a period of dark adaptation. Our aim was to identify the minimum length of adaptation required to optimise microperimetry performance. METHODS: MAIA microperimetry using the 10-2 grid was performed on 40 right eyes of 40 healthy participants aged 18-73 with no ocular pathology and vision of at least 0.1 logMAR after ambient light exposure, with 0, 5, 10, 15, 20 and 30 min of adaptation in mesopic settings. Ten right eyes of 10 participants with choroideremia were also tested following 0 and 20 min of adaptation. We further tested 10 right eyes of 10 healthy participants after bright light exposure, with 0, 10 and 20 min of adaptation. We compared changes in threshold sensitivity and fixation stability across time points. RESULTS: Microperimetry performance did not improve with increasing adaptation time in healthy participants or patients with choroideremia after ambient light exposure. After bright light exposure, we found microperimetry thresholds improved after 10 min of adaptation, but did not improve further at 20 min. CONCLUSION: Mesopic adaptation is not required before MAIA microperimetry after exposure to ambient light. Ten minutes of adaptation is sufficient after exposure to a bright light stimulus, such as ophthalmoscopy or retinal imaging. The brief time of dark adaptation required corresponds to cone adaptation curves and provides further evidence for cone-mediated central retinal function under mesopic conditions.