The surgical metaverse.

Recent developments have seen acceleration in the development of virtual reality (VR) and augmented reality (AR) technology. Through these developments, the metaverse has emerged. Within the metaverse, users create an avatar to experience an immersive, interactive extended reality. Current front-runners in its implementation are the financial, communication and entertainment sectors. This technology, however, is receiving greater recognition in the medical world, with national and international surgical bodies acknowledging the benefits that VR and the metaverse will have on surgical training and patient care. Its versatility means that we are likely to see VR related technology become intimately woven into the fabric of surgery in the next two decade. In this article, the impact of the metaverse on the surgical field will be discussed.

Management of urolithiasis in pregnancy.

Urolithiasis is the most common cause of nonobstetric abdominal pain, resulting in 1.7 admissions per 1000 deliveries. Urolithiasis most commonly occurs in the second and third trimesters, with an incidence between 1:125 and 1:2000. Acute urinary system obstructions are challenging to manage in obstetric patients because they contribute to physiological and anatomical changes that result in pathological outcomes. The restricted use of computed tomography in diagnosing and managing urolithiasis is particularly challenging. In addition, a prompt diagnosis is required because the presence of renal calculi during pregnancy increases the risk of fulminating sepsis and preterm delivery. Affected pregnancies are conservatively managed; however, 1 in 4 requires surgical intervention. Indications for surgical interventions are complex and range from nephrostomy insertion to empirical stent placement or ureteroscopy. Therefore, a multidisciplinary approach is required to optimize patient care. The diagnosis and management of urolithiasis in pregnancy are complex. We reviewed the role, safety, advantages and disadvantages of diagnostic tests and treatment used to manage acute urinary obstructions in pregnancy.

Percutaneous Cholecystostomy for Acute Cholecystitis: A Three-Year Single-Centre Experience Including During COVID-19.

Introduction Percutaneous cholecystostomy is a recognised treatment modality for acute cholecystitis. Traditionally, its use was reserved for patients deemed unfit for surgery. However, the coronavirus disease 2019 (COVID-19) pandemic had a detrimental effect on both elective and emergency surgery. The utilisation of cholecystostomy thus increased. Unanswered questions remain over timing with respect to interval cholecystectomy. We evaluated our local practice over the preceding three years. Methods A retrospective analysis was performed of all patients who had a percutaneous cholecystostomy inserted over a three-year period (1 January 2018-1 January 2021). The primary outcome was time to cholecystectomy. Secondary outcomes were cholecystostomy-related complications, 30-day mortality, cholecystectomy-related complications and length of postoperative hospital stay. Results A total of 31 patients were identified during the period. Thirteen (42%) patients went on to have a laparoscopic cholecystectomy. The median time interval from cholecystostomy to cholecystectomy was 97 days (interquartile range [IQR]: 81-140, minimum: 47 and maximum: 791). One case was complicated by small bowel perforation; this occurred after an interval of 106 days. The median length of postoperative stay was one day (IQR: 1-1, minimum: 0 and maximum: 4). Cholecystostomy-related complications were observed in four (13%) patients, whereby three became displaced and one developed blockage. Thirty-day mortality following cholecystostomy insertion was zero. Conclusions Percutaneous cholecystostomy is a safe and effective intervention for the management of acute cholecystitis. Interval cholecystectomy should be carefully considered; it may be safer to perform prior to 90 days.

Lessons for Emergency Surgery in the Second Wave: One-Month Single-Centre Experience During the First Wave of COVID-19.

Introduction The global COVID-19 pandemic had a deleterious effect upon elective and emergency surgery. Focus of patient care was directed to emergency services. Association of Surgeons of Great Britain and Northern Ireland guidelines advised a trend towards conservative management. Traditional surgical intervention was reserved only for selected cases only. We evaluated our emergency practice over a four-week period during the first peak of COVID-19. Methods A retrospective single-centre analysis was performed of consecutive patients seen by the emergency general and vascular surgery on-call team in a District General Hospital over a four-week period (30 March 2020-26 April 2020). Primary outcome was 30-day COVID-19 mortality. Secondary outcomes were 30-day complications, readmission rate and non-COVID-19-related mortality. Adherence to intercollegiate guidelines was also assessed.  Results A total of 184 patients were assessed during the period. The median age was 55 years (interquartile range 34-75), with a male:female ratio of 1:0.7. Thirty-day COVID-19- and non-COVID-19-related mortalities were 3% and 8%, respectively. Thirteen percent of patients developed complications and 9% represented to the emergency department within 30 days. Conservative management was initially employed in 78% of patients. This had success rates in appendicitis and cholecystitis of 72% and 75%, respectively. A CT thorax was included in 89% having a CT abdomen and pelvis. Thirty-eight percent had a COVID-19 polymerase chain reaction (PCR) swab test performed throughout the study period. Fifty-two percent of individuals who underwent emergency surgery had a swab performed prior to operative intervention. Conclusions Conservative management seems to be reasonably effective and may re-shape the way we treat a proportion of surgical pathologies in the future. Further long-term data are required in order to evaluate this. A paucity of PCR testing was due to nationwide capacity shortcomings. This must be addressed in future peaks with rapid testing in order to triage patients to the appropriate setting.

An exploration of the potential mechanisms and translational potential of five medicinal plants for applications in Alzheimer's disease.

Alzheimer's disease (AD) is the most common type of dementia, and represents a vast worldwide socio-economic burden, and in the absence of a current cure, effective therapeutic strategies are still needed. Cholinergic and cerebral blood flow deficits, excessive levels of oxidative stress, neuroinflammation and glutamate excitatory mechanisms are all believed to contribute to the development and progression of the disease. Scoparia dulcis, Catharanthus roseus, Sesamum indicum, Erythrina senegalensis and Vigna unguiculata represent five plants that have been used as traditional medicines for the treatment of AD in certain cultures. Review of the scientific literature was conducted to explore the properties of these plants that might be beneficial and explain what would be perceived by many to be largely anecdotal evidence of their benefit. All plants were found to possess varying levels of anti-oxidant capability. Scoparia dulcis was also found to potentiate nerve growth factor-like effects upon cell lines. Catharanthus roseus appears to inhibit acetylcholinesterase with relatively high potency, while Sesamum indicum demonstrated the strongest antioxidant ability. Comparisons with currently used plant derived therapeutics illustrate how these plants may be likely to have some therapeutic benefits in AD. The evidence presented also highlights how appropriate dietary supplementation with some of these plants in various cultural settings might have effects analogous or complementary to the so-called protective Mediterranean diet. However, prior to embarking on making any formal recommendations to this end, further rigorous evaluation is needed to better elucidate the breadth and potential toxicological aspects of medicinal properties harboured by these plants. This would be vital to ensuring a more informed and safe delivery of preparations of these plants if they were to be considered as a form of dietary supplementation and where appropriate, how these might interact with more formally established therapies in relation to AD.