CytoSorb on the Septic Shock

Background: Septic shock, defined as organ dysfunction caused by a dysregulated host response to infection, is a condition associated with high morbidity and mortality. One of the hallmarks of sepsis is the excessive release of cytokines and other inflammatory mediators that cause septic shock and multi-organ failure (MOF). New adsorbents are now available as adjuvant therapy aimed at modulating the cytokine "storm" in sepsis. They are thought to be useful if adopted early (within 8-24 hours of the diagnosis of septic shock) in patients who are unresponsive to standard therapy. Here we report our experience with CytoSorb. Method(s): From January 2021 to May 2022, 46 patients with septic shock were treated with continuous renal replacement therapy (CRRT) associated with hemoadsorption with CytoSorb. All cases presented organ failure including AKI. Surgical patients (n = 13) were treated with surgery, COVID patients (n = 15) and medical patients (n = 16) with medical therapy;all surgery cases were operated on before starting the haemadsorption and in some cases reoperation with the need to suspend the adsorption. The mean age was 69 +/- 17 years (SD). On admission the mean SAPSII score was 50 +/- 11 (SD). CRRT as hemodiafiltration (CVVHDF) was performed. All patients received at least one CytoSorb treatment and additional treatments (up to 21 filters in a Covid patient) according to our indication. The CytoSorb cartridge was installed in series to the high cut-off filter;blood flow rates were maintained between 120 and 150 mL/min while dialysis doses from 18 to 45 mL/kg/hour. CytoSorb was renewed every 24 hours. We evaluated the impact of CytoSorb on 30-day survival, haemodynamics and relevant outcomes. Result(s): The 30-day survival was 30%. During treatment with CytoSorb, patients had a hemodynamic stabilization with a significant improvement in MAP, a reduction in amines and a decrease in PCR and PCT (Figure 1). Mortality at 30 days among medical patients was almost comparable to that of COVID patients and higher than that of surgical patients (70%, 69% and 61%, respectively). It should be noted that almost half of the deceased patients arrived late in the hospital, thus leading to a late start of treatment. Conclusion(s): We confirm the efficacy and usefulness of the CytoSorb if adopted early in patients who do not respond to standard therapy. CytoSorb treatment was safe and well tolerated with no device-related adverse events during or after treatment sessions.

Outcomes of cancer patients with Covid-19 admitted to the Intensive Care Unit: A retrospective study

Introduction: Active cancer increases the odds of death among patients with COVID-19.1 Cancer patients may be at increased risk of complications and mortality from COVID-19 owing to the systemic effects of malignancy, immune suppression after chemotherapy, treatment-related complications and presence of co-morbidities.2 They may develop serious complications necessitating ICU admission. In a meta-analysis, the pooled mortality in cancer patients with COVID-19 admitted to an ICU was 60.2%.3 Our hospital is a tertiary referral cancer centre, and the ICU admitted cancer patients with Covid-19 throughout the pandemic. Objective(s): To determine the 30-day in-hospital mortality of adult cancer patients with Covid-19 admitted to the ICU. We also aimed to determine the factors associated with mortality in cancer patients with Covid-19. Method(s): After approval from the Institutional Ethics Committee, data of all cancer patients (age = 16 years) with Covid-19 admitted to the ICU between March 2020 and March 2021 were retrieved from the hospital records. In case of multiple ICU admissions, data from the first admission was recorded. Data recorded included demographic details, type of cancer (solid, haematological), surgical status, APACHE-II and SOFA scores, C-reactive protein, and interventions in ICU. The primary outcome was 30-day in-hospital mortality. Data were analysed using Man-Whitney test and chi-square test. A multivariable regression analysis was carried out to determine factors associated with mortality. Result(s): Data of 127 cancer patients with Covid-19 was analysed. The median [interquartile range, IQR] age was 55 (43-62) years, and there were 50 females (39.3%). Comorbidities were present in 46 (36%) patients, the commonest being diabetes (29 patients) and hypertension (31 patients). The median [IQR] APACHE-II and SOFA scores were 15[8-20] and 4[2-7], respectively. Overall, 62/127 patients died, and 30-day hospital mortality was 49%. There were 30 patients with haematological malignancy and 97 with solid tumours with 30-day in-hospital mortality rates of 46.7% and 49.5%, respectively;p = 0.84). Amongst patients with solid tumours, there was no difference in mortality in surgical patients compared to non-surgical patients (43.3% vs. 52.2%;p = 0.42). Table 1 summarises the parameters and interventions in survivors and non-survivors. On multivariable analysis, only the change in SOFA score from Day 1 to Day 3 was independently associated with outcome (Odds ratio 1.36 (95% confidence interval 1.01-1.84, p-0.04). Conclusion(s): In patients with cancer and Covid-19 and age =16 years admitted to our ICU, the crude 30-day hospital mortality was 47%. There was no association of mortality with cancer type or surgical status. The only independent predictor of mortality was progression of organ failure. Cancer patients with Covid-19 have a reasonable outcome and should be given a trial of intensive care.

Frail Scale as Predictor of 30-Day Postoperative Outcomes in Geriatric Surgical Patients at a Tertiary Hospital in the Philippines from June 2020 to June 2021

Introduction: The geriatric population is a growing subset of surgical patients. Specialized surgical risk management is important since physiologic changes are only loosely associated with age. Searching for better risk assessment tools, we come across the 5-point FRAIL scale, a validated measure of weakness and physiologic malfunction resulting to vulnerability to stressors like surgery. Method(s): Our objective was to assess the effectiveness of FRAIL scale in predicting 30-day complications in geriatric surgical patients. We conducted this research at a tertiary hospital in the Philippines from June 2020 to June 2021. Patients were classified preoperatively as frail or robust, and they were monitored 30 days post-surgery for adverse outcomes. Result(s): Out of 100 patients, fifty-seven were frail. Postoperatively, 20% had complications, while 18% expired, with 76% of all adverse outcomes belonging to frail group. FRAIL scale had a significantly better predictive value as compared with Charlson comorbidity index and ACS surgical risk calculator in cases of mortality, but there was no significant difference in predicting morbidity for the three assessment tools. The increase in adverse outcomes compared with previous years was attributed to (1) the proportion of colorectal procedures, and (2) patients were probably in a more advanced stage of illness due to the delays in treatment caused by the COVID-19 pandemic. Conclusion(s): In conclusion, FRAIL scale is an easy-to-use and effective risk assessment tool for geriatric surgical patients. Since most frail patients admit of weakness, resistance training and aerobic exercises may be an appropriate strategy to improve surgical outcomes.

Management of the Surgical Patient during the First and Second Wave of COVID-19 Pandemic: Experience of a Tertiary Care Centre

Objective: Due to the COVID 19 pandemic healthcare providers all over the world had brought some changes in the management of surgical patients. This study is aimed to estimate the impact of pandemic on surgical practices. Material(s) and Method(s): We conducted a retrospective review of the medical records of all patients admitted to the department of general surgery (both elective & emergency), SCB Medical College and Hospital, Odisha, India from April 1 to July 31, 2020, and 2021 and the records were those of patients who were admitted in the same period in 2019. Data collection includes the number of admissions, the reason for admission, the age & gender of the patients admitted patients and type of management. Result(s): There was a 57.5% reduction in total admission during first COVID in pandemic 2020 and 58.7% reduction during second wave of pandemic in 2021. The proportion of patient presenting to emergency department was more in 2020 and 2021 than 2019. Number of emergency admission decreased by 46.54% in 2020 and 46% in 2021. There was a 79.5% drop in the number of out-patients admission in 2020 and 84% in 2021. Furthermore a 79.8% reduction in elective surgical intervention noticed in 2020 and 80% in 2021. Conservative management was preferred over surgical management during the COVID era. Conclusion(s): COVID-19 has led to a drastic reduction in outpatient and elective surgical practices. Hence creating a major concern for all surgeons about the critical situation.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

COVID-19- A Challenge for Urology Subspecialty in an overwhelmed public sector hospital: A Descriptive Review of Urology Department, Lady Reading Hospital

Background: COVID-19 has brought unprecedented changes in every aspect of life throughout the world including the healthcare delivery system. After a grinding halt in surgical practice due to this pandemic, the conventional protocols needed a thorough overhaul before kick-starting formal services. This study discusses ways and procedure changes adopted at the Urology department to navigate this crisis and extend adequate urological care to patients at the same time. Aim(s): To share our experience of patient management in the era of the COVID-19 pandemic. Method(s): It's a descriptive review article based on patient management protocols and clinical audit in the era of COVID-19 pandemic at the Departmentof Urology, MTI, Lady Reading Hospital from 20th Marchto 20th June 2020. Clinical implication the benefit of this study is how to organize things and continue health care provision in a deadly pandemic. Furthermore, it will set a precedence that how to cope with such a pandemic in the future. Conclusion(s): All surgical patients should be screened for COVID-19, with preference given to PCR tests. All elective surgeries should be put on hold as a result of the limited availability of ventilators, manpower, and hospital beds. Only semi-elective, lifesaving and oncologic surgeries that cannot be delayed should be done with full PPEs provided to every personnel frequenting operating theaters during the procedure. Furthermore, more efforts are needed to lift the infrastructure of hospitals and make them capable to face problems of such proportions in the future.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.

Indirect Calorimetry Critical in Identifying Early Hypometabolism and Late-Stage Hypermetabolism in Post-surgical Patients

Background: Indirect calorimetry (IC) is the gold-standard procedure for measuring resting energy expenditure (REE) in hospitalized patients. Predictive energy equations commonly use static variables and rarely account for changes in REE throughout hospitalization. We hypothesize that predictive equations are typically inaccurate in surgical intensive care unit (ICU) patients. More specifically, we hypothesize that predictive equations often overpredict measured resting energy expenditure (mREE) in early-stage critical illness and underpredict needs later in surgical ICU stay, leading to over-/under-feeding and associated complications. Method(s): This prospective observational trial enrolled surgical ICU patients who underwent emergent or urgent operations for abdominal trauma, perforated viscus, or ischemic bowel within 72 hours of their surgical procedure. Metabolic assessments were performed using the COSMED Q-NRG + Metabolic Monitor ventilator, mask, and canopy at regular intervals during and post ICU admission until hospital discharge. Measurements were categorized by post-surgical intervention ICU admission days 0-3, 4-7, 8-14, 15-21, and 22-28. Patients with multiple measurements taken during the same time interval were averaged. mREE reported in calories (kcal) per kilogram (kg) of admission body weight per day were compared in obese (BMI > 30 kg/m2) and non-obese (BMI < 30 kg/m2) subgroups. Compared to IC, the Mifflin St Jeor (MSJ) equation determined predicted REE using ICU admission anthropometrics. Data are reported as mean+/-standard error of the mean (SEM) and median (interquartile range), and a two-sided p-value of <0.05 was determined significant. Result(s): In total, 18 surgical ICU patients who contributed 47 IC measurements were included in the analysis (Table 1). Most measures were obtained within the first 7 days of post-surgical ICU admission (72%). mREE peaked between days 8-14 in obese and non-obese subgroups (20.6 vs 28.5 kcal/kg;p = 0.02) and was lowest during 0-3 days of post-surgical ICU admission in both groups. Across all 5-time intervals, average kcal/ kg ranged from 14.7-20.6 among obese patients and from 20.1-28.5 in non-obese counterparts (Table 2). Non-obese patients had higher mREE per kg of body weight than obese patients at all time points (Figure 1). MSJ over-predicted mREE during the first 7 days post ICU admission in non-obese patients and within the first 3 days in obese patients and underpredicted mREE in both groups thereafter. Conclusion(s): Equations such as MSJ over- and under-predict mREE in post-operative surgical ICU patients depending on the days elapsed since post-surgical ICU admission. ASPEN's current guideline recommendation of 12-25 kcal/kg may also underfeed post-surgical populations while 25 kcal/kg may not support hypermetabolism among non-obese patients seen in week 2 following post-surgical ICU admission. Alternatively, MSJ multiplied by a 1.2 activity factor may account for hypermetabolism during this time. Notably, non-obese patients experienced greater hypermetabolism than obese patients during week 2 which is consistent with our previously published data in mechanically ventilated COVID- 19 patients. Additionally, the striking dichotomy between the mREE of obese and non-obese patients at all post-surgical time points should be considered in the clinical care of patients. Ultimately, IC remains the gold-standard means of measuring REE and is a critical tool to capture the dynamic nature of energy requirements in post-surgical populations as weight-based and predictive equations continually fall short. (Table Presented).

Quantifying caregiver workload during the COVID-19 pandemic using ambient intelligence

Introduction: The COVID-19 pandemic has increased caregiver workload [1]. It is unclear how this workload is distributed across patients with varying presentations. Ambient intelligence (AmI) utilizes neural networks to monitor multiple data points in video feeds, and automatically tracks various aspects of human movement [2]. AmI was used to examine the workload of healthcare staff in relation to temporal and patient characteristics on a COVID ward at a major metropolitan hospital. Method(s): Sensors were deployed in patient rooms on a COVID ward to detect caregiver visits at 5-min intervals. Electronic medical records were used to identify variables hypothesized to contribute to visits. Result(s): 5514 h across 55 patients (mean age 72, range 17-98) were analyzed. The primary reason for admission was medical in 45 cases (81.8%), psychiatric in 8 cases (14.5%) and surgical in 2 cases (3.6%). Medical emergency (MET) calls occurred in 21 (38.2%) cases. As summarized in Fig. 1, visitation was lowest between 0000 and 0400 (27.3 +/- 1.1 min/hour (min/hr)) and highest between 1200 and 1600 (65.5 +/- 1.3 min/hr). The mean +/- SE visitation spent with medical, psychiatric, and surgical patients was 51.7 +/- 0.6, 38.8 +/- 1.3, and 33.7 +/- 3.9 min/hr respectively (p < 0.005). Overall lowest visitation was in surgical patients between 0400 and 0800 (4.5 +/- 4.5 min/hr). Mean +/- SE visitation were 66.7 +/- 4.6 min/hr in the three hours preceding and following MET calls compared to 50.2 +/- 0.5 min/hr in periods without MET calls (p < 0.005). There was no difference in visitation time between patients with respiratory symptoms and those without (50.7 +/- 0.9 vs 48.8 +/- 0.7 min/hr, p = 0.1). Conclusion(s): AmI can help quantify patient workload, potentially improving staff planning. Further studies comparing healthcare attendance between patients on COVID wards and non-COVID wards may provide insight into the impact of unique factors associated with the pandemic.

The use of monopolar diathermy in laparoscopic appendectomy, Is it really safe?

Background: There have been numerous techniques used in laparoscopic appendectomy (LA) to divide the mesoappendix, including LigaSure, Harmonic scalpel, clips, endoloop ligatures, Endo GIA staplers, and bipolar coagulation. However, few studies have investigated monopolar diathermy for mesoappendix division. Therefore, this study aimed to assess both its safety and efficacy in LA. Method(s): In this prospective non-randomized study, patients (n = 87) who underwent LA for acute appendicitis were included. The bipolar electrocautery was used for mesoappendix division in the first 33 patients (BC group), while the monopolar electrocautery was used in the next 54 patients (MC group). Result(s): The median operative time was significantly shorter in the MC group (42 min. vs 47 min. in BE group, p = 0.01). One patient converted to open surgery in the MC group due to uncontrollable bleeding. There were no significant differences between both groups regarding postoperative complications and hospital stay (p = 0.91, p = 0.13, respectively). Conclusion(s): Monopolar electrocautery is safe and effective for mesoappendix division in LP in comparison to bipolar electrocautery. However, larger and multicentric studies are required to validate our results.Copyright © 2023 The Authors

SASA 2023 Congress

The proceedings contain 34 papers. The topics discussed include: comparison of intra-arterial blood pressures versus two noninvasive measuring systems: a cross-sectional analytic study employing Bland-Altman and error grid analyses;prevalence of vitamin D deficiency amongst anesthesia providers at the Universitas Academic Hospital;chemical and physical stability of an admixture of anesthetic drugs;postoperative pulmonary complications in adult surgical patients in low- and middle-income countries: a systematic review and meta-analysis;the prevalence of SARS-CoV-2 infection in an academic department of anesthesiology;evaluation of the use of a 3D printed video laryngoscope for tracheal intubation in a manikin;the prevalence of caregiver anxiety in theatre at universitas academic hospital;the spectrum of disease and short-term outcomes of obstetric patients with cardiac disease at a tertiary hospital in South Africa;and almost 30% reduction in carbon footprint using volatile anesthesia - a quality improvement project introducing low-flow anesthesia in a regional hospital.

8th International Multidisciplinary Course on Iron Deficiency

The proceedings contain 37 papers. The topics discussed include: Are normal iron and hemoglobin levels needed for acquiring innate immunity and optimizing responses to COVID-19 vaccination?;management of iron deficiency in PBM: the pandemic's barriers;iron deficiency and celiac disease;treating iron deficiency in patients with ulcerative colitis;iron deficiency anemia in children: risk factors, prevention, diagnosis and therapy;iron therapy in children with inflammatory bowel disease (IBD);iron supplementation in pediatric patients with primary iron deficiency anemia: An IRIDA clinical case;iron-deficiency anemia and functional capacity in post-cardiac surgical patients: comparison between two martial treatments;iron prophylaxis in pregnant women and pregnancy outcomes;patient blood management: Anemia in obstetrics;and clinical safety and efficacy of iron supplementation in cancer patients.

Impact of Covid-19 Pandemic on Otorhinolaryngology Practice in India

Background: Covid-19 has dramatically changed everyday life across the globe. Otorhinolaryngologists were at the forefront of being exposed to the virus. As the virus evolved so did the practice of otorhinolaryngology in the country. Some innovative tacks for protecting otorhinolaryngologists and improving patient care were put into our practice by many doctors. Assessment of these techniques will help us to overcome the difficulties if a similar situation arises in the future. Material(s) and Method(s): An online survey was conducted among Indian otorhinolaryngologists. The invitation to participate in the survey was circulated among otolaryngology consultants and postgraduates all over India through multiple modalities on social media. The survey consisted of 4 sections with a total of 24 questions, related to covid vaccination status, changes made in practice, OPD (outpatient department) consultations during the lockdown period, and modifications done in outpatient and operation theatre setups. Google forms were kept open for one month. Result(s): There were changes in outpatient and operation procedure management like screening of patients before treatment and surgery, patient health care declarations, vaccination status, improvisation done in the methods of sterilization of ENT instruments, endoscopes, case selection of elective OT (operation theatre) cases. This paper aims to give a brief overview of current knowledge about the impact of covid 19 on otolaryngology practice using the best available evidence. Conclusion(s): COVID-19 had made crucial changes in ENT practice forever which will help otorhinolaryngologists in the better care of patients if a similar situation arises in the future.Copyright © 2022, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Preliminary Recommendations on the Timing of Lung Surgery after Novel Coronavirus Infection in Patients with Pulmonary Nodules and Lung Cancer.

In recent years, the corona virus disease 2019 (COVID-19) pandemic has had a huge impact on the global medical, political and economic fields. Since the beginning of the COVID-19 epidemic, our understanding of the impact of COVID-19 has grown exponentially. Recently, the COVID-19 epidemic has changed rapidly in China, and there has been controversy over how to carry out surgical operations for patients with lung neoplastic lesions. Some studies have shown that lung cancer patients undergoing surgery are more likely to experience respiratory failure and perioperative death after contract-ing COVID-19 than the general population, however, delays in cancer treatment are also associated with increased mortality among these patients. In particular, the novel coronavirus Omikron variant has a higher transmissibility and may escape the immunity obtained through the previous novel coronavirus infection and vaccination. In order to minimize the risk of novel coronavirus infection in surgical patients, it is necessary to develop new treatment guidelines, expert consensus and preventive measures. However, the current rapid change of the epidemic situation has led to insufficient time and evidence to develop guidelines and consensus. Therefore, thoracic surgeons need to evaluate specific patient populations at higher risk of severe complications before surgery and weigh the benefit of surgical treatment against the risk of novel coronavirus infection. We try to give some recommendations on lung surgery during the current domestic epidemic situation based on the guidelines and consensus of oncology and thoracic surgery organizations in different regions on lung surgery.Copyright © 2023, Chinese Journal of Lung Cancer. All rights reserved.

SARS-CoV-2 infection and venous thromboembolism after surgery: an international prospective cohort study

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery);recent (1-6 weeks before surgery);previous (>=7 weeks before surgery);or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2;2.2% (50/2317) in patients with peri-operative SARS-CoV-2;1.6% (15/953) in patients with recent SARS-CoV-2;and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3-6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.Copyright © 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

Two-thirds of patients may not require review after Mohs micrographic surgery

One of the many challenges facing the department during the COVID-19 pandemic was how to provide follow-up safely for Mohs surgical patients. With the need to practice social distancing and avoid unnecessary face-to-face (F2F) follow-up, we felt the system could be improved to ensure patient and staff safety. We created, reviewed and adapted a new system to follow-up on patients. We designed a questionnaire that was sent out to patients 3 months postprocedure. This included questions on aesthetic and functional outcomes, and postoperative complications, including bleeding and infection. Recording these outcomes is a requirement for all Mohs surgical patients, outlined by the British Society for Dermatological Surgery. Information collected via the questionnaire allowed us to identify those who required further follow-up and those who could be discharged. A patient was felt to be suitable for discharge if they reported no postoperative complications, their scar bothered them 'a little' at most and they had no functional complications besides paraesthesia. Otherwise, patients were invited for medical photography and an appointment was arranged for them, either by telephone, or if necessary, F2F. Patients were given the option to request a consultation even if they did not meet the criteria for one. Data were collected for 131 patients who had Mohs micrographic surgery between April 2020 and July 2020. Sixty-six per cent did not require follow-up as defined by the criteria. Eighty-nine per cent of patients found the questionnaire 'acceptable' or 'somewhat acceptable'. Feedback from staff has been positive and the questionnaire continues to be our first step in follow-up. Patients are informed of this new format at the time of surgery. Our next step is to identify factors that predict the requirement for review so these patients can have a suitable appointment scheduled. We intend to review the process after the pandemic, as while this approach is considered acceptable in the current climate, we understand that it may be less so once the pandemic is over. We have demonstrated a novel approach to the follow-up of Mohs surgical patients during the COVID-19 pandemic. Our data suggest that two-thirds of postoperative reviews may not be required and propose a sustainable method to identify these cases. This is significant, not only in relation to the pandemic, but in the long term. Appointments should be reserved for a clinical need to ensure efficient use of clinicians' time.

Perioperative management strategies for surgical patients during the COVID-19 outbreak.

At present, the prevention and control situation of epidemics of Corona Virus Disease 2019 (COVID-19) is still serious, medical institutions should provide quality and safe routine medical services while doing their best in the prevention and control of this disease. The purpose of this article is to suggest a way to give quality and safe medical services to patients who need surgical treatment, especially to those who need emergency surgical treatment, with strict classified managements and standard precaution during perioperative period. With those suggestions, we may reduce the incidence of nosocomial infection and contribute to the prevention and control of COVID-19.Copyright © 2020 by the Chinese Medical Association.

Epidemiology And Treatment Of Pain Associated With Osteoarthritis Of The Knee In Germany: A Retrospective Health Claims Data Analysis

Purpose: Osteoarthritis of the knee (knee OA) is the most prevalent form of OA, frequently leading to significant pain and an overall reduction in quality of life. The available options for managing pain, associated with knee OA, are well documented. They include various oral analgesic medications (for example, NASIDs and opioids), intraarticular agents, notably, hyaluronic acid and corticosteroids, and where pharmacological and lifestyle options have been exhausted, orthopedic surgery, including total knee replacement (TKR). The treatment option(s) a patient may receive, in which order and at what time point, post-diagnosis may vary significantly between healthcare centers. The current study focuses specifically on knee OA in Germany, aiming to determine the epidemiology, patient characteristics and treatment schemes for the management of pain associated with knee OA. Method(s): A non-interventional, retrospective health claims data analysis was performed with an anonymized, age- and sex-representative sample of the Institute for Applied Health Research Berlin GmbH (InGef) database. The database that was used for this study includes approximately 4.8 million persons from approx. 60 statutory health insurances (SHI). Patients >=18 years of age were analyzed cross-sectionally for each year 2015-2020. Using ICD-10 and ATC codes, newly diagnosed patients in 2015 were also analyzed longitudinally until end of 2020. Result(s): The average period prevalence of knee OA was 7.34%, with a slight increase during the years 2015-2020. Incidence ranged from 1.71% of patients in 2015 to 1.46% of patients in 2020. Females and patients aged >=66 years had both a higher prevalence and incidence proportion compared to males and younger persons. Approximately 62% of newly diagnosed patients in 2015 received medical treatment during follow-up, most of whom were prescribed non-opioid analgesics;WHO I category (96.84%), followed by WHO II (2.45%) and WHO III (0.71%), as first line treatment. This analysis could not account for the use of any over the counter medications, or medicines prescribed in hospital, prior to, or after diagnosis. As many as 16.58% of newly diagnosed patients had surgery within 5 years. Knee replacement was the most common type of surgery with rising prevalence. The number of patients in whom surgery was performed decreased slightly from 5,38% to 4,03% during the study years considered (Figure 1);the decrease in 2020 may, in-part, be a reflection of the COVID-19 pandemic and the knock-on impact on healthcare systems. Of the 8,318 surgical patients, 2,101 patients (25.26%) had no record of having received any prescription pharmacological treatment prior to first surgery. The median time from first diagnosis until surgery in newly diagnosed patients was 346 days for any surgery, and 564 days for knee replacement. [Formula presented] Conclusion(s): With a stable incidence and a growing population, the number of patients with knee OA in Germany is slowly rising. In parallel, there is an slight decrease in total knee surgeries occurring each year with an increasing proportion of TKRs. Time until first surgery, in general, and TKR in newly diagnosed patients is relatively short, compared to other countries, with some patients having no record of having received any prescription medication prior to first surgery. Other treatment options such as opioids and intraarticular agents, appear to play a relatively minor role, in newly diagnosed patients, in current practice in Germany.Copyright © 2023

Learning from Covid-19 Pandemic: Utilising Telephone Consultation in Colorectal Surgical Patients

Aim: This quality improvement project's aim is to see the difference in number of appointments and investigations between patients presenting via telephone or face to face (F2F) clinics. Method(s): We reviewed 61 referrals to Colorectal clinic between January and February 2021, 34 were telephone appointments, 22 F2F appointments and 5 were excluded due to unidentifiable patient data or incorrect referral. We assessed 14 different parameters. Result(s): The first phase data showed F2F clinic patients were older (n = 66.91 years vs 56.21 years), had more appointments (n = 1.72 vs 1.38) and a shorter RTT (Referral To Treatment) (n = 26.65 days vs 136 days). The shorter RTT correlates with the larger number of 2 week wait referrals that were seen in F2F clinic (n = 11) vs in the Telephone group (n = 3). Adjusting for patients with ongoing treatment in the F2F group (O-F2F) or telephone patients that awaited a F2F appointment for further investigation (T to F2F) the data showed that the O-F2F patients had 1.76 appointments vs 2.2 average appointments in the T to F2F patient group. Investigations were higher in the O-F2F group (n = 3 versus n = 0.5) vs the T to F2F group. There was a higher rate of DNA (Did Not Attend) (n = 11.7% versus 4.5%) and discharge (n = 20.5% versus n = 18%) in Telephone clinics vs F2F clinics. The most common reason for more appointments in the Telephone group was the inability to properly assess the patient's pathology and plan accordingly especially in benign proctological disease which was seen more commonly in the Telephone group. Conclusion(s): Risk stratification may be appropriate when deciding patients to attend telephone vs F2F clinics. A combination of red flag symptoms and increased age may be appropriate tools to start identifying suitable patients for F2F clinics. Patients with chronic or complex proctological disease likely need F2F appointments to reduce overall number of appointments which will expedite investigation and treatment. Telephone clinics may be appropriate for benign disease follow-up.

Surgical Simulation-Does it improve the undergraduate surgical experience?

Aims: Many final year undergraduate students rotating through Surgery in our DGH have had their clinical experience adversely affected by COVID due to missed or cancelled patient contact, absence, or cancelled placements earlier in The curriculum. We sought to improve The experience by designing a new simulation programme of acute surgical presentations to become embedded in The teaching schedule and to audit The feedback from this and make improvements. Method(s):Weheldasmall focus group with FYs and medical students to identify surgical presentations that they would benefit from practice on. We wrote a package of simulated cases including "unwell pancreatitis", "wound dehiscence" and "post op pyrexia". All scenarios had The aim of encouraging A-E assessment by The student pitched at incoming-FY1 level, and available equipment in The SIM lab includes SIM man, realtime obs, and General ward equipment. Scenarios were written to include multidisciplinary input from nursing, anaesthetic and surgical colleagues and include flexible options depending on student performance. The hospital resus of ficer helped to run The scenarios. Result(s): The scenarios were run with 4 consecutive blocks of students. All feedback was positive with all students grading feedback as "very good" or "excellent". Other feedback included "more scenarios" and "helps prepare for FY1". Small improvements were made to The written documentation through PDSA cycles over The 4 blocks and are now embedded in The curriculum. Conclusion(s): Availability of surgical simulation helped students to become more confident in A-E assessment of unwell surgical patients despite loss of patient interactions due to COVID.

Development of a Novel Near-peer Surgical Simulation-based Teaching Programme for Intern Doctors

Background: Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Method(s): Interns pursuing a career in Surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Result(s): Of The 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a Simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. on completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusion(s): Near-peer delivery of surgical training has enhanced The basic surgical skills of interns. Similar programmes in other sites would ensure that interns have The skills required to safely care for surgical patients.

Pattern of Perioperative Surgical Patient Care, Equipment Handling and Operating Room Management During COVID-19 Pandemic at Jimma Medical Center.

Background: The nature of COVID-19 transmission creates significant risks in surgical departments owing to the close contact of medical staff with patients, the limited physical environment of the operating room and recovery room, the possibility of shared surgical equipment and challenges in the delivery of surgical care in all surgical departments. Globally, studies have reported that the effects of the pandemic on surgical departments are profound, potentially long-lasting and extensive. To manage these effects, different local guidelines and recommendations have been developed, with potential differences in their effectiveness and implementation. Therefore, harmonized and effective national/international guidelines for specific surgical departments during perioperative periods are pertinent to curtail the infection, and will inevitably need to be adapted for consistent and sustainable implementation by all medical staff. The pattern of surgical patient care during the COVID-19 pandemic at Jimma Medical Center (JMC), Ethiopia, has not been explored yet. The present study aimed to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC. Methods: A cross-sectional study was conducted to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC, using five-point Likert scales (0, not at all; 1, rarely; 2, sometimes; 3, most of the time; 4, frequently). A total of 90 respondents [35 patients (five patients from each of seven surgical departments) and 55 healthcare providers (six professionals from each of nine units, including the center of sterility room and anesthesia)] who were available during the study period, selected by a convenience sampling technique with multistage clustering, participated in the study. Data were collected using a structured questionnaire via direct observation and face-to-face interviews with patients undergoing surgery, healthcare providers and hospital administrators, against the standard surgical patient care guidelines. The collected data were manually checked for missing values and outliers, cleared, entered into EpiData (v4.3.1) and exported to SPSS (v22) for analysis. The mean score of practice was compared among different disciplines by applying the unpaired t-test. The findings of the study were reported using tables and narration. A p-value of less than 0.05 was declared as statistically significant. Results: Despite the surgical care practice having changed during the COVID-19 pandemic in all service domains, it is not implemented consistently among different surgical departments owing to different barriers (lack of training on the updated guidelines and financial constraints). The majority of surgical staff were implementing the use of preventive measures against COVID-19, while they were practiced less among patients. The guidelines for surgical practice during the preoperative phase were well applied, especially screening patients by different methods and the application of telemedicine to reduce physical contacts. But, against guidelines, elective patients were planned and underwent surgery, especially in the general surgery department. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. The extent of practice for anesthesia care, operating room management and postoperative care in the recovery room also changed, and the guidelines were sometimes applied. Conclusion and Recommendations: Although perioperative surgical care practice differed before and during the pandemic, the standard guidelines were inconsistently implemented among surgical departments. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. Thus, the authors developed safe surgical care guidelines throughout the different domains (infection prevention and PPE use; preoperative care, intraoperative care, operating room management, anesthesia care, equipment handling process and postoperative care) for all disciplines and shared them with all staff. We recommend that all surgical staff should access these guidelines and strictly adhere to them for surgical service during the pandemic.