Cost-comparison of robotic versus laparoscopic colorectal resections: a mapped systematic review and meta-analysis of published studies.

Background: Robotic colorectal resections (RCR) have been gaining popularity recently due to several advantages in addition to oncological safety. The objective of this review is to evaluate the cost comparison of RCR versus laparoscopic colorectal resections (LCR). Methods: All types of comparative studies reporting the cost of RCR versus LCR were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5. Results: The search of medical databases yielded 13 studies (one randomised trial and 12 comparative studies) on 16,082 patients undergoing oncological and non-oncological colorectal resections. Eleven studies reported total cost whereas seven studies reported only operative cost. In the random effects model analysis, LCR was associated with the reduced total cost [standardised mean difference -62.34, 95% confidence interval (CI): -75.14 to -49.54, Z=9.55, P<0.001] as well as reduced operative cost (standardised mean difference -4.60, 95% CI: -5.90 to -3.31, Z=6.96, P<0.001) compared to RCR. However, there was significant heterogeneity [Tau2=346.74, Chi2=29,559.11, df =11 (P<0.001; I2=100%); Tau2=2.73, Chi2=832.21, df =6 (P<0.001; I2=99%)] among included studies. Conclusions: The LCR seems to be more economical as compared to the RCR in terms of operative cost as well as total cost (operative plus in-patient stay). However, due to statistically significant heterogeneity among included studies and paucity of the randomised trials, these findings should be taken cautiously.

Exploring mosquito abundance and Plasmodium infection through nested-PCR: implications for disease surveillance and control.

The Plasmodium is responsible for malaria which poses a major health threat, globally. This study is based on the estimation of the relative abundance of mosquitoes, and finding out the correlations of meteorological parameters (temperature, humidity and rainfall) with the abundance of mosquitoes. In addition, this study also focused on the use of nested PCR (species-specific nucleotide sequences of 18S rRNA genes) to explore the Plasmodium spp. in female Anopheles. In the current study, the percentage relative abundance of Culex mosquitoes was 57.65% and Anopheles 42.34% among the study areas. In addition, the highest number of mosquitoes was found in March in district Mandi Bahauddin at 21 °C (Tmax = 27, Tmin = 15) average temperature, 69% average relative humidity and 131 mm rainfall, and these climatic factors were found to affect the abundance of the mosquitoes, directly or indirectly. Molecular analysis showed that overall, 41.3% of the female Anopheles pools were positive for genus Plasmodium. Among species, the prevalence of Plasmodium (P.) vivax (78.1%) was significantly higher than P. falciparum (21.9%). This study will be helpful in the estimation of future risk of mosquito-borne diseases along with population dynamic of mosquitoes to enhance the effectiveness of vector surveillance and control programs.

Laparoscopic versus robotic cholecystectomy: a systematic review with meta-analysis to differentiate between postoperative outcomes and cost-effectiveness.

Background: Robotic cholecystectomy (RC) has shown promising outcomes in multiple studies when compared with the gold standard laparoscopic cholecystectomy (LC). The objective of this study is to compare the postoperative surgical outcomes and cost in patients undergoing RC versus LC. Methods: Studies reporting postoperative outcomes and costs in patients undergoing RC versus LC were selected from medical electronic databases and analysis was conducted by the values of systematic review on the statistical software RevMan version 5. Results: Six trials on 1,013 affected individuals for post-operative outcomes and cost comparison were used. Random effect model analysis was used in the analysis. Duration of operation (mean difference: -10.23, 95% CI: -16.23 to -4.22, Z=3.34, P=0.0008) was shorter in the LC group with moderate heterogeneity. Bile leak (odds ratio: 3.34, 95% CI: 0.85 to 13.03, Z=1.73, P=0.08) and no heterogeneity was seen, Postoperative complications (odds ratio: 1.49, 95% CI: 0.50 to 4.46, Z=0.72, P=0.47) with moderate heterogeneity. Both were statistically similar. LC had reduced cost (standardised mean difference: -7.42, 95% CI: -13.10 to -1.74, Z=2.56, P=0.01) with significant heterogeneity. Conclusions: RC failed to prove any clinical advantage over LC for postoperative outcomes including longer duration of operation moreover LC was more cost effective. Due to the paucity of randomised control trial (RCT) and significant heterogeneity, a major multicentre RCT is required to strengthen and validate the findings.

Comprehensive systematic review on the self-gripping mesh vs sutured mesh in inguinal hernia repair.

Objective: The objective of this systematic review is to analyse the randomised control trials (RCTs) comparing the self-gripping mesh (SGM) with sutured mesh fixation (SMF) in open inguinal hernia repair. Materials and methods: RCTs comparing SGM with SMF in open inguinal hernia repair were selected from medical electronic databases and analysis was performed using the principles of meta-analysis with RevMan version 5 statistical software. Results: Seventeen RCTs involving 3863 patients were used for the final analysis. In the random effect model analysis, the operative time [mean difference - 7.72, 95 %, CI (-9.08, -6.35), Z = 11.07, P = 0.00001] was shorter for open inguinal hernia repair with SGM. However, there was noteworthy heterogeneity (Tau2 = 4.24; Chi2 = 1795.04, df = 12; (P = 0.00001; I2 = 99 %) among the included studies. The incidence of chronic groin pain [odds ratio 1.17, 95 %, CI (0.88, 1.54), Z = 1.09, P = 0.28], postoperative complications [odds ratio 0.92, 95 %, CI (0.73, 1.16), Z = 0.71, P = 0.48] and recurrence [odds ratio 1.31, 95 %, CI (0.80, 2.12), Z = 1.08, P = 0.28] were statistically similar between both groups, without heterogeneity. Conclusion: SGM failed to demonstrate a clinical advantage over SMF in terms of perioperative outcomes although the duration of surgery was shorter in SGM.

Comparing Thoracic Epidural Anaesthesia to Rectus Sheath Catheter Analgesia for Postoperative Pain After Major Abdominal Surgeries: A Systematic Review.

Controlling postoperative pain is essential for the greatest recovery following major abdominal surgery. Thoracic epidural analgesia (TEA) has traditionally been considered the preferred method of providing pain relief after major abdominal surgeries. Thoracic epidural analgesia has a wide range of complications, including residual motor blockade, hypotension, urine retention with the need for urinary catheterisation, tethering to infusion pumps, and occasional failure rates. In recent years, rectus sheath catheter (RSC) analgesia has been gaining popularity. The purpose of this review is to compare the effectiveness of TEA and RSC in reducing pain following major abdominal surgeries. Four randomised controlled trials (RCTs) reporting outcomes of the visual analogue scale (VAS) pain score were included according to the set criteria. A total of 351 patients undergoing major abdominal surgery were included in this meta-analysis. There were 176 patients in the TEA group and 175 patients in the RSC group. In the random effect model analysis, there was no significant difference in VAS pain score in 24 hours at rest (standardised mean difference (SMD) -0.46; 95% CI -1.21 to 0.29; z=1.20, P=0.23) and movement (SMD -0.64; 95% CI -1.69 to -0.14; z=1.19, P=0.23) between TEA and RSC. Similarly, there was no significant difference in pain score after 48 hours at rest (SMD -0.14; 95% CI -0.36 to 0.08; z=1.29, P=0.20) or movement (SMD -0.69; 95% CI -2.03 to 0.64; z=1.02, P=0.31). In conclusion, our findings show that there was no significant difference in pain score between TEA and RSC following major abdominal surgery, and we suggest that both approaches can be used effectively according to the choice and expertise available.

Preoperative antibiotic prophylaxis in acute cholecystectomy: a systematic review and meta-analysis of randomised controlled trials.

Background: Laparoscopic cholecystectomy (LC) in patients admitted with acute cholecystitis is considered the preferred, feasible and safe mode of managing gallstone disease. The objective of this study is to evaluate the role of single-dose pre-operative prophylactic antibiotics in patients undergoing emergency LC for mild to moderate acute cholecystitis. Methods: All randomized control trials (RCTs) reporting the use of single-dose pre-operative prophylactic antibiotics in patients undergoing acute cholecystectomy were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5. Results: Standard medical databases search produced only 3 RCTs on 781 patients undergoing acute cholecystectomy. There were 384 patients in single dose pre-operative antibiotics group whereas 397 patients were recruited in the no-antibiotics group. In the random effects model analysis, the use of single-dose preoperative prophylactic antibiotics in patients undergoing acute cholecystectomy for mild to moderate cholecystitis failed to demonstrate any extra advantage of reducing the risk of [risk ratio (RR) =0.69; 95% confidence interval (CI): 0.46-1.03; Z=1.80; P=0.07] infective complications. There was no heterogeneity [Tau2 =0; Chi2 =1.74, df =2 (P=0.42; I2=0%)] among included studies. Conclusions: A preoperative single dose of prophylactic antibiotics in patients undergoing acute LC for mild to moderate acute cholecystitis does not offer extra benefits to reduce infective complications.

Appendiceal Foreign Bodies in Adults: A Systematic Review of Case Reports.

Adults can accidentally swallow foreign bodies (FBs) with food. In rare occasions, these can lodge in the appendix lumen causing inflammation. This is known as foreign body appendicitis. We conducted this study to review different types and management of appendiceal FBs. A comprehensive search on PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar was performed to detect appropriate case reports for this review. Case reports eligible for this review included patients above 18 years of age with all types of FB ingestion causing appendicitis. A total of 64 case reports were deemed to be eligible for inclusion in this systematic review. The patient mean age was 44.3 ± 16.7 years (range, 18-77). Twenty-four foreign bodies were identified in the adult appendix. They were mainly lead shot pellet, fishbone, dental crown or filling, toothpick, and others. Forty-two percent of the included patients presented with classic appendicitis pain, while 17% were asymptomatic. Moreover, the appendix was perforated in 11 patients. Regarding modalities used for diagnosis, computed tomography (CT) scans confirmed the presence of FBs in 59% of cases while X-ray only managed to detect 30%. Almost all of the cases (91%) were treated surgically with appendicectomy and only six were managed conservatively. Overall, lead shot pellets were the most common foreign body found. Fishbone and toothpick accounted for most of the perforated appendix cases. This study concludes that prophylactic appendicectomy is recommended for the management of foreign bodies detected in the appendix, even if the patient is asymptomatic.

Systematic review with meta-analysis of transverse vs. vertical midline extraction incisional hernia risk following laparoscopic colorectal resections.

Background: The aim of this article is to explore the risk of incisional hernia (IH) occurrence at the site of specimen extraction following laparoscopic colorectal resection (LCR), highlighting the comparison between transverse incision versus midline vertical abdominal incision. Methods: Analysis was conducted according to PRISMA guidelines. Systematic search of medical databases, EMBASE, MEDLINE, PubMed and Cochrane Library were performed to find all types of comparative studies reporting the incidence of IH at the specimen extraction site of transverse or vertical midline incision following LCR. The analysis of the pooled data was done using the RevMan statistical software. Results: Twenty-five comparative studies (including 2 randomised controlled trials) on 10,362 patients fulfilled the inclusion criteria. There were 4,944 patients in the transverse incision group and 5,418 patients in the vertical midline incision group. In the random effects model analysis, the use of transverse incision for specimen extraction following LCR reduced the risk of IH development (odds ratio =0.30, 95% CI: 0.19-0.49, Z=4.88, P=0.00001). However, there was significant heterogeneity (Tau2=0.97; Chi2=109.98, df=24, P=0.00004; I2=78%) among included studies. The limitation of the study is due to lack of RCTs, this study includes both prospective and retrospective studies along with 2 RCTs which makes the meta-analysis potentially biased in source of evidence. Conclusions: Transverse incision used for specimen extraction following LCR seems to reduce the risk of postoperative IH incidence compared to vertical midline abdominal incisions.

Post-injury born oligodendrocytes incorporate into the glial scar and contribute to the inhibition of axon regeneration.

Failure of central nervous system projection neurons to spontaneously regenerate long-distance axons underlies irreversibility of white matter pathologies. A barrier to axonal regenerative research is that the axons regenerating in response to experimental treatments stall growth before reaching post-synaptic targets. Here, we test the hypothesis that the interaction of regenerating axons with live oligodendrocytes, which were absent during developmental axon growth, contributes to stalling axonal growth. To test this hypothesis, first, we used single cell RNA-seq (scRNA-seq) and immunohistology to investigate whether post-injury born oligodendrocytes incorporate into the glial scar after optic nerve injury. Then, we administered demyelination-inducing cuprizone and stimulated axon regeneration by Pten knockdown (KD) after optic nerve crush. We found that post-injury born oligodendrocyte lineage cells incorporate into the glial scar, where they are susceptible to the demyelination diet, which reduced their presence in the glial scar. We further found that the demyelination diet enhanced Pten KD-stimulated axon regeneration and that localized cuprizone injection promoted axon regeneration. We also present a resource for comparing the gene expression of scRNA-seq-profiled normal and injured optic nerve oligodendrocyte lineage cells.

Regional vessels wrapping following pancreaticoduodenectomy reduces the risk of post-operative extra-luminal bleeding. A systematic review.

Background: Post-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether wrapping of regional vessels with omentum or falciform/teres ligament following pancreaticoduodenectomy reduces the risk of extra-luminal bleeding. Materials and method: Standard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) and any type of comparative trial were shortlisted according to the inclusion criteria. The summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software. Result: Two RCTs and 5 retrospective studies on 4100 patients undergoing pancreaticoduodenectomy were found suitable for this meta-analysis. There were 1404 patients in the wrapping-group (WG) and 2696 patients in the no-wrapping group (NWG). In the random effects model analysis, the incidence of extra-luminal haemorrhage was statistically lower in WG [odds ratio 0.51, 95%, CI (0.31, 0.85), Z = 2.59, P = 0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant. Conclusion: The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres) following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting a greater number of patients are required to validate these findings as this study presents the combined data of two RCTs and 5 retrospective studies.

Caution Influences Avoidance and Approach Behaviors Differently.

While conflict between incompatible goals has well-known effects on actions, in many situations the same action may produce harmful or beneficial consequences during different periods in a nonconflicting manner, e.g., crossing the street during a red or green light. To avoid harm, subjects must be cautious to inhibit the action specifically when it is punished, as in passive avoidance, but act when it is beneficial, as in active avoidance or active approach. In mice of both sexes performing a signaled action to avoid harm or obtain reward, we found that addition of a new rule that punishes the action when it occurs unsignaled delays the timing of the signaled action in an apparent sign of increased caution. Caution depended on task signaling, contingency, and reinforcement type. Interestingly, caution became persistent when the signaled action was avoidance motivated by danger but was only transient when it was approach motivated by reward. Although caution is represented by the activity of neurons in the midbrain, it developed independent of frontal cortex or basal ganglia output circuits. These results indicate that caution disrupts actions in different ways depending on the motivational state and may develop from unforeseen brain circuits.SIGNIFICANCE STATEMENT Actions, such as crossing the street at a light, can have benefits during one light signal (getting somewhere) but can be harmful during a different signal (being run over). Humans must be cautious to cross the street during the period marked by the appropriate signal. In mice performing a signaled action to avoid harm or obtain reward, we found that addition of a new rule that punishes the action when it occurs unsignaled, delays the timing of the signaled action in an apparent sign of increased caution. Caution became persistent when the signaled action was motivated by danger, but not when it was motivated by reward. Moreover, the development of caution did not depend on prototypical frontal cortex circuits.

Intraperitoneal local anesthesia for postoperative pain management in patients undergoing laparoscopic colorectal surgery: a systematic review and meta-analysis.

INTRODUCTION: Intraperitoneal instillation of local anesthetic agents has been reported as an effective adjunct to pain management and early functional recovery in colorectal surgery. Laparoscopic colorectal resection (LCR) is considered as the gold standard approach to resect benign and malignant lesions of the colon and rectum due to the advantages of reduced pain score, quicker recovery, and shorter hospitalization. The objective of this study was to systematically analyze the published RCTs evaluating the effectiveness of intraperitoneal local anesthetic (IPLA) instillation versus standard analgesia in patients undergoing LCR. EVIDENCE ACQUISITION: Electronic databases such as Embase, Medline, PubMed, PubMed Central and the Cochrane library pertaining to the use of IPLA infiltration after LCR were systematically reviewed using the principles of meta-analysis. EVIDENCE SYNTHESIS: Five RCTs on 292 patients undergoing LCR were either given IPLA or standard postoperative analgesia. In the random-effects model analysis using the statistical software Review Manager (Cochrane, London, UK), statistically 2-4 hours pain score (Standardized mean difference [SMD]=-1.72; 95% CI: -2.62 to -0.81; z=3.71; P=0.0002) was significantly lower in the IPLA group. The 12 hours postoperative pain score (P=0.23) was also lower in the IPLA group but failed to reach the statistical significance. Opioid analgesia requirement was lower in the IPLA group (SMD=-7.60; 95% CI: -11.21 to -3.90; z=4.12; P=0.0001) but the time to flatus, length of stay and the frequency of nausea/vomiting were statistically similar in both groups. CONCLUSIONS: IPLA instillation is an effective modality to reduce the postoperative pain score and lower the opioid analgesic requirements in patients undergoing LCR without influencing the time to first flatus, length of stay, and postoperative nausea/vomiting.

Detection of Babesia odocoilei in Humans with Babesiosis Symptoms.

Human babesiosis is a life-threatening infectious disease that causes societal and economic impact worldwide. Several species of Babesia cause babesiosis in terrestrial vertebrates, including humans. A one-day clinic was held in Ontario, Canada, to see if a red blood cell parasite, which is present in blacklegged ticks, Ixodes scapularis, is present in humans. Based on PCR testing and DNA sequencing of the 18S rRNA gene, we unveiled B. odocoilei in two of 19 participants. DNA amplicons from these two patients are almost identical matches with the type strains of B. odocoilei in GenBank. In addition, the same two human subjects had the hallmark symptoms of human babesiosis, including night sweats, chills, fevers, and profound fatigue. Based on symptoms and molecular identification, we provide substantive evidence that B. odocoilei is pathogenic to humans. Dataset reveals that B. odocoilei serologically cross-reacts with Babesia duncani. Clinicians must realize that there are more than two Babesia spp. in North America that cause human babesiosis. This discovery signifies the first report of B. odocoilei causing human babesiosis.

Detection of Babesia odocoilei in Ixodes scapularis Ticks Collected in Southern Ontario, Canada.

Tick-borne zoonotic diseases have an economic and societal impact on the well-being of people worldwide. In the present study, a high frequency of Babesia odocoilei, a red blood cell parasite, was observed in the Huronia area of Ontario, Canada. Notably, 71% (15/21) blacklegged ticks, Ixodes scapularis, collected from canine and feline hosts were infected with B. odocoilei. Consistent with U.S. studies, 12.5% (4/32) of questing I. scapularis adults collected by flagging in various parts of southwestern Ontario were positive for B. odocoilei. Our data show that all B. odocoilei strains in the present study have consistent genetic identity, and match type strains in the GenBank database. The high incidence of B. odocoilei in the Huronia area indicates that this babesial infection is established, and is cycling enzootically in the natural environment. Our data confirm that B. odocoilei has wide distribution in southern Ontario.

Detection of Babesia odocoilei in Ixodes scapularis Ticks Collected from Songbirds in Ontario and Quebec, Canada.

Songbirds widely disperse ticks that carry a diversity of pathogens, some of which are pathogenic to humans. Among ticks commonly removed from songbirds, the blacklegged tick, Ixodes scapularis, can harbor any combination of nine zoonotic pathogens, including Babesia species. From May through September 2019, a total 157 ticks were collected from 93 songbirds of 29 species in the Canadian provinces of Ontario and Québec. PCR testing for the 18S gene of Babesia species detected Babesia odocoilei in 12.63% of I. scapularis nymphs parasitizing songbirds in Ontario and Québec; none of the relatively small numbers of Ixodes muris, Ixodes brunneus, or Haemaphysalis leporispalustris were PCR-positive. For ticks at each site, the prevalence of B. odocoilei was 16.67% in Ontario and 8.89% and 5.26% in Québec. Of 31 live, engorged I. scapularis larvae and nymphs held to molt, 25 ticks completed the molt; five of these molted ticks were positive for B. odocoilei. PCR-positive ticks were collected from six bird species-namely, Common Yellowthroat, Swainson's Thrush, Veery, House Wren, Baltimore Oriole, and American Robin. Phylogenetic analysis documented the close relationship of B. odocoilei to Babesia canis canis and Babesia divergens, the latter a known pathogen to humans. For the first time in Canada, we confirm the transstadial passage of B. odocoilei in I. scapularis molting from larvae to nymphs. A novel host record reveals I. scapularis on a Palm Warbler. Our findings show that B. odocoilei is present in all mobile life stages of I. scapularis, and it is widely dispersed by songbirds in Ontario and Québec.

Limberg flap for the management of pilonidal sinus reduces disease recurrence compared to Karydakis and Bascom procedure: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: The objective of this study is to compare the effectiveness of Limberg flap (LF) versus Karydakis and Bascom procedure to reduce the recurrence of pilonidal sinus disease. EVIDENCE ACQUISITION: The data retrieved from the published randomized controlled trials (RCT) comparing the effectiveness of LF versus Karydakis and Bascom procedure was analyzed using the principles of meta-analysis. The summated outcome of the dichotomous data was presented in risk ratio (RR). EVIDENCE SYNTHESIS: Eighteen RCTs on 2073 patients comparing the effectiveness of LF versus Karydakis and or Bascom procedure for the surgical excision of pilonidal sinus disease were analyzed. In the random effects model analysis using the statistical software Review Manager 5.3, the LF was associated with the reduced risk (RR, 0.52; 95% CI: 0.29, 0.93; z=2.19; P=0.03) of disease recurrence after pilonidal sinus excision compared to Karydakis and Bascom procedure. On subgroup analysis the LF was still superior to Karidakys procedure (RR, 0.52; 95% CI: 0.23, 1.17; z=1.57; P=0.12) and Bascom procedure (RR, 0.49; 95% CI: 0.19, 1.29; z=1.44; P=0.15) but statistically it was not significant. CONCLUSIONS: LF seems to have clinical advantage over Karydakis and Bascom procedure in terms of reduced recurrence rate following surgical excision of pilonidal sinus. Although, this advantage was clinically persisted on subgroup analysis but failed to achieve statistical significance.

Epigastric port retrieval of the gallbladder following laparoscopic cholecystectomy is associated with the reduced risk of port site infection and port site incisional hernia: An updated meta-analysis of randomized controlled trials.

AIMS: The objective of this article is to compare the surgical outcomes for epigastric port or umbilical port retrieval of the gallbladder (GB) following laparoscopic cholecystectomy (LC). METHODS: The data retrieved from the published randomized, controlled trials (RCT) comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC was analysed using the principles of meta-analysis. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR). RESULTS: Eight RCTs on 2676 patients comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the GB retrieval through epigastric port was associated with the reduced duration of operation (SMD, 0.41; 95% CI, 0.18, 0.64; z = 3.52; P = 0.0004). Epigastric retrieval was also associated with reduced risk of surgical site infection (OR, 1.95; 95% CI, 0.75, 5.11; z = 1.36; P = 0.17), and port site incisional hernia (OR, 4.22; 95% CI, 0.43, 41.40; z = 1.24; P = 0.22) compared to umbilical port retrieval though it did not reach statistical significance. The need for port enlargement to retrieve the GB was similar in both groups. In contrast, the umbilical port retrieval of the GB was associated with significantly less post-operative pain (SMD, -0.51; 95% CI, -0.95, -0.06; z = 2.24; P = 0.03), reduced GB perforation rate, reduced port site bleeding rate and reduced difficulty in GB retrieval. CONCLUSION: GB retrieval through epigastric port following LC has clinically proven advantage of reduced retrieval site infection rate, lower operation time and incisional hernia rate but at the cost of increased pain at 24 h, higher risk of GB perforation, port site bleeding and technical difficulties.

Should nasogastric tube insertion during the COVID-19 pandemic be considered as an aerosol-generating procedure?

Nasogastric tubes are used frequently in surgical patients for bowel decompression, provision of enteral nutritional support and preventing aspiration of gastric contents. There is no conclusive research into the risk of COVID-19 transmission associated with nasogastric tube insertion, although evidence from the severe acute respiratory syndrome outbreak appears to suggest that there is no increased risk of transmission. However, close contact with a COVID-19 patient, especially those displaying respiratory symptoms, is likely to increase the risk of transmission. Nasogastric tube insertion requires increased time spent at a patient's bedside and can also cause pharyngeal irritation, resulting in coughing. In addition, the nasogastric tube can expose the healthcare worker to potentially infectious saliva. Therefore, there is a clear need for increased evidence regarding the risk of transmission associated with nasogastric tube insertion, to ensure that such risks can be mitigated.

South Coast appendicular mass management (SCAM) survey.

BACKGROUND: Management of appendicular mass and interval appendicectomy remains a controversial issue. Recent publication of a randomized controlled trial (RCT) reported the incidence of around 20% neoplastic lesions in the age group of more than forty years among the interval appendicectomy group against magnetic resonance imaging (MRI) surveillance only which led to trial termination. The objective of this study is to evaluate the current practice of the management of appendicular mass in five major hospitals of South Coast of the England. METHODS: A proforma was designed and emailed to the general surgical department of five hospitals in the South Coast of England. The proforma completion rate and compliance were improved by direct telephone call to the on-call registrars and consultants to collect data. RESULTS: Fifty-three surgeons (22 consultants, 27 ST3-ST8 grade surgical trainees and 4 SAS grades) completed the proforma. The clinical, hematological and computerized tomography (CT) based diagnostic criteria, and in-patient intravenous antibiotics (IV ABTXs) in addition to the radiological drainage in amenable cases for appendicular mass/abscess were mostly agreed initial management plan among surgeons. Normalization of inflammatory markers and radiological resolution were agreed discharge indicators. Agreed follow up investigations were CT scan (by 23%), Colonoscopy (by 13%), and both CT and colonoscopy (by 57%) after discharging patients. Only 17% surgeons offered planned interval appendicectomy and 62% surgeons offered interval appendectomy in selective cases of appendicular mass within 6 weeks to 6 months after discharge. CONCLUSIONS: South Coast appendicular mass management (SCAM) survey confirms diverse practice to manage appendicular mass/abscess among surgeons working in South Coast hospitals. A substantial percentage of surgeons do not offer interval appendectomy to patients potentially leaving neoplastic lesions in situ.

Monitoring of Nesting Songbirds Detects Established Population of Blacklegged Ticks and Associated Lyme Disease Endemic Area in Canada.

This study provides a novel method of documenting established populations of bird-feeding ticks. Single populations of the blacklegged tick, Ixodes scapularis, and the rabbit tick, Haemaphysalis leporispalustris, were revealed in southwestern Québec, Canada. Blacklegged tick nymphs and, similarly, larval and nymphal rabbit ticks were tested for the Lyme disease bacterium, Borrelia burgdorferi sensu lato (Bbsl), using PCR and the flagellin (flaB) gene, and 14 (42%) of 33 of blacklegged tick nymphs tested were positive. In contrast, larval and nymphal H. leporsipalustris ticks were negative for Bbsl. The occurrence of Bbsl in I. scapularis nymphs brings to light the presence of a Lyme disease endemic area at this songbird nesting locality. Because our findings denote that this area is a Lyme disease endemic area, and I. scapularis is a human-biting tick, local residents and outdoor workers must take preventive measures to avoid tick bites. Furthermore, local healthcare practitioners must include Lyme disease in their differential diagnosis.