Abdominal Drainage in Complicated Appendicectomy - Resources Down the Drain?

BACKGROUND: There is currently no clear consensus on the use of drains during an appendicectomy to prevent abscess formation. Our aim was to ascertain whether the use of drains in complicated appendicitis reduces post-operative complications and length of stay. METHODS: We performed a retrospective review of patients with complicated appendicitis undergoing appendicectomy from March-November 2018. Complicated appendicectomy (perforated or gangrenous appendicitis) patients were divided into two groups; with drain Group 1 (G1) and no drain Group 2 (G2). Groups were compared for post-operative complications and length of stay. RESULTS: Out of a total 76 patients, 26 (34%) had drain (G1) and 50 (66%) had no drain (G2). The pre-operative CRP in G1 vs. G2 (124.8 vs. 48.3, p= 0.02); post-operative complication 9 (34.6%) vs. 6 (12%), p=0.019); intra-abdominal abscess 5 (19.2%) vs. 3 (6%), p=0.07 and LOS 5.5 days vs. 3 days, p=0.0001 were significantly higher in patients with a drain. CONCLUSIONS: The use of an intra-operative drain in complicated appendicitis increases the risk of a post-operative complication and increases length of stay.

General surgeon's antibiotic stewardship: Climbing the Rogers Diffusion of Innovation Curve-Prospective Cohort Study.

INTRODUCTION: The primary aim of this study was to establish concordance of general surgeon's prescribing practice with local IV-oral antibiotic guidelines. The secondary aim was to evaluate the effect of introducing educational antibiotic measures. The Rogers Diffusion of Innovation Model was used to explore the adoption of antibiotic stewardship practices. METHODS: In this prospective, cohort study, data was collected on 100 pre and 100 post awareness intervention programme patients. The educational intervention comprised raising awareness of a) the guidelines b) pre-intervention results c) introducing an IV-oral antibiotic prompt sheet. The concordance with local guidelines was compared between pre- and post-intervention groups using Fisher's Exact Test or Pearson's Chi Test (SPSS Statistics V22). RESULTS: The concordance of general surgical doctors with local IV-oral antibiotic guidelines was poor and did not improve significantly following the awareness intervention programme. There was no uptake of the antibiotic prompt sheet. There was a trend towards increase in the number of patients switched from IV to oral antibiotics at 48-72 h and significant increase (p < 0.05) in number of patients with clearly documented intention to review IV antibiotics. CONCLUSION: Antibiotic governance measures failed to inspire even an initial group of innovators to use the antibiotic prompt sheets. It appears educational measures are effective in improving prescribing behavior and intent amongst a group of early adopters, but this fails to reach a critical mass. In order to improve antibiotic governance and embark upon the Rogers Diffusion of Innovation Curve, more must be done to engage general surgical doctors in timely, judicious antibiotic prescribing.

Transcriptional profiling identifies the long noncoding RNA plasmacytoma variant translocation (PVT1) as a novel regulator of the asthmatic phenotype in human airway smooth muscle.

BACKGROUND: The mechanism underlying nonsevere and severe asthma remains unclear, although it is commonly associated with increased airway smooth muscle (ASM) mass. Long noncoding RNAs (lncRNAs) are known to be important in regulating healthy primary airway smooth muscle cells (ASMCs), whereas changed expression has been observed in CD8 T cells from patients with severe asthma. METHODS: Primary ASMCs were isolated from healthy subjects (n = 9) and patients classified as having nonsevere (n = 9) or severe (n = 9) asthma. ASMCs were exposed to dexamethasone and FCS. mRNA and lncRNA expression was measured by using a microarray and quantitative real-time PCR. Bioinformatic analysis was used to examine relevant biological pathways. Finally, the lncRNA plasmacytoma variant translocation 1 (PVT1) was inhibited by transfection of primary ASMCs with small interfering RNAs, and the effect on ASMC phenotype was examined. RESULTS: The mRNA expression profile was significantly different between patient groups after exposure to dexamethasone and FCS, and these were associated with biological pathways that might be relevant to the pathogenesis of asthma, including cellular proliferation and pathways associated with glucocorticoid activity. We also observed a significant change in lncRNA expression, yet the expression of only one lncRNA (PVT1) is decreased in patients with corticosteroid-sensitive nonsevere asthma and increased in patients with corticosteroid-insensitive severe asthma. Subsequent targeting studies demonstrated the importance of this lncRNA in controlling both proliferation and IL-6 release in ASMCs from patients with severe asthma. CONCLUSIONS: lncRNAs are associated with the aberrant phenotype observed in ASMCs from asthmatic patients. Targeting PVT1 might be effective in reducing airway remodeling in asthmatic patients.

Co-operation with pre-operative cardiovascular monitoring amongst children for chair dental general anaesthesia.

INTRODUCTION: The Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines Recommendations for standards of monitoring during anaesthesia and recovery state that cardiovascular monitoring for induction of general anaesthesia should include pulse oximetry and non-invasive blood pressure measurement, but recognise that young patients may not co-operate sufficiently to allow this. The aim of this study was to look at levels of compliance possible for pulse oximetry and non-invasive blood pressure measurement, in a population known to be unco-operative with therapeutic interventions. PATIENTS AND METHODS: A retrospective review of 500 records of patients attending for chair dental general anaesthesia was carried out. It was recorded whether pre-operatively pulse oximetry and non-invasive blood pressure measurement had been allowed in addition to the child's age and sex. RESULTS: Of the children, 52% were male and 48% were female. The age range was 2-15 years. Overall, 448 children co-operated with both pulse oximetry and non-invasive blood pressure measurement. Co-operation appeared to increase with increasing age. DISCUSSION: Of the children, 90% were co-operative with pre-operative monitoring. It could easily be assumed that many of these children, who are referred for general anaesthesia because they are less co-operative than their peers, would not allow proper pre-operative cardiovascular monitoring. This does not appear to be the case. CONCLUSIONS: The majority of children, including the very young, attending for chair dental general anaesthesia, will co-operate sufficiently to allow cardiovascular monitoring during induction of anaesthesia, even though the majority will not tolerate exodontia under local anaesthesia.

Mental nerve anaesthesia; a complication of sickle cell crisis during childbirth.

This report describes the case of an Afro-Caribbean lady diagnosed with sickle cell anaemia, who presented with permanent mental nerve anaesthesia as a result of a sickle cell crisis during childbirth.