Exploring pandemic preparedness in higher education: lessons learnt from students' lived experiences during a critical time.

Background: The COVID-19 pandemic has had a marked impact on educational disruption and progression of students. Linked to this, studies have demonstrated increases in depression, anxiety, and stress, with long-term outcomes yet to be understood. Students in Higher Education (HE) were at particular risk due to circumstances such as financial stress from job loss, shifting to online learning and uncertainties about the future, with many international students isolated from social support networks. This study explored lived experiences of determinants for academic disruption in HE students during the COVID-19 pandemic across Germany and the UK. Methods: The study used qualitative secondary data collected from extension and mitigation claim forms from 2019 until 2021 from a university with campuses in the UK and Germany. A phenomenological perspective was utilised to draw out experiences and insights into determinants for mitigation from students to enhance our understanding of real problems encountered during a period of crisis. Thematic data analysis was used to create themes of influence for mitigation of assessments. Results: Themes identified pre and during the COVID-19 pandemic included; pre-COVID: work-related commitments; bereavement; illness of a family member; mental and physical health issues; natural disasters, during 2020/21, themes created were; COVID-19 social impacts; workplace and financial demands; psychological distress; physical illness, with subthemes evolving such as family responsibilities; and caring for others; furlough and its financial impacts; heavy workload for frontline health care workers; mental health impacts; physical abuse and crime, COVID-19 physical symptoms. Conclusion: We suggest an Integrated 'Determinants of Wellbeing Framework' for supporting HE students during critical times such as a pandemic. Our suggested framework was adapted from determining health inequalities and the concept of the 'flourishing student' that maps the relationship between the student, their environment and well-being. It is hoped the framework will serve to inform future theories around disruption to student progression and to explore the relevant impact on educational outcomes in HE thus assisting in appropriate support planning.

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

COVID-19 the showdown for mass casualty preparedness and management: the Cassandra Syndrome.

Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. COVID-19 epidemic warrants consideration as a mass casualty incident (MCI) of the highest nature. An optimal MCI/disaster management should consider all four phases of the so-called disaster cycle: mitigation, planning, response, and recovery. COVID-19 outbreak has demonstrated the worldwide unpreparedness to face a global MCI.This present paper thus represents a call for action to solicitate governments and the Global Community to actively start effective plans to promote and improve MCI management preparedness in general, and with an obvious current focus on COVID-19.

Cholecystectomy in Emilia-Romagna region (Italy): A retrospective cohort study based on a large administrative database.

BACKGROUND: The aim of this study was to ascertain the variability and to identify a trend for the outcome of cholecystectomy surgery when used to treat cholelithiasis and acute cholecystitis. METHODS: This was a large retrospective cohort study following patients up to 11 years post surgery, based on administrative data collected from 2002 to 2012 in the Emilia-Romagna Region (Northern Italy) and comparing the effectiveness and efficiency of surgical activity (laparoscopic (LC) and open cholecystectomy (OC)). Analyses included patient characteristics, length of hospital stay, type of admission and mortality risk. Outcomes considered were death from all causes (during the index hospital admission or thereafter), hospital readmissions with cholecystitis or cholelithiasis as principal diagnosis and time to surgery. RESULTS: A total of 84,628 cholecystomies were performed from 2002 to 2012 out of 123,061 admissions with primary diagnostic category of cholecystitis or cholelitiasis. Laparoscopic procedure was used in 69,842 patients. Over time there was a rising linear statistically significant trend in the use of LC. Mortality rate at 1 year of OC treated patients showed a statistically significant difference compared to LC treated patients (using a cohorts match with propensity score). Only a small number of patients with acute cholecystitis was operated according guidelines within 72 hours. CONCLUSIONS: The analysis of aggregate administrative data is a powerful tool to support regional health management, improve the quality of medical care, and assess the appropriateness of therapeutic or diagnostic approaches. It is important to stress a short hospital stay for laparoscopic cholecystectomy patients (50% less than open surgery): this shorter hospital stay leads to a significant economic advantage. Moreover, mortality is significantly higher in open surgery for acute cholecystitis. Interestingly, the same finding was confirmed after 30 days and 1 year, probably due to comorbidities that are more evident in open surgery. KEY WORDS: Cholecystitis, Cholelithiasis, Delivery of health care, Disease management, Surgical.

Benefits of WSES guidelines application for the management of intra-abdominal infections.

INTRODUCTION: The use of antibiotics is very high in the departments of Emergency and Trauma Surgery above all in the treatment of the intra-abdominal infections, to decrease morbidity and mortality rates; often the antimicrobial drugs are prescribed without a rationale and they are second-line antibiotics; this clinical practice increases costs without decreasing mortality. Aim of our study is to report the results in the application to the clinical practice of the World Society Emergency Surgeons (WSES) guidelines for the management of intra-abdominal infections, at the department of Emergency and Trauma Surgery of the University Hospital of Parma (Italy) in 2012. METHODS: A retrospective observational analysis was carried out about patients admitted in the department of Emergency and Trauma Surgery of Parma (Italy), between January 2011 and December 2012. The data are expressed as percentages (%) and means (± SD). The results of the compared groups were analyzed using the Pearson's Chi-Square and Fisher's tests. For means involving continuous numerical data, the independent sample T test and the Mann-Whitney U-test were used for normally and abnormally distributed data, respectively (the data had been previously tested for normality using the Kolmogorov-Smirnov test). A p-value < 0.05 was considered statistically significant. RESULTS: Between January 2011 and December 2012, 2121 (968 in 2011 and 1153 in 2012) patients were admitted in the department of Emergency and Trauma Surgery (Italy) of Parma University Hospital with a diagnosis of acute IAI. Morbidity in 2012 was 10,2% compared to 22.7% in 2011 and mortality in 2012 was 1,1% compared to 3,2% in 2011 (p < 0,05). Costs for antibiotics in 2012 was 51392 euro, with a reduction of 31% compared to 2011. CONCLUSIONS: This study demonstrates that an inexpensive and easily application of guidelines based on medicine evidence in the use of antibiotics can lead to a significative reduction of hospital costs with outcomes improvement.

The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis.

BACKGROUND: The HARMONIC SCALPEL (H) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages, such as: reduced ligature demand; greater precision due to minimal lateral thermal tissue damage; minimal smoke production; absence of electric corrents running through the patient. However, there are no prospective RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy (MD) during laparoscopic cholecystectomy (LC) in cases of acute cholecystitis (AC). METHODS: This study was a prospective, single-center, randomized trial (Trial Registration Number: NCT00746850) designed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC, compared to the use of MD. Patients were divided into two groups: both groups underwent early LC, within 72 hours of diagnosis, using H and MD respectively (H = experimental/study group, MD = control group). The study was designed and conducted in accordance with the regulations of Good Clinical Practice. RESULTS: 42 patients were randomly assigned the use of H (21 patients) or MD (21 patients) during LC. The two groups were comparable in terms of basic patient characteristics. Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group (p=ns); overall blood loss was significantly lower in the H group. Conversion rate was 4.7% for the H group, which was significantly lower than the 33% conversion rate for the control group (p<0.05). Post-operative morbidity rates differed slightly: 19% and 23% in the H and control groups, respectively (p=ns). Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group (p=ns). CONCLUSIONS: The use of H appears to correlate with reduced rates of laparoscopic-open conversion. Given this evidence, H may be more suitable than MD for technically demanding cases of AC.

The Bolognese surgeon Giuseppe Ruggi: how and why the aseptic surgery was introduced in Bologna in the middle half of the XIX century.

BACKGROUND: The first reliable statistic data about perioperatory mortality were published in 1841 by the French Joseph-Francois Malgaigne (1806-1863): he referred to a mean mortality of 60% for amputations and this bad result was to be attributed mainly to hospital acquired diseases. The idea of "hospital acquired disease" although vague, included five infective nosologic entities, which at that time were diagnosed more frequently: erysipelas, tetan, pyemia, septicemia, and gangrene. Nonetheless, the suppuration with pus production was considered from most of the surgeons and doctors of that time as a necessary and unavoidable step in the process of wound healing. During the end of the eighteenth century, hospitals of the main European cities were transforming into aggregations of several wards, where the high concentration of patients created poor sanitary conditions and a consistent increase of perioperatory mortality. In 1865, Lister applied his first antiseptic dressing on the surface of an exposed fracture. These experimental attempts lead to an effective reduction of wound infections respect to the dressing with strings used previously. DISCUSSION: Lister's innovations in the field of wound treatment were based on two brand new concepts: germs causing rot were ubiquitarious and the wound infection was not a normal step in the process of wound healing. The concept of antisepsis was hardly accepted in the European surgical world: "Of all countries, Italy is the most indifferent and uninterested in experimenting this method, which has been so favorably judged from the greatest surgical societies in Germany". This quotation from the young surgeon Giuseppe Ruggi (1844-1925) from Bologna comes from his article where he presented his first experiences on aseptic medications started the previous year in the Surgical Department of Maggiore Hospital in Bologna. In his report, Ruggi described the adopted technique and suggested that the medication should be extended to all the surgical patients of the hospital:"… this is needed to totally remove from the hospital all those elements of infection which grow in the wounds dressed with the old method". The experimentation of this new dressing for the few treated cases was rigorous and concerned both the sterilization of surgical tools with the fenic acid (5%) and the shaving of the skin. Ruggi also observed that there was no correlation between the seriousness of the wound and its extension or way of healing: when "simple" cases that "should heal without complication" showed fever he often realized that "it was often due to a medication performed without following the rules for an accurate disinfection and dressing". Ruggi thought that the fever was connected to "reabsorption of pyrogenic substances, which can be removed cleaning and disinfecting the wound" in cases of wounds not accurately dressed and rarely medicated. Frequent postoperative medications of the wound were able to eliminate the fever within 2 h. Ruggi's attitude toward the fine reasoning lead him to introduce the concept of immunodeficiency related to physical deterioration: "… patients treated for surgical disease may sometimes suffer from complications of medical conditions, which initially escape the most accurate investigations… The surgical operation could, in some cases, hold the balance of power". CONCLUSIONS: The obtained results, published in 1879, appear extremely interesting. As he wrote in 1898, for the presentation of his case record of more than 1000 laparotomies, he had started "… operating as a young surgeon without any tutor, helped only by his mind and what he could deduce from publications existing at the moment …".