The reorganisation of emergency general surgery services during the COVID-19 pandemic in the UK: outcomes of delayed presentation, socio-economic deprivation and Black, Asian and Minority Ethnic patients.

INTRODUCTION: The COVID-19 pandemic is a global public health emergency. Lockdown restrictions and the reconfiguration of healthcare systems to accommodate an increase in critical care capacity have had an impact on 'non-COVID' specialties. This study characterises the utilisation of emergency general surgery (EGS) services during the UK lockdown period at a university teaching hospital with a catchment population that represents one of the most deprived and ethnically diverse areas in the UK. METHODS: EGS admissions during the UK lockdown period (March to May 2020) were compared with the same period in 2019. Patient demographics were recorded together with clinical presentation, hospital stay and treatment outcomes, and readmission data. RESULTS: The study included 645 patients, comprising 223 in the COVID-19 period and 422 in the non-COVID-19 period. There was no difference in age, sex, comorbidity or socio-economic status. A lower proportion of patients of Black, Asian and Minority Ethnicity (BAME) were admitted during the pandemic (20.6% vs 35.4%, p < 0.05). The duration of symptoms prior to presentation was longer, and admission clinical parameters and serum inflammatory markers. More patients presented with an acute kidney injury (9.9% vs 4.7%, p = 0.012). There was no difference in perioperative outcomes or 30-day mortality, but more patients were readmitted following conservative management (10.6% vs 4.7%, p = 0.023). CONCLUSIONS: The reorganisation of EGS to a senior-led model has been successful in terms of outcomes and access to treatment despite a more unwell population. There was a significantly lower proportion of BAME admissions suggesting additional barriers to healthcare access under pandemic lockdown conditions.

Congenital diaphragmatic hernia causing cardiac arrest in a 30-year-old woman.

Congenital diaphragmatic hernia (CDH) usually presents in infancy with respiratory failure requiring urgent surgical correction. Mortality in this group of patients remains poor and persistent pulmonary hypertension is a significant contributor. It is therefore rare for patients to reach adulthood undiagnosed. CDH is often identified incidentally in adults but when symptoms arise, they relate to the organ involved, and include gastrointestinal symptoms of dyspepsia and obstruction, as well as respiratory complaints such as dyspnoea. We present the case of a 30-year-old woman who was admitted with non-specific symptoms of upper abdominal discomfort but whose deteriorating condition culminated in a cardiac arrest, as an unreported presentation of CDH. The patient presented initially with severe left upper quadrant pain. Her chest x-ray on admission suggested a raised left hemidiaphragm. She went on to have computed tomography (CT) of the thorax and abdomen as well as oesophagogastroduodenoscopy, which raised the suspicion of diaphragmatic eventration. Repeat CT was performed after the patient collapsed on the ward five days following admission, revealing tracheal deviation, and a strangulated Bochdalek hernia containing stomach and spleen. After transfer to the anaesthetic room, she suffered a cardiac arrest. Advanced life support was required to return spontaneous cardiac function. She was intubated and ventilated, and a needle thoracostomy was performed to decompress the tension gastrothorax. Emergency laparotomy revealed a gangrenous stomach and spleen. Total gastrectomy with primary Roux-en-Y reconstruction, splenectomy and insertion of a feeding jejunostomy were performed. The patient recovered well postoperatively and was discharged two weeks following surgery.

Analysis of the Herschel/HEXOS Spectral Survey Towards Orion South: A massive protostellar envelope with strong external irradiation.

We present results from a comprehensive submillimeter spectral survey toward the source Orion South, based on data obtained with the HIFI instrument aboard the Herschel Space Observatory, covering the frequency range 480 to 1900 GHz. We detect 685 spectral lines with S/N > 3σ, originating from 52 different molecular and atomic species. We model each of the detected species assuming conditions of Local Thermodynamic Equilibrium. This analysis provides an estimate of the physical conditions of Orion South (column density, temperature, source size, & V LSR ). We find evidence for three different cloud components: a cool (T ex ~ 20 - 40 K), spatially extended (> 60″), and quiescent (ΔVFWHM ~ 4 km s -1) component; a warmer (T ex ~ 80 - 100 K), less spatially extended (~ 30″), and dynamic (ΔVFWHM ~ 8 km s -1) component, which is likely affected by embedded outflows; and a kinematically distinct region (T ex > 100 K; V LSR ~ 8 km s -1), dominated by emission from species which trace ultraviolet irradiation, likely at the surface of the cloud. We find little evidence for the existence of a chemically distinct "hot core" component, likely due to the small filling factor of the hot core or hot cores within the Herschel beam. We find that the chemical composition of the gas in the cooler, quiescent component of Orion South more closely resembles that of the quiescent ridge in Orion-KL. The gas in the warmer, dynamic component, however, more closely resembles that of the Compact Ridge and Plateau regions of Orion-KL, suggesting that higher temperatures and shocks also have an influence on the overall chemistry of Orion South.

VELOCITY-RESOLVED [C ii] EMISSION AND [C ii]/FIR MAPPING ALONG ORION WITH HERSCHEL.

We present the first ~7.5'×11.5' velocity-resolved (~0.2 km s-1) map of the [C ii] 158 µm line toward the Orion molecular cloud 1 (OMC 1) taken with the Herschel/HIFI instrument. In combination with far-infrared (FIR) photometric images and velocity-resolved maps of the H41α hydrogen recombination and CO J=2-1 lines, this data set provides an unprecedented view of the intricate small-scale kinematics of the ionized/PDR/molecular gas interfaces and of the radiative feedback from massive stars. The main contribution to the [C ii] luminosity (~85 %) is from the extended, FUV-illuminated face of the cloud (G0>500, nH>5×103 cm-3) and from dense PDRs (G≳104, nH≳105 cm-3) at the interface between OMC 1 and the H ii region surrounding the Trapezium cluster. Around ~15 % of the [C ii] emission arises from a different gas component without CO counterpart. The [C ii] excitation, PDR gas turbulence, line opacity (from [13C ii]) and role of the geometry of the illuminating stars with respect to the cloud are investigated. We construct maps of the L[C ii]/LFIR and LFIR/MGas ratios and show that L[C ii]/LFIR decreases from the extended cloud component (~10-2-10-3) to the more opaque star-forming cores (~10-3-10-4). The lowest values are reminiscent of the "[C ii] deficit" seen in local ultra-luminous IR galaxies hosting vigorous star formation. Spatial correlation analysis shows that the decreasing L[C ii]/LFIR ratio correlates better with the column density of dust through the molecular cloud than with LFIR/MGas. We conclude that the [C ii] emitting column relative to the total dust column along each line of sight is responsible for the observed L[C ii]/LFIR variations through the cloud.

Target and nontarget effects of novel "triple-stacked" Bt-transgenic cotton 1: canopy arthropod communities.

Transgenic cotton varieties (Bollgard II) expressing two proteins (Cry1Ac and Cry2Ab) from Bacillus thuringiensis (Bt) have been widely adopted in Australia to control larvae of Helicoverpa. A triple-stacked Bt-transgenic cotton producing Cry1Ac, Cry2Ab, and Vip3A proteins (Genuity Bollgard III) is being developed to reduce the chance that Helicoverpa will develop resistance to the Bt proteins. Before its introduction, nontarget effects on the agro-ecosystem need to be evaluated under field conditions. By using beatsheet and suction sampling methods, we compared the invertebrate communities of unsprayed non-Bt-cotton, Bollgard II, and Bollgard III in five experiments across three sites in Australia. We found significant differences between invertebrate communities of non-Bt and Bt (Bollgard II and Bollgard III) cotton only in experiments where lepidopteran larval abundance was high. In beatsheet samples where lepidopterans were absent (Bt crops), organisms associated with flowers and bolls in Bt-cotton were more abundant. In suction samples, where Lepidoptera were present (i.e., in non-Bt-cotton), organisms associated with damaged plant tissue and frass were more common. Hence in our study, Bt- and non-Bt-cotton communities only differed when sufficient lepidopteran larvae were present to exert both direct and indirect effects on species assemblages. There was no overall significant difference between Bollgard II and III communities, despite the addition of the Vip gene in Bollgard III. Consequently, the use of Bollgard III in Australian cotton provides additional protection against the development of resistance by Helicoverpa to Bt toxins, while having no additional effect on cotton invertebrate communities.

Characterization of Δ7/11, a functional prolactin-binding protein.

Prolactin is essential for normal mammary gland development and differentiation, and has been shown to promote tumor cell proliferation and chemotherapeutic resistance. Soluble isoforms of the prolactin receptor (PrlR) have been reported to regulate prolactin bioavailability by functioning as 'prolactin-binding proteins'. Included in this category is Δ7/11, a product of alternate splicing of the PrlR primary transcript. However, the direct interactions of prolactin with Δ7/11, and the resulting effect on cell behavior, have not been investigated. Herein, we demonstrate the ability of Δ7/11 to bind prolactin using a novel proximity ligation assay and traditional immunoprecipitation techniques. Biochemical analyses demonstrated that Δ7/11 was heavily glycosylated, similar to the extracellular domain of the primary PrlR, and that glycosylation regulated the cellular localization and secretion of Δ7/11. Low levels of Δ7/11 were detected in serum samples of healthy volunteers, but were undetectable in human milk samples. Expression of Δ7/11 was also detected in six of the 62 primary breast tumor biopsies analyzed; however, no correlation was found with Δ7/11 expression and tumor histotype or other patient demographics. Functional analysis demonstrated the ability of Δ7/11 to inhibit prolactin-induced cell proliferation as well as alter prolactin-induced rescue of cell cycle arrest/early senescence events in breast epithelial cells. Collectively, these data demonstrate that Δ7/11 is a novel regulatory mechanism of prolactin bioavailability and signaling.

Metastasis of colorectal adenocarcinoma to the thyroid: a case report and review of the literature.

Purpose. We present a rare case of colorectal metastasis to the thyroid five years following primary colonic resection. This case highlights the need to be cognisant of unusual sites of metastasis from colorectal neoplasms. Case Report. An 82-year-old male patient had a panproctocolectomy for synchronous colorectal tumours. Five years later he was found to have lung and thyroid metastases found incidentally on imaging for an acute presentation with small bowel obstruction. Conclusion. Metastases to the thyroid should be considered in the differential diagnosis of the thyroid lesion with any history of malignancy, particularly with increasing patient age and when renal cell carcinoma or lung, colon, or breast primaries are involved.

Hydride spectroscopy of the diffuse interstellar medium: new clues on the gas fraction in molecular form and cosmic ray ionization rate in relation to H3+.

The Herschel-guaranteed time key programme PRobing InterStellar Molecules with Absorption line Studies (PRISMAS)(1) is providing a survey of the interstellar hydrides containing the elements C, O, N, F and Cl. As the building blocks of interstellar molecules, hydrides provide key information on their formation pathways. They can also be used as tracers of important physical and chemical properties of the interstellar gas that are difficult to measure otherwise. This paper presents an analysis of two sight-lines investigated by the PRISMAS project, towards the star-forming regions W49N and W51. By combining the information extracted from the detected spectral lines, we present an analysis of the physical properties of the diffuse interstellar gas, including the electron abundance, the fraction of gas in molecular form, and constraints on the cosmic ray ionization rate and the gas density.

Extreme achalasia presenting as anorexia nervosa.

Background. Achalasia may lead to cachexia if not diagnosed in an early stage. Surgery in cachectic patients is hazardous and complications may result in a protracted recovery or even death. Different treatment options have been described. In this paper, we report a stepwise surgical laparoscopic approach which appears to be safe and effective. Methods. Over a one-year period, a patient with a body mass index (BMI) below 17 being treated for anorexia nervosa was referred with dysphagia. Because of the extreme cachexia, a laparoscopic feeding jejunostomy (LFJ) was fashioned to enable long-term home enteral feeding. The patient underwent a laparoscopic Heller myotomy (LHM) when the BMI was normal. Results. The patient recovered well following this stepwise approach. Conclusion. Patients with advanced achalasia usually present with extreme weight loss. In this small group of patients, a period of home enteral nutrition (HEN) via a laparoscopically placed feeding jejunostomy allows weight gain prior to safe definitive surgery.

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons.

AIM: The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection. METHOD: A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained. RESULTS: Four hundred and twenty-four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection. CONCLUSION: Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.

Comparable outcomes in donation after cardiac death and donation after brainstem death: a matched analysis of renal transplants.

Donation after cardiac death (DCD) donors provide a valuable source of grafts for renal transplantation. They are exposed to an initial warm ischemic insult, which can affect early function. We sought to compare our initial DCD experience in renal transplantation with a case-matched donation after brain death (DBD) cohort from the same period. We included all DCD transplantations in the first 5 years of the program. A control DBD group was matched with a variety of donor and recipient factors. We demonstrated a significantly increased early dysfunction (DGF and primary nonfunction). DCD graft function was poorer than the DBD equivalent at 1- and 3-years. However, medium-term recipient and graft outcomes were comparable. DCD grafts continue to play a vital role in renal transplantation despite evidence of early graft dysfunction.

Predicting donor asystole following withdrawal of treatment in donation after cardiac death.

Donation after cardiac death donation allows donor pool expansion. The period between withdrawal of treatment and donor a systole is extremely variable; its prolongation often results in unsuccessful organ procurement. We sought to assess a variety of donor variables to determine whether they predicted successful organ retrieval. We included all Donation after Cardiac Death (DCD) retrievals between 2002 and 2009, which were grouped as successful (n = 104) versus unsuccessful (n = 42). Factors that predicted unsuccessful organ procurement included older donor age, donor history of hypertension, higher at withdrawal, and absence of inotropic support. On multivariate analysis, mean arterial pressure retained its significance. Prediction of withdrawal-to-asystole time is complex, but our analysis suggested that donor blood pressure at withdrawal is an important predictor of whether retrieval would be successful.

Impact of cold ischemia on renal transplant outcomes following donation after cardiac death.

Donation after cardiac death (DCD) provides grafts in renal transplantation but is associated with increased early graft dysfunction. Cold ischemia time (CIT) is a factor that is thought to affect outcomes in renal transplantation. We sought to assess the impact of the length of CIT among our DCD cohort of renal transplants performed between April 2002 and December 2009. Since the median CIT was 15.5 hours, we formed two groups CIT < 15.5 (n = 100) and CIT > 15.5 hr (n = 98). We demonstrated an increased incidence of DGF among the extended CIT group, but the long outcomes and the mean graft function were otherwise comparable. In conclusion, CIT affects early graft function; every effort should be made to minimize it in renal transplantation using DCD kidneys.

Impact of age matching of donors to recipients on renal transplant outcomes following donation after cardiac death.

Organ donation after cardiac death (DCD) provides a valuable supply of grafts for renal transplantation. Age matching of donors to recipients is often used. We sought to determine the impact of age matching on the outcomes among our cohort of DCD renal transplant recipients. Using our institutional database, we gathered information on all DCD renal transplants performed between April 2002 and December 2009. We divided the cohort into two groups based upon the donor:recipient age ratio: age-matched (between 25th and 75th percentiles, n = 99) and non-age-matched (<25th percentile and >75th centile, n = 100). We failed to demonstrate any significant difference between the two groups in terms of early complications or long-term outcome or function. Age matching did not appear to affect graft outcomes, particularly for young donors, but may have a role in older donors.

Sequential transplant of paired kidneys following donation after cardiac death: impact of longer cold ischemia time on the second kidney on graft and patient outcome.

The United Kingdom has no national sharing scheme for kidneys received from donation after cardiac death (DCD). Therefore, both kidneys retrieved by a transplant team are implanted at a single unit, often sequentially. This study analyzes the impact of a prolonged cold ischaemia time on the second transplanted kidney and the effects on short-term and long-term outcomes in all our DCD renal implants from 2002 to 2009. Cold ischaemia time was significantly longer with the second kidney (P = .04) as was delayed graft function (P = .02). Acute rejection was increased in the first transplanted kidney (P < .001). Five-year patient survival was comparable between groups, but 5-year graft survival was higher in the second transplanted group (P = .04). The results confirm that, provided recipient centers are willing to accept higher initial rates of delayed graft function, it is acceptable to transplant DCD grafts sequentially without jeopardizing long-term graft or recipient outcome.

Outcomes following renal transplantation after multiorgan retrieval versus kidney-only retrieval in donation after cardiac death donors.

With the increase of donation after cardiac death (DCD) now including procurements for not only kidney but also liver, pancreas, and lung transplantations, we analyze whether multiorgan DCD retrievals have a negative impact on immediate and short-term renal transplant outcomes due to increased length of time of explantation of the kidney from the donor and the associated risks of re-warming. We performed a retrospective study of all DCD donors from 2002 to 2009 at a single unit. Immediate and short-term outcomes between kidney-only versus multiorgan retrieval were compared. Cold ischaemia was significant between the two groups (P = .04), but all other variables were nonsignificant. The results show that immediate graft function, rates of acute rejection and graft/recipient survival are comparable when DCD allografts are procured from both multiorgan and kidney-only donors. The comparable outcomes from kidney-only and multiorgan donations in this study may be due to by the highly selective use of donors for multiorgan DCD donation. This selectivity may explain the "better" quality of kidney for these cases in which patients were able to tolerate potentially injurious rewarming.

Renal transplantation following donation after cardiac death: impact of duration from withdrawal to asystole.

Donation after cardiac death (DCD) allows for expansion of the donor pool, however, the process for DCD donation can lead to a donor's physiological instability before asystole. This may have a detrimental effect on graft and patient outcomes. We analyzed all 201 DCD donations at our unit from 2002 to 2009 and compared short versus long durations to asystole around the median time (20 min). Delayed graft function was comparable between the groups (P = .13), primary nonfunction was increased in the long duration to asystole group (P < .0001), and acute rejection was increased in the short duration group (P < .001). Five year patient survival was comparable (P = .6). In conclusion, long duration asystole may have an immediate effect on graft survival, but it has no overall detrimental effect on longer-term outcomes. Further studies are required to investigate the acceptable time to wait from withdrawal to asystole.