Regional Elective Day Procedure Centre Pilot- the solution to waiting lists and trainee deficit in the reshaping of services following COVID-19?

Background: Consequences from the COVID-19 pandemic have resulted in the secondary impact of cessation of elective surgical services, amplifying the waiting list problem with devastating patient and surgical training repercussions. With the introduction of the first regional inter-trust daycase elective care centre pilot in Northern Ireland, we aim to assess the impact of this pathway on elective inguinal hernia waiting lists, patient outcomes, and influence on surgical training. Methods: Data was collected prospectively over a 10-week pilot of consecutive elective day case hernia lists at a newly established regional day surgery centre. Key operative time points for each patient were collated via the Theatre Management System (TMS). Retrospective patient feedback was collected from participating patients via 26-question telephone survey at 6 weeks post-operatively. Trainees allocated to the participating units during this pilot received a retrospective electronic survey. Results: Fifty-five patients underwent open unilateral elective inguinal hernia repair, 54% of cases were trainee led. Median trainee operating time of 53 minutes compared with 51 minutes for consultant led procedures, with no significant difference consultant vs non-consultant as primary operator (p>0.05). On completion of the pilot, waiting list numbers were reduced by a third, 75% of trainees feedback reported increased confidence with surgical operative exposure, and high levels of patient satisfaction reported. Conclusion: Inter-trust day surgery at a dedicated green site could successfully contribute to resuming and reforming surgical services, addressing the impact on mounting waiting lists with positive patient impact as well as providing an excellent training opportunity to narrow the observed training deficit.

Association between insulin dysregulation and adrenocorticotropic hormone in aged horses and ponies with no clinical signs of pituitary pars intermedia dysfunction.

BACKGROUND: High concentrations of adrenocorticotropic hormone (ACTH) are used as an indicator of pituitary pars intermedia dysfunction (PPID), but other factors that may influence ACTH need to be understood, if diagnostic reference ranges for ACTH are to be used with confidence. Insulin dysregulation (ID) could be one such factor, as insulin affects pituitary hormones in other species. OBJECTIVES: To test the hypothesis that a relationship exists between high insulin and high ACTH in aged (>15-year-old) animals with no clinical signs of PPID. STUDY DESIGN: A cohort study. METHODS: Thirteen horses and eleven ponies (17-25 years-old; mares and geldings) were clinically examined for signs of PPID in the spring (November 2020) and autumn (April 2021). On the same day, blood samples were taken before and 2 h after an oral glucose test (OGT). Concentrations of insulin, glucose, ACTH and cortisol were measured. RESULTS: There was no association between ACTH and cortisol. However, there was a positive linear correlation between ACTH and post-OGT (insulin in the autumn (r = 0.427, p = 0.04). Two horses and six ponies had ACTH above the cut-off value for PPID diagnosis, and of these eight animals, six also had insulin concentrations above the cut-off value for ID. MAIN LIMITATIONS: The cohort was small and thyrotropin-releasing hormone (TRH) stimulation tests were not performed. CONCLUSIONS: In autumn, high ACTH was associated with ID, when no clinical signs of PPID were present. Because ACTH is used in PPID diagnosis, further work is required to understand this interaction.

Is qFIT a useful tool in prioritising symptomatic patients referred with suspect colorectal cancer in the COVID-19 era?

Background: The COVID-19 pandemic is an evolving healthcare challenge causing secondary disruption of cancer services. Quantitative Faecal Immunochemical Testing (qFIT) has been established as a screening method in asymptomatic patients. We aim to assess its utility as a triage tool to prioritise investigations in symptomatic patients with suspected colorectal cancer. Methods: At the commencement of the COVID-19 pandemic a database was established to include patients awaiting red flag outpatient consultation or colonic investigations and new red flag referrals from March to June 2020. Patients were supplied with qFIT kits and returned results categorised into 3 priority groups according to the qFIT value. Group 1 >150µg Hb/g, Group 2 ≥10 to ≤150µg Hb/g and Group 3 <10µg Hb/g. Subsequent colonic evaluation was offered by colonoscopy or cross-sectional imaging with urgency determined by qFIT priority group. When identified colorectal cancer, inflammatory bowel disease or high-risk polyps were recorded as "significant colorectal pathology." Findings: Three hundred and seventeen patients were identified with data analysed on 290 patients. Colorectal malignancy was identified in 17 patients; 94% of these patients were in Group 1. A qFIT result >150 µg Hb/g had a sensitivity and specificity for colorectal cancer of 94.12% (95% CI 71.31-99.85) and 91.21% (95% CI 87.20-94.29) respectively. No malignancy was detected in Priority Group 3; negative predictive value of 100% (95% CI 98.06-100). Conclusions: In symptomatic, suspect lower GI cancer patients qFIT is a useful adjunct for prioritising patients and can be used to determine the urgency of colorectal investigations.

Effects of an anti-IGF-1 receptor monoclonal antibody on laminitis induced by prolonged hyperinsulinaemia in Standardbred horses.

Currently, there are no registered veterinary drugs for the treatment of endocrinopathic equine laminitis, and although this form of the disease is known to be caused by prolonged hyperinsulinaemia, the mechanism of insulin toxicity is unclear. One possibility is that high concentrations of insulin activate IGF-1 receptors (IGF-1R) in lamellar tissue, leading to uncontrolled cell proliferation and epidermal lamellar dysregulation. An equinized version of a human anti-IGF-1R therapeutic monoclonal antibody (mAb11) was generated to test this theory, using a modification of the prolonged euglycaemic-hyperinsulinaemic clamp technique. Healthy Standardbred horses were infused for 48 h with 0.9% saline (negative-control, n = 6), a combination of insulin (4.5 mIU/kgBW/min) and a variable infusion of 50% glucose to maintain euglycaemia (positive-control, n = 6), or insulin and glucose, preceded by a low dose of mAb11 (20 mg), designed to treat one foot only and delivered by retrograde infusion into one forelimb (mAb-treated, n = 7). Maximum insulin concentrations were 502 ± 54.4 and 435 ± 30.4 µIU/mL in the positive-control and mAb11-treated groups, respectively (P = 0.33). While the control group remained healthy, all the insulin-treated horses developed laminitis within 30 h, as judged by clinical examination, foot radiographs and histological analysis. Some effects of insulin were not attenuated by the antibody, however, relative to the positive-control group, horses treated with mAb11 showed less sinking of the distal phalanx (P < 0.05) and milder histological changes, with markedly less elongation at the tips of the secondary epidermal lamellae (P < 0.05). These differences were apparent in both front feet and were statistically significant when the values for both feet were combined. The results confirm that IGF-1R may have a role in insulin-induced laminitis and suggest that mAb11 warrants further research as a potential agent to prevent or treat the disease.

The effect of diet change and insulin dysregulation on the faecal microbiome of ponies.

The equine microbiome can change in response to dietary alteration and may play a role in insulin dysregulation. The aim of this study was to determine the effect of adding pasture to a hay diet on the faecal bacterial microbiome of both healthy and insulin-dysregulated ponies. Faecal samples were collected from 16 ponies before and after dietary change to enable bacterial 16S rRNA sequencing of the V3-V4 region. The dominant phyla in all samples were the Firmicutes and Bacteroidetes. The evenness of the bacterial populations decreased after grazing pasture, and when a pony was moderately insulin dysregulated (P=0.001). Evenness scores negatively correlated with post-prandial glucagon-like peptide-1 concentration after a hay-only diet (r²=-0.7, P=0.001). A change in diet explained 3% of faecal microbiome variability. We conclude that metabolically healthy ponies have greater microbial stability when challenged with a subtle dietary change, compared with moderately insulin-dysregulated ponies.

An investigation of the equine epidermal growth factor system during hyperinsulinemic laminitis.

Equine laminitis is a disease of the digital epidermal lamellae typified by epidermal cell proliferation and structural collapse. Most commonly the disease is caused by hyperinsulinemia, although the pathogenesis is incompletely understood. Insulin can activate the epidermal growth factor (EGF) system in other species and the present study tested the hypothesis that upregulation of EGF receptor (EGFR) signalling is a key factor in laminitis pathophysiology. First, we examined lamellar tissue from healthy Standardbred horses and those with induced hyperinsulinemia and laminitis for EGFR distribution and quantity using immunostaining and gene expression, respectively. Phosphorylation of EGFR was also quantified. Next, plasma EGF concentrations were compared in healthy and insulin-infused horses, and in healthy and insulin-dysregulated ponies before and after feeding. The EGFR were localised to the secondary epidermal lamellae, with stronger staining in parabasal, rather than basal, cells. No change in EGFR gene expression occurred with laminitis, although the receptor showed some phosphorylation. No difference was seen in EGF concentrations in horses, but in insulin-dysregulated ponies mean, post-prandial EGF concentrations were almost three times higher than in healthy ponies (274 ± 90 vs. 97.4 ± 20.9 pg/mL, P = 0.05). Although the EGFR does not appear to play a major pathogenic role in hyperinsulinemic laminitis, the significance of increased EGF in insulin-dysregulated ponies deserves further investigation.

Renal failure parathyroidectomy - Is pre-operative imaging worthwhile?

BACKGROUND: Tertiary hyperparathyroidism is a significant issue in renal failure patients and some require surgery to control their serum calcium. A number of imaging techniques are used to localise the position of the parathyroid glands prior to surgery. Currently, a combination of ultrasound and isotope preoperative localisation imaging is accepted as useful in parathyroid surgery for primary disease. However, the use of pre-operative imaging in parathyroid surgery in renal failure patients is uncertain. The role of pre-operative imaging of the parathyroid glands in patients with renal failure hyperparathyroidism was assessed with imaging outcomes compared to operative and pathological findings in two cohorts of patients undergoing parathyroid surgery - primary and tertiary. METHODS: All data were collected prospectively over a 10-year period (2003-2013) from the practice of a single surgeon. Patients were grouped into either primary hyperparathyroidism (49 patients) or tertiary hyperparathyroidism (41 patients). The majority, 63 of 90 (70%) patients, underwent both ultrasound (US) and isotope (MIBI) pre-operative imaging. Pre-operative imaging was correlated with operative and pathological findings. FINDINGS: Comparison of the results of the two groups using ordinal regression analysis confirmed these imaging techniques are significantly more accurate in primary than tertiary parathyroid surgery (p = 0.022). CONCLUSIONS: While accepted practice of pre-operative combined USS and MIBI imaging is essential in unilateral imaged-focused neck exploration for primary disease, these imaging techniques have a more limited use pre-operatively in renal failure parathyroidectomy.

A systematic review of the association between a single strenuous event and the development of an inguinal hernia: A medicolegal grey area.

BACKGROUND: Inguinal hernia is a common surgical presentation. Evidence for its causation regarding occupational and recreational physical exposures is limited. The aim of this study is to conduct a systematic review objectively evaluating the evidence for a causal link between a single strenuous event and the development of an inguinal hernia. METHOD: A systematic review was carried out in accordance with PRISMA guidelines. PubMed, Ovid Embase, SCOPUS, and Cochrane Library were searched. In addition, the ISRCTN register, ClinicalTrials.gov, ICTR Platform, and EU Clinical Trials Register were searched. Identified publications were collated and both reviewers independently reviewed their contents. FINDINGS: 5508 records were identified, resulting in 5 studies being selected. These 5 studies were all case series. Of 957 patients identified, 1003 hernias were described, of which 983 were inguinal hernias which 255 (26%) were attributed by patients to a single strenuous event. Only two of these studies applied Smith's Criteria (causation of a hernia from a single strenuous event): officially reported, severe pain at the time of the event, no prior history of inguinal hernia, and the diagnosis was made by a doctor within 30 days (preferably 3 days). Only 2 of 54 patients (4%) met all four criteria and so could be considered as having an inguinal hernia relating to a single strenuous event. CONCLUSION: Many patients associate hernias to a single episode, however upon application of more stringent criteria such as Smith's, a much smaller proportion are deemed to be actually attributable to a single strenuous event.

Complete Genome Sequences of Four Isolates of Plutella xylostella Granulovirus.

Granuloviruses are widespread pathogens of Plutella xylostella L. (diamondback moth) and potential biopesticides for control of this global insect pest. We report the complete genomes of four Plutella xylostella granulovirus isolates from China, Malaysia, and Taiwan exhibiting pairs of noncoding, homologous repeat regions with significant sequence variation but equivalent length.

Draft Genome Sequence of Enterococcus faecalis Strain PF3, Isolated from Adelie Penguin Feces from Antarctica.

Enterococcus faecalis is one of the leading causes of nosocomial infections and is a common commensal organism in humans and other animals. In this study, we report a draft genome sequence for the E. faecalis strain PF3, isolated from Adélie penguin feces collected from Warriner Island, Antarctica.

Encapsulating peritoneal sclerosis - a 5 year experience.

TITLE: Encapsulating peritoneal sclerosis - A 5 year experience. AIM: Encapsulating peritoneal sclerosis (EPS) is a rare, life-threatening condition, characterised by a progressive, intra-abdominal inflammatory process resulting in fibrotic visceral constriction. We report the aetiology, management, and outcome of EPS in Belfast. METHOD: All patients diagnosed with EPS in Belfast over the past 5 years are included. Presentation, aetiology, imaging, pathology, and outcome are retrospectively analysed and reported. RESULTS: 7 patients (4 males) were identified with EPS with a mean age 54 years (range 33-69). Aetiology included peritoneal dialysis (3), radiation enteritis (1), peritoneal dialysis and radiation enteritis (1), tuberculosis, cirrhosis, and beta-blocker use (1), infected aorto-bifemoral graft (1). Of the 7 patients, 5 underwent definitive surgery. Bowel conserving surgery (laparotomy, division of adhesions, excision of membrane) was performed in 4 patients. One patient required an ileocaecal resection for radiation enteritis. Median pre-operative and post-operative hospital stay were 25 and 62 days respectively. Three patients required total parenteral nutrition (TPN) pre-operatively, 3 patients post-operatively; with 4 of the 7 patients discharged on TPN. 5 out of 7 patients are alive at median follow-up of 24 months. There was no 30-day in-hospital mortality. CONCLUSIONS: Patients with EPS often require parenteral nutrition before and after surgery. Peritoneal dialysis is a major risk factor for the development of EPS but other aetiologies should be considered. These patients have multiple co-morbidities, and operations for EPS are challenging with a high risk of peri-operative complications. Therefore these patients are best managed in a specialised unit with experience in intestinal failure surgery and access to a multi-disciplinary nutrition support team.

Overview of the investigation and management of cystic neoplasms of the pancreas.

BACKGROUND: Cystic neoplasms of the pancreas contribute to 10-20% of pancreatic tumours. Malignant cystic tumours of the pancreas behave similar to adenocarcinomas and thus warrant aggressive management. However, certain benign cystic neoplasms do not require operative intervention. It is, therefore, important to differentiate benign lesions from malignant lesions and from those with malignant potential. AIMS: To provide an overview of the role of radiological investigations in the management of cystic neoplasms of the pancreas, with emphasis on the characteristic features of aggressive tumours. The role of different imaging modalities is discussed, and an investigative algorithm suggested. METHODS: A literature review was carried out on Medline, Cochrane library, and PubMed using the MeSH terms 'pancreas' and 'cysts' to source relevant papers. Search criteria were limited to English literature, meta-analyses, systematic reviews, prospective and retrospective case series, published during or after 1998. DISCUSSION: Each pancreatic cystic lesion has characteristic radiological findings. However, the diagnostic accuracy of individual imaging techniques is still limited. A combination of imaging modalities is essential for preoperative diagnosis. CT complemented by endoscopic ultrasound and cyst fluid analysis appears to be the most promising investigation in diagnosing cystic neoplasms. Follow-up with serial imaging is useful for lesions of uncertain aetiology.

Association of increasing burn severity in mice with delayed mobilization of circulating angiogenic cells.

OBJECTIVE: To perform a systematic exploration of the phenomenon of mobilization of circulating angiogenic cells (CACs) in an animal model. This phenomenon has been observed in patients with cutaneous burn wounds and may be an important mechanism for vasculogenesis in burn wound healing. DESIGN: We used a murine model, in which burn depth can be varied precisely, and a validated culture method for quantifying circulating CACs. SETTING: Michael D. Hendrix Burn Research Center, Baltimore, Maryland. PARTICIPANTS: Male 129S1/SvImJ mice, aged 8 weeks, and 31 patients aged 19-59 years with burn injury on 1% to 64% of the body surface area and evidence of hemodynamic stability. MAIN OUTCOME MEASURES: Burn wound histological features, including immunohistochemistry for blood vessels with CD31 and alpha-smooth muscle actin antibodies, blood flow measured with laser Doppler perfusion imaging, and mobilization of CACs into circulating blood measured with a validated culture technique. RESULTS: Increasing burn depth resulted in a progressive delay in the time to mobilization of circulating CACs and reduced mobilization of CACs. This delay and reduction in CAC mobilization was associated with reduced perfusion and vascularization of the burn wound tissue. Analysis of CACs in the peripheral blood of the human patients, using a similar culture assay, confirmed results previously obtained by flow cytometry, that CAC levels peak early after the burn wound. CONCLUSION: If CAC mobilization and wound perfusion are important determinants of clinical outcome, then strategies designed to augment angiogenic responses may improve outcome in patients with severe burn wounds.

Using ordinal logistic regression to evaluate the performance of laser-Doppler predictions of burn-healing time.

BACKGROUND: Laser-Doppler imaging (LDI) of cutaneous blood flow is beginning to be used by burn surgeons to predict the healing time of burn wounds; predicted healing time is used to determine wound treatment as either dressings or surgery. In this paper, we do a statistical analysis of the performance of the technique. METHODS: We used data from a study carried out by five burn centers: LDI was done once between days 2 to 5 post burn, and healing was assessed at both 14 days and 21 days post burn. Random-effects ordinal logistic regression and other models such as the continuation ratio model were used to model healing-time as a function of the LDI data, and of demographic and wound history variables. Statistical methods were also used to study the false-color palette, which enables the laser-Doppler imager to be used by clinicians as a decision-support tool. RESULTS: Overall performance is that diagnoses are over 90% correct. Related questions addressed were what was the best blood flow summary statistic and whether, given the blood flow measurements, demographic and observational variables had any additional predictive power (age, sex, race, % total body surface area burned (%TBSA), site and cause of burn, day of LDI scan, burn center). It was found that mean laser-Doppler flux over a wound area was the best statistic, and that, given the same mean flux, women recover slightly more slowly than men. Further, the likely degradation in predictive performance on moving to a patient group with larger %TBSA than those in the data sample was studied, and shown to be small. CONCLUSION: Modeling healing time is a complex statistical problem, with random effects due to multiple burn areas per individual, and censoring caused by patients missing hospital visits and undergoing surgery. This analysis applies state-of-the art statistical methods such as the bootstrap and permutation tests to a medical problem of topical interest. New medical findings are that age and %TBSA are not important predictors of healing time when the LDI results are known, whereas gender does influence recovery time, even when blood flow is controlled for.The conclusion regarding the palette is that an optimum three-color palette can be chosen 'automatically', but the optimum choice of a 5-color palette cannot be made solely by optimizing the percentage of correct diagnoses.

The challenge of reconstruction for severe facial burn deformity.

This article presents the story of the development of an expanded transposition flap that evolved from a desire to optimally reconstruct facial burn deformities. The story spans 25 years and demonstrates how an algorithm was developed from its use, and how the algorithm is used to analyze large facial burn deformities and provide a reconstructive surgical decision making tree. The experience suggests that versatility, reliability, and minimization of the donor site defect and reconstructive time are all benefits of this approach.

Case report: treatment of open femoral shaft fracture in a severely burned patient.

OBJECTIVE: To present a case report of a patient with an open fracture and severe burns and review the literature. METHODS: The patient was treated with intubation, intravenous antibiotics, and debridement and intramedullary nailing for the femur fracture. He later underwent multiple burn excision procedures with allograft and autograft skin coverage. The wound over the fracture was treated with dressing changes. The fracture was treated with nail exchange and bone grafting for atrophic nonunion. RESULTS: The patient was returned to full weightbearing and good function with a fully healed femur. CONCLUSIONS: Treatment of open fractures in burn patients should be tailored to the specific needs of the individual; they should be reduced and stabilized via internal fixation at the earliest opportunity and should be managed by minimizing wound colonization through successive debridement, wound care, and consideration of flap coverage.

An algorithm for total and subtotal facial reconstruction using an expanded transposition flap: a 20-year experience.

BACKGROUND: Reconstruction of major facial soft-tissue deformities and deficits is a continuing challenge for surgeons who wish to reliably restore facial function and appearance. A primary problem is deficiency of well-matched donor skin. Others include the unique characteristics of facial skin, the fine anatomical nuances, and the unique functional demands placed on the face making reconstruction difficult. The author presents an algorithm developed for total and subtotal reconstruction of the face using an expanded shoulder transposition flap as a key element. METHODS: Expanded shoulder transposition flaps have been used since 1986 for head and neck resurfacing. An algorithm using the expanded shoulder transposition flap as a key element was developed for total and subtotal resurfacing of the face. The validity of this approach was evaluated by clinical results over 20 years. During that time, expanded shoulder transposition flaps were used 58 times in 41 patients ranging in age from 2 to 62 years. RESULTS: With the expanded shoulder transposition flap as its central component, the algorithm proved remarkably reliable and reproducible in resurfacing the peripheral facial aesthetic units with the main flap, and the pedicle skin often used for grafting the central face with its finer features. The donor site of the flap is closed primarily. CONCLUSIONS: This study examines the experience using an algorithm developed with the expanded shoulder transposition flap for major facial reconstruction. The experience suggests that the algorithm provides versatility and reliability; minimizes the donor-site defect; and is well within the skill, patience, and courage of most reconstructive surgeons.