Reducing last-minute cancellations of elective urological surgery-effectiveness of specialist nurse preoperative assessment.

Last-minute cancellations in urological surgery are a global issue, resulting in the wastage of resources and delays to patient care. In addition to non-cessation of anticoagulants and inadequately treated medical comorbidities, untreated urinary tract infections are a significant cause of last-minute cancellations. This study aimed to ascertain whether the introduction of a specialist nurse clinic resulted in a reduction of last-minute cancellations of elective urological surgery as part of our elective recovery plan following the Coronavirus disease 2019, the contagious disease caused by severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2 pandemic. A specialist urology nurse-led clinic was introduced to review urine culture results preoperatively. Specialist nurses contacted patients with positive urine cultures and their general practitioners by telephone and email to ensure a minimum of 2 days of 'lead-in' antibiotics were given prior to surgery. Patients unfit for surgery were postponed and optimized, and vacant slots were backfilled. A new guideline was created to improve the timing and structure of the generic preassessment. Between 1 January 2021 and 30 June 2021, a mean of 40 cases was booked each month, with average cancellations rates of 9.57/40 (23.92%). After implementing changes on 1 July 2021, cancellations fell to 4/124 (3%) for the month. On re-audit, there was a sustained and statistically significant reduction in cancellation rates: between 1 July 2021 and 31 December 2021 cancellations averaged 4.2/97.5 (4.3%, P < .001). Two to nine (2%-16%) patients were started on antibiotics each month, while another zero to two (0%-2%) were contacted for other reasons. The implementation of a specialist urology nurse-led preassessment clinic resulted in a sustained reduction in cancellations of last-minute elective urological procedures.

Paraureteric space post-ureteric re-implantation: a rare cause of small bowel obstruction.

A female patient in her 80s presented with a 2-day history of abdominal pain and absolute constipation, having previously undergone a robotic left distal ureterectomy with ureteric re-implantation. CT revealed a closed-loop small bowel obstruction with transition point adjacent to the left ureter and resultant upstream hydronephrosis. An emergency laparotomy revealed small bowel herniation into a paraureteric space created by her previous surgery and defined by the distal ureter medially, the common iliac vessels laterally and the mobilised bladder dome anteriorly. The viable small bowel was reduced, and the space was eliminated by omental flap transposition after omentoplasty. The patient made a full recovery. Preoperative diagnosis of such an unusual cause of internal herniation can be challenging. This very rarely reported case raises awareness of the condition and proposes a treatment strategy.

The Effect of Sociodemographic Factors on Obtaining a Place in Core Surgical Training.

Competition for Core Surgical Training (CST) is rising, placing a strong emphasis on interview performance. Several interview courses offer to help candidates secure their chosen surgical job but at premium fees. A group of London-based CSTs started a free course offering high-quality mock interview experiences to over 90 applicants in 2022, with the aim of providing an accessible opportunity for financially disadvantaged candidates. Course candidates completed three sets of questionnaires, pre- and post-mock interview, and a final one upon job allocation. Candidates' educational background and schooling history were obtained as well as their self-assessment score, eventual rank after interview and the rank of the job they had accepted. The three sets of questionnaires were completed by 87, 73 and 45 candidates respectively. Overall, there was a statistically significant difference in self-reported confidence scores after the course (P < 0.001). There was no significant difference in the self-assessment score of the 44.2% of candidates who had attended private education in the UK, compared to publicly educated (P = 0.0525), nor was there a difference in their rank after interviews (P = 0.236). Candidates who spent £50 or more had higher self-assessment scores (P = 0.042) but they didn't rank higher in overall scores (P = 0.591). Interview preparation courses are helpful in increasing candidates' confidence, however spending more money does not translate into a better overall interview performance. Our study suggests that candidates from private education backgrounds do not have an advantage in the CST application process.

Troponin and short-term mortality in hospitalised patients with COVID-19 infection: a retrospective study in an inner-city London hospital.

OBJECTIVE: To investigate the association between troponin positivity in patients hospitalised with COVID-19 and increased mortality in the short term. SETTING: Homerton University Hospital, an inner-city district general hospital in East London. DESIGN: A single-centre retrospective observational study. PARTICIPANTS: All adults admitted with swab-proven RT-PCR COVID-19 to Homerton University Hospital from 4 February 2020 to 30 April 2020 (n=402). OUTCOME MEASURES: We analysed demographic and biochemical data collected from the patient record according to the primary outcome of death at 28 days during hospital admission. METHODS: Troponin positivity was defined above the upper limit of normal according to our local laboratory assay (>15.5 ng/L for females, >34 ng/L for males). Univariate and multivariate logistical regression analyses were performed to evaluate the link between troponin positivity and death. RESULTS: Mean age was 65.3 years for men compared with 63.8 years for women. A χ2 test showed survival of patients with COVID-19 was significantly higher in those with a negative troponin (p=3.23×10-10) compared with those with a positive troponin. In the multivariate logistical regression, lung disease, age, troponin positivity and continuous positive airway pressure were all significantly associated with death, with an area under the curve of 0.889, sensitivity of 0.886 and specificity of 0.629 for the model. Within this model, troponin positivity was independently associated with short-term mortality (OR 2.97, 95% CI 1.34 to 6.61, p=0.008). CONCLUSIONS: We demonstrated an independent association between troponin positivity and increased short-term mortality in COVID-19 in a London district general hospital.

Prostate cancer metastasis mimicking a primary urothelial carcinoma of the bladder.

We report on a 79-year-old male patient who presented with asymptomatic elevation of prostate-specific antigen and a concurrent papillary lesion, which raised the suspicion of synchronous bladder and prostatic malignancies. He underwent a trans-perineal prostate biopsy as well as transurethral resection of bladder tumour, which revealed a Gleason 9 adenocarcinoma of prostatic origin. While synchronous bladder and prostate cancer is a possibility, differential diagnosis in a patient presenting with lesions of the bladder neck should include advanced prostate cancer.

A bit about me: Bedside boards to create a culture of patient-centered care in pediatric intensive care units (PICUs).

INTRODUCTION: This project assessed whether the introduction of personalized bedside boards containing nonmedical information about patients in a pediatric intensive care unit (PICU) help provide health care professionals (HCPs) better insight about each child's personal qualities and preferences and thereby help improve patient-centered care and patient safety. METHODS: Staff and parents of children in a PICU unit completed a questionnaire assessing how well HCPs knew their patients and their design preferences for the board. The questionnaire was completed before and after board introduction, and patient involvement was central to the design of the board. RESULTS: There was an improvement in all parameters assessed. Significant improvements include the perception of PICU as a welcoming environment, nurses' understanding about what comforts their patients, and doctors' ability to recognize their patients outside the hospital. Doctors and nurses felt they knew their patients better. Parents' views regarding whether HCPs know what comforts their child and would recognize them outside the hospital also improved. Feedback about board aesthetics and usefulness was positive. CONCLUSION: Personalized bedside boards significantly improved how well HCPs knew their patients across various elements. Patient-centered care and, in turn, patient safety in PICUs can be promoted by using personalized bedside boards containing nonmedical information to help HCPs understand their patients' individual needs and tailor their treatment.

Intraoperative Optimization of Both Depth of Anesthesia and Cerebral Oxygenation in Elderly Patients Undergoing Coronary Artery Bypass Graft Surgery-A Randomized Controlled Pilot Trial.

OBJECTIVES: Does intraoperative optimization of both depth of anesthesia and regional cerebral tissue oxygenation (rScO2) in elderly patients reduce postoperative cognitive decline (primary outcome) or delirium (secondary outcome)? DESIGN: Prospective randomized controlled single blind trial. SETTING: A single major urban teaching and university hospital and tertiary referral center. PARTICIPANTS: Patients, 65 years of age and older, undergoing elective coronary artery bypass graft surgery on cardiopulmonary bypass. INTERVENTIONS: Intraoperative depth of anesthesia bispectral index (BIS) values were targeted at 50 ± 10. Regional cerebral tissue desaturations of more than 15% of the pre-induction value, or below 50%, were avoided. MEASUREMENTS AND MAIN RESULTS: Eighty-two patients were included, and mean depth of anesthesia values using BIS were significantly higher during surgery in the intervention group with 40.6 (7.3) versus 35.4 (6.7) in the control group, mean (standard deviation), p = 0.004. The cognitive function was similar between the treatment and control groups at 6 weeks postoperatively with a Mini Mental State Examination (MMSE) of 27 (26,29) in the intervention group and an MMSE of 29 (27,29) in the control group, median (interquartile range), with p = 0.12. The authors observed a reduction in the incidence of delirium, occurring in 2.4% (n = 1) of patients in the intervention group and in 20% (n = 8) in the control group (p = 0.01). CONCLUSIONS: This pilot trial demonstrates that noninvasive target-controlled depth of anesthesia monitoring is feasible. Cognitive function at 6 weeks showed no difference between the treatment and control groups; however, postoperative delirium was reduced in the intervention group.

The Use of Biophysical Flow Models in the Surgical Management of Patients Affected by Chronic Thromboembolic Pulmonary Hypertension.

Introduction: Chronic Thromboembolic Pulmonary Hypertension (CTEPH) results from progressive thrombotic occlusion of the pulmonary arteries. It is treated by surgical removal of the occlusion, with success rates depending on the degree of microvascular remodeling. Surgical eligibility is influenced by the contributions of both the thrombus occlusion and microvasculature remodeling to the overall vascular resistance. Assessing this is challenging due to the high inter-individual variability in arterial morphology and physiology. We investigated the potential of patient-specific computational flow modeling to quantify pressure gradients in the pulmonary arteries of CTEPH patients to assist the decision-making process for surgical eligibility. Methods: Detailed segmentations of the pulmonary arteries were created from postoperative chest Computed Tomography scans of three CTEPH patients. A focal stenosis was included in the original geometry to compare the pre- and post-surgical hemodynamics. Three-dimensional flow simulations were performed on each morphology to quantify velocity-dependent pressure changes using a finite element solver coupled to terminal 2-element Windkessel models. In addition to transient flow simulations, a parametric modeling approach based on constant flow simulations is also proposed as faster technique to estimate relative pressure drops through the proximal pulmonary vasculature. Results: An asymmetrical flow split between left and right pulmonary arteries was observed in the stenosed models. Removing the proximal obstruction resulted in a reduction of the right-left pressure imbalance of up to 18%. Changes were also observed in the wall shear stresses and flow topology, where vortices developed in the stenosed model while the non-stenosed retained a helical flow. The predicted pressure gradients from constant flow simulations were consistent with the ones measured in the transient flow simulations. Conclusion: This study provides a proof of concept that patient-specific computational modeling can be used as a noninvasive tool for assisting surgical decisions in CTEPH based on hemodynamics metrics. Our technique enables determination of the proximal relative pressure, which could subsequently be compared to the total pressure drop to determine the degree of distal and proximal vascular resistance. In the longer term this approach has the potential to form the basis for a more quantitative classification system of CTEPH types.