Hybrid Surgical Hot Clinic (HSHC): Evaluation of Surgical Hot Clinic Services during COVID-19 Lockdown.

BACKGROUND: Surgical Hot Clinic (SHC) is an acute, ambulatory service for management provided on an outpatient basis. Following the start of global Novel Coronavirus (COVID-19) pandemic and as per the statement released by the Association of Surgeons of Great Britain and Ireland (ASGBI), we also modified our services to hybrid SHC (HSHC) by mainly providing telephonic follow-up with an occasional face-to-face (F2F) service. We conducted a service evaluation to assess the effectiveness and serviceability of HSHC during a pandemic. METHODS: This service evaluation was conducted from 30th March till 26th May 2020. The pathway was developed to mostly telephonic consultation with selective face-to-face consultation at a designated area in the medical ambulatory unit. The analysis then performed using SPSS version 21. RESULTS: As the overall attendance fell in hospital, 149 patients, including 54(36.2%) male, and 95(63.8%) females, attended SHC during COVID-19 lockdown. Out of these 149, 87(58.3%) were referred from Accident & Emergency (A&E), 2(1.3%) from GP, 9(6.04%) after scan through radiology department, while 51(34.2%) after discharge from hospital. Out of those who have telephonic consultation (n = 98), 12 patients were called in for review with either blood tests or further clinical examination. In total, only 10 out of 149 patients required admission to the hospital, for either intervention or symptomatic treatment. CONCLUSION: Hybrid Surgical Hot Clinic (HSHC) with both telephonic & face-to-face consultation, as per requirement, is flexible, effective and safe patient-focused acute surgical service during COVID-19 like crisis.

Retrospective Analysis of Specimen Quality in Temporal Artery Biopsies for Giant Cell Arteritis and Disease Association in North Midlands, England.

Background Temporal artery biopsy (TAB) is the recommended index diagnostic method for giant cell arteritis (GCA). Per the British Society for Rheumatology (BSR) guidelines, we assessed our procedural performance. Additionally, we evaluated the occurrence of GCA diagnosis in immunosuppressed patients and other comorbidities. Methods Following the audit registration, a retrospective analysis of prospectively collected data was conducted from 2017 to 2022 at a large university hospital in North Midlands, England. Data on demographics and comorbidities were gathered. The study's primary outcome was adherence to BSR guidelines and our service provisions. Secondary outcomes included examining the relationship between biopsy-confirmed GCA and other comorbidities. Statistical analysis was carried out using SPSS version 29 (IBM Corporation, Armonk, New York, United States of America). Two-sample t-test and Chi-square/Fisher exact test were used for continuous and categorical variables, respectively. Holm-Bonferroni method was incorporated to adjust for multiple comparisons. Results A total of 156 patients who underwent temporal artery biopsy (TAB) were included in the study, with a male-to-female ratio of 0.44:1. The median age was 73. Among the patients, 19% were smokers. The procedures were performed by either a vascular surgeon (119, 76%) or by an ophthalmologist (37, 24%). Two-thirds of the patients underwent TAB within seven days of referral. In 73, 47% of cases, the post-fixation biopsy sample size exceeded 10 mm. Positive biopsy results were found in 45 patients (29%). GCA was confirmed in 39% of patients with polymyalgia rheumatica (PMR), 24% with diabetics, 20% with hypothyroidism, 29% with hypertension, 32% with hyperlipidaemia, and 26% with other inflammatory diseases. However, the p-value was below the statistically significant threshold. The biopsy outcome was also not dependent on the speciality, time from referral to biopsy, nor on the length of the post-fixation specimen. Conclusions Temporal artery biopsy remains a valuable and crucial diagnostic tool in challenging equivocal cases of giant cell arteritis (GCA), although it is limited by its sensitivity, but there is also room for improvement. There is still uncertainty regarding the relationship between biopsy positivity, post-fixation sample size, and the interval between referral and procedure. Additionally, the speciality of the clinician performing the biopsy does not appear to significantly influence the likelihood of a positive result. We still do not fully understand why this is, but the association of the GCA with other comorbidities was unpredictably insignificant.

Another lost tribe: Quantifying the experience of international medical graduates applying for a national training number (NTN) in the United Kingdom with a cross-sectional study.

BACKGROUND: International medical graduates (IMGs) have a primary medical qualification obtained from outside their country of practice. In the United Kingdom (UK), postgraduate medical training after foundation years involves obtaining a national training number (NTN) in their specialty of choice by national selection. In this paper, we aim to quantify how IMGs feel to obtain an NTN and what unique obstacles they may face in doing so. MATERIALS AND METHODS: A survey with a combination of closed and open-ended questions was circulated to IMGs via social media and text message. The survey was aimed at those IMGs practising at a middle grade (non-consultant) level, whether they had obtained a training number or not. Data collected included demographics, years of postgraduate experience before UK arrival, number of attempts at obtaining a training number, and the most significant perceived difficulty to obtaining a training number. We also asked whether difficulties in obtaining a training number would cause IMGs to contemplate changing specialty. Data from the survey responses were analysed using SPSS 22. RESULTS: Out of a total of 203 doctors approached, 197 responded, of which the majority were male. All responders had at least five years of postgraduate experience before relocating to the UK. Only 56 (28.8%) had a training number at the time of the survey. Almost all the responders had made at least one unsuccessful attempt to obtain a training number. In addition, 152 (76.6%) of responders felt that timely career progression in the UK was unlikely without having a training number. 57 (29.6%) of responders considered changing specialty due to inability to obtain a training number. CONCLUSION: Obtaining an NTN remains a crucial goal among IMGs in the UK, despite the obstacles and repeated failures in doing so.

The Benefits and Risks of the Provision of a Hospital-Wide High-Definition Video Conferencing Virtual Visiting Service for Patients and Their Relatives.

Background Since the start of the coronavirus disease 2019 (COVID-19) pandemic, virtual visiting (VV) has become important because of visiting restrictions in hospitals. This project aimed to determine the impact of VV on staff and patients' loved ones (visitors). Methodology VV is defined as high-resolution video communication between admitted COVID-19 patients and their loved ones in the presence of a staff member using a healthcare platform. VV was introduced in a 419-bedded hospital in the UK in April 2020. Qualitative data on the VV experience were collected from relatives and staff via an open feedback email address and reflective practice. Data were entered and analyzed in person by two independent assessors. Grounded theory methodology and thematic analysis were used to draw conclusions. Results Between April 16, 2020 and November 30, 2020, 1,009 visits were delivered. There were 138 feedback responses; 108 (78.3%) from relatives and 30 (21.7%) from staff. The amalgamation of data was resolved into five themes: appreciative factors (129, 93.5%), organizational skills (44, 31.9%), palliative care (38, 27.5%), staff communication (14, 10.1%), and VV process issues (11, 7.9%). A total of 131 (94.9%) responses had positive comments (111 from relatives, 20 from staff); negative comments were greater in the staff cohort (23%) than the relative group (4%). Trends included sub-themes in overwhelming emotions, emotional strain for staff members, and difficult situations. Conclusions VV in hospitals is a new and valuable way to connect patients with loved ones with mostly positive consequences. VV also has risks to mental health and well-being, particularly for healthcare workers facilitating the call.

Use of Prophylactic Steroids to Prevent Hypocalcemia and Voice Dysfunction in Patients Undergoing Thyroidectomy: A Randomized Clinical Trial.

Importance: Total thyroidectomy is associated with risks related to temporary hypocalcemia and vocal quality dysfunction. Dexamethasone has been proposed to have a physiological effect on hypocalcemia and voice quality. Objective: To assess the effect of preoperative dexamethasone used to improve hypocalcemia and postthyroidectomy voice dysfunction. Design, Setting, and Participants: This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted from January 15, 2014, to December 31, 2019, at the Department of Surgery, Holy Family Hospital in Rawalpindi, Pakistan. All patients with a benign thyroid condition and no preoperative corrected hypocalcemia and voice or vocal quality dysfunction were included. Patients were excluded if they had previous thyroid or neck surgery, known vocal cord dysfunction on laryngoscopy, hearing or voice problems, a history of gastroesophageal reflux, stomach ulcer disease, or contraindications to steroid use. Interventions: Corrected serum calcium levels and Voice Analog Score defined and measured preoperatively. The dexamethasone group received a 2-mL intravenous dose of 8 mg of dexamethasone 60 minutes before the induction of anesthesia. In contrast, the placebo group received 2 mL of intravenous normal saline (0.9%) 60 minutes before the induction of anesthesia. Main Outcomes and Measures: Evidence of hypocalcemia and voice dysfunction. Voice dysfunction was defined as a subjective score of less than 50 on a Voice Analog Score scale of 0 to 100 points. Results: A total of 192 patients (mean [SD] age, 38.9 [12.4] years; 156 women [81.2%]) were included in the study, with 96 patients randomized to each study group (dexamethasone group, mean [SD] age, 39.2 [12.1] years; 75 women [78.1%]; placebo group, mean [SD] age, 38.5 [12.9] years; 81 women [84.5%]). In the first 24 hours after undergoing thyroidectomy, 47 patients (24.4%) developed hypocalcemia and 18 (9.4%) were symptomatic. At 3 days postthyroidectomy, 4 of 96 patients (4.2%) in the placebo group had hypocalcemia compared with no patients in the dexamethasone group. At 24 hours postthyroidectomy, 8 of 96 patients (8.3%) in the dexamethasone group had voice dysfunction compared with 32 of 96 patients (33.3%) in the placebo group. A total of 40 patients (20.8%) reported voice dysfunction. The absolute reduction in the rate of hypocalcemia at 24 hours was 24% (95% CI, 11.9%-35.2%) and at 3 days was 4.2% (-0.44% to 10.0%). The rate of symptomatic hypocalcemia was 19% lower in the dexamethasone group than in the placebo group (95% CI, 11.1%-27.7%). The rate of voice dysfunction was 25% lower in the dexamethasone group than in the placebo group (95% CI, 13.7%-35.7%). Conclusions and Relevance: In this randomized clinical trial, a single preoperative dose of dexamethasone was safe and effective in reducing postoperative hypocalcemia and voice dysfunction rates in patients undergoing thyroidectomy. Trial Registration: ClinicalTrials.gov identifier: NCT04752852.

Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement.

Importance: The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. Objective: To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. Evidence Review: A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. Findings: The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. Conclusions and Relevance: Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

Agile Application of Video Telemedicine During the COVID-19 Pandemic.

Background The coronavirus disease 2019 (COVID-19) pandemic led to a need to introduce video telemedicine for outpatients as an emergency measure without widespread stakeholder consultation. The patient and clinician experience of video outpatient consultation during the peak of the pandemic was studied for acceptability and to gather recommendations to improve the service during continuing infection control measures. Methods Outpatient video telemedicine was introduced over a 14-day period including the provision of equipment, systems integration and stakeholder communication. Patient and clinician experience were measured between 15 April 2020 and 5 May 2020. Results A total of 43 patients and 79 clinicians provided feedback. Of the patients, 86% were above the age of 30 years, with the largest patient group aged 51-70 years. Patient experience was positive. All (100%) patients found joining the video consultation easy; 93% of them recommended to use it for future consultations. Clinician satisfaction was >90% with sound and video quality. Patients were less satisfied than clinicians in that they had communicated everything they wanted to (86% versus 95%). All (100%) patients thought that the video telemedicine solution met their needs, but 25% of clinicians believed that the patient experience of a video consultation was worse than a face-to-face clinic appointment. The three significant factors identified for introducing video consultations were successful IT, improved patient experience and digital healthcare records. Conclusions In the COVID-19 crisis, video telemedicine played a central role in outpatient consultations with excellent levels of success. With some differences in satisfaction level, clinicians significantly underestimate the level of patient satisfaction with outpatient video consultation.

A cross-sectional survey on availability of facilities to healthcare workers in Pakistan during the COVID-19 pandemic.

INTRODUCTION: COVID-19 pandemic has caused a healthcare crisis across the world. Low-economic countries like Pakistan lag behind in an adequate response including supply of Personal Protective Equipment (PPE), leading to panic among healthcare workers. We aim to evaluate hospital settings and state in Pakistan regarding availability of resources and views of healthcare workers on COVID-19. METHOD: A questionnaire survey was carried out among healthcare workers in public and private sector hospitals across Pakistan for a period of one month. The primary measured outcomes were presence of local Standard Operating Procedures (SOPs), availability and training of PPE, specific isolation wards and staff wellbeing support by the hospital management. RESULTS: There were 337 participants, 307 (91.1%) doctors and 11 nurses (3.3%). About two-third of the participants (n = 199, 59%) reported non-availability of PPE and 40% (n = 136) denied availability of local Standard Operating Procedures. About a quarter of the participants (n = 94, 27.8%) had training in Donning and Doffing. Most of the participants (n = 277, 82.1%) felt that it was necessary to have testing available for frontline workers. CONCLUSION: There is lack of PPE and adequate facilities in hospitals as COVID-19 continue to spread in Pakistan. Local medical governing bodies and societies should come forward with guidelines to ascertain wellbeing of the healthcare workers.

Single centre concept of 'cold site' elective surgery during the peak of COVID-19 pandemic : A cohort study.

OBJECTIVE: The COVID-19 pandemic caused a major strain on healthcare systems across the globe. As these systems got overwhelmed with the emergency care of the infected patients, widespread cancellations of elective surgery occurred. Our hospital utilised local private hospital as a dedicated cold site (CS) for urgent elective surgery during the peak of the COVID-19 pandemic. We aim to analyse the outcomes at this dedicated cold site. METHOD: A retrospective review of a prospectively maintained database of all the cases operated at the CS during a 2-month period (30 March 2020 to 29 May 2020) was carried out. The primary outcome was 30-day COVID-19 related mortality. The secondary outcomes were 30-day non-COVID-19 related mortality, complications, readmission and development of COVID-19 symptoms. RESULTS: A total of 153 patients were operated at the CS over the study period with a median age of 57 years (Interquartile range, IQR 47-70). 62% were females and 82% had a Body Mass Index (BMI) less than 30. 73% of the operations were performed for cancer. 59% of the surgeries were graded as intermediate and 26% as major or complex. There was no mortality at 30 days from COVID-19 or non COVID-19 causes. There was only 1 (0.65%) readmission. 7 patients (4.57%) developed complications. 1 (0.65%) patient was diagnosed with COVID-19 in the postoperative period while 3 had COVID-19 symptoms but were tested negative. CONCLUSION: Urgent elective surgery is safe and feasible during the COVID-19 pandemic if a dedicated cold site is available.

Algorithm-Based Online Software for Patients' Self-Referral to Breast Clinic as an Alternative to General Practitioner Referral Pathway.

Introduction The study aimed to assess the accuracy of online software in the use of self-referral to breast surgery clinics for patients with new signs and symptoms. The study also evaluated the appropriateness of GP referrals to breast clinics and evaluated patients' perceptions of an online self-referral portal to the breast clinic for the assessment of breast signs and symptoms.  Design and methods The pilot study was divided into two phases. In the first phase, prospective questionnaire-based data was collected from patients who were referred by a GP and presented to the regional breast unit with new signs and symptoms for breast conditions, Princess Alexandra Hospital NHS Trust (May - October 2018). The questionnaire assessed the time at each stage required by the patient to have a visit at the breast unit. It also asked the patient's opinion about an online self-referral portal to the surgical clinic. They were given hypothetical scenarios to evaluate their understanding of breast conditions. In the second phase, the patients presenting to symptomatic breast clinics were provided with the iPad to fill in their medical information in the online software. The data was collected between July and October 2019. The software algorithm was based on the National Institute of Clinical Health and Excellence (NICE) guidelines for breast conditions (2015). Breast surgeons' recommendations acted as a standard to evaluate the accuracy of GPs' referrals and software outcome for each patient.  Results There were 80 patients (mean age 49.1 [SD: 17.7], all females) included in the first phase of the study. The most common clinical presentation was a breast lump (47.6%), followed by breast pain (26.9%) and nipple changes (7.9%). Breast surgeons considered appropriate 75.6% of the referrals made by the GP. Seventy-two percent of the patients got an urgent appointment to see their GP, and 94.8% of the patients were urgently referred by their GP to see the breast surgeon. Only 37.8% of the urgent referrals were correctly referred as urgent. Having a direct online referral system for breast conditions will be beneficial for patients was agreed by 78.4%. The majority (98.1%) of the participants answered correctly for the hypothetical questions requiring breast surgeon review. In the second phase, there were a total of 86 patients with a mean age of 43.9 (SD: 13.3). The most common presentation was breast lump (n=68, 79.1%) and other presentations included breast pain, nipple changes, and discharge. The GPs' accuracy of correct referral was 69.1%. One third (30.9%) of the referrals could have been managed in the community or as a routine review by the breast surgeon. In comparison, the online software's accuracy was 85.1% accurate (p=0.001). The accuracy for detecting patients who needed urgent breast clinic review was 100% for online software.  Conclusion A large proportion of referrals could have been dealt with in the community or referred routinely. Patients would prefer a direct online referral system to the breast clinic. They understand red flag signs and symptoms. Online software has the potential to streamline patients for symptomatic breast clinics. It can reduce the burden on the GPs who are constantly under pressure to diagnose patients accurately and refer to the correct specialty appropriately within a short time.

"The psychological impact of COVID-19 on medical education of final year students in Pakistan: A cross-sectional study".

INTRODUCTION: COVID-19 pandemic has resulted in a strong impact on students' wellbeing, with associated uncertainty about the future. We conducted a cross-sectional survey to assess the psychological effects of COVID-19 on the medical education of final year students in Pakistan. METHODS: We conducted prospective, cross-sectional survey, as a snapshot, from June 07, 2020 till June 16, 2020, among final year medical and dental students. The 20-questions survey questionnaire was based on rating-scale items to focus on psychological symptoms, institutional preparedness for such crisis and confidence in becoming a future doctor. Descriptive statistics were calculated using Multivariate regression analysis. RESULTS: Majority of participants (n = 1753/2661, 65.9%) were female. Despite timely closure of institutes, delay in the start of the online teaching (beta coefficient 0.08, P-value 0.02) was significantly correlated with the depressive symptoms. A significant percentage of students (n = 1594, 59.9%) wanted a delay in exit exams due to intimidation. A similar proportion of students also lost confidence to be a competent doctor in future which was positively associated with male gender (beta coefficient 0.21, P-value < 0.001). CONCLUSION: Our study shows that COVID-19 pandemic has brought significant psychological influence on the medical education of final year students. Despite a stressful crisis, final year medical and dental students are still willing to serve the community. In addition to supporting their emotions and psychological wellbeing, stress counselling, and transforming current medical curricula is crucial to pursue ceaseless medical education and to become a safe future doctor.

Informed Consent for Surgery at Resumption of Elective Activity After the First Wave of COVID-19.

Background The coronavirus disease 2019 (COVID-19) pandemic has changed the dynamics of healthcare, and the elective surgical consent process has also evolved. The Royal College of Surgeons of England published guidance on consent during COVID-19. Through this study, we aimed to assess our local consent adherence to these guidelines on the resumption of elective activity after the first wave of COVID-19. Methods This prospective review of consecutive elective surgical consent forms was conducted from 20 July 2020 to 16 August 2020 at the Princess Alexandra Hospital NHS Trust, England. The primary outcome was evidence of COVID-19 risk documentation on the consent forms. Results A total of 116 patients' consent forms were reviewed. Most patients were American Society of Anaesthesiologists (ASA) grade 2 (n=70; 60.34%). Only 25 consent forms (21.55%) had COVID -19 and its associated risks documented, with registrars being the most compliant (19/46; 41.3%) followed by consultants (6/51; 11.7%). With regards to the surgical sub-specialities, general surgery, orthopaedics and ENT had the highest compliance with the guidance. Conclusions As the elective activity resumes, peri-operative risks of COVID-19 should be weighted in during the informed consent process, as mentioned in the latest international guidelines on consent to avoid litigation and negligence claims.