Oral versus intravenous antibiotics in the treatment of uncomplicated colonic diverticulitis: results of a randomized non-inferiority control trial

BACKGROUND

Colonic diverticular disease is common and its incidence increases with age, with uncomplicated diverticulitis being the most common acute presentation (1). This typically results in inpatient admission, placing a significant burden on healthcare services (2). We aimed to determine the safety and effectiveness of using intravenous or oral antibiotics in the treatment of uncomplicated diverticulitis on 30-day unplanned admissions, c-reactive protein (CRP), White Cell Count (WCC), pain resolution, cessation of pain medication, return to normal nutrition, and return to normal bowel function.

METHODS

This single centre, 2-arm, parallel, 1:1, unblinded non-inferiority randomized controlled trial compared the safety and efficacy of oral antibiotics versus intravenous antibiotics in the outpatient treatment of uncomplicated colonic diverticulitis. Inclusion criteria were patients older than 18 years of age with CT proven acute uncomplicated colonic diverticulitis (Modified Hinchey Classification Stage 0-1a). Patients were randomly allocated receive either intravenous or oral antibiotics, both groups being treated in the outpatient setting with a Hospital in the Home (HITH) service. The primary outcome was the 30-day unplanned admission rate, secondary outcomes were biochemical markers, time to pain resolution, time to cessation of pain medication, time to return to normal function and time to return to normal bowel function.

RESULTS

In total 118 patients who presented with uncomplicated colonic diverticulitis were recruited into the trial. Fifty-eight participants were treated with IV antibiotics, and 60 were given oral antibiotics. We found there was no significant difference between groups with regards to 30-day unplanned admissions or inflammatory markers. There was also no significant difference with regards to time to pain resolution, cessation of pain medication use, return to normal nutrition, or return to normal bowel function.

CONCLUSION

Outpatient management of uncomplicated diverticulitis with oral antibiotics proved equally as safe and efficacious as intravenous antibiotic treatment in this randomized non-inferiority control trial.

Failure to Rescue in Major Abdominal Surgery: A Regional Australian Experience

BACKGROUND

Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient's pre-operative status and FTR following major abdominal surgery.

METHODS

A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien-Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of < 35 g/L. Operative risk factors included emergency surgery, cancer surgery, greater than 500 ml intraoperative blood loss and need for ICU admission. Patients who suffered end-organ failure were more likely to die from their complication.

CONCLUSION

Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.

Post-acute COVID-19 condition (PACC): a perspective on collaborative Australian research imperatives and primary health models of care

Post-acute COVID-19 condition (PACC) - also known as long COVID - is a serious and growing problem in primary health. This letter describes the work of the Victorian Post-Acute COVID-19 Study (VPACS) group, which comprises clinician researchers, basic scientists and consumers. Two key priorities for PACC research in Australia are identified and discussed: (1) the establishment of COVID-19 patient registries and data linkage; and (2) the consolidation of clinical guidelines. Collaboration between consumers, researchers, clinicians and institutions must be the foundation of PACC management in Australia. Ongoing research should focus on large, multicentre controlled studies, the protective effect of vaccination, differential impacts from variants, pathobiological underpinnings, disease mechanisms to avoid severe and enduring impacts on the Australian economy. The lived experience of people with PACC is also essential to enable the design and implementation of effective models of care. VPACS brings a diverse group of people together to work on a shared vision of holistic and high-quality care, and collectively maximise their impact on outcomes for patients and the broader community.

Strategic partnerships to improve surgical care in the Asia-Pacific region: proceedings

Emergency and essential surgery is a critical component of universal health coverage. Session three of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on strategic partnerships. During this session, a range of partner organisations, including intergovernmental organisations, professional associations, academic and research institutions, non-governmental organisations, and the private sector provided an update on their work in surgical system strengthening in the Asia-Pacific region. Partner organisations could provide technical and implementation support for National Surgical, Obstetric, and Anaesthesia Planning (NSOAP) in a number of areas, including workforce strengthening, capacity building, guideline development, monitoring and evaluation, and service delivery. Participants emphasised the importance of several forms of strategic collaboration: 1) collaboration across the spectrum of care between emergency, critical, and surgical care, which share many common underlying health system requirements; 2) interprofessional collaboration between surgery, obstetrics, anaesthesia, diagnostics, nursing, midwifery among other professions; 3) regional collaboration, particularly between Pacific Island Countries, and 4) South-South collaboration between low- and middle-income countries (LMICs) in mutual knowledge sharing. Partnerships between high-income countries (HIC) and LMIC organisations must include LMIC participants at a governance level for shared decision-making. Areas for joint action that emerged in the discussion included coordinated advocacy efforts to generate political view, developing common monitoring and evaluation frameworks, and utilising remote technology for workforce development and service delivery.

Learning and teaching stage 4 clinical decision making: progression from novice to expert

BACKGROUND

This paper describes the development of learning from novice to expert in Stage 4: Clinical Decision Making (CDM) in surgery: Postoperative reflection and review. It also outlines some or the assessment and teaching approaches suitable to facilitate that transition in skill level.

METHODS

This paper is drawn from a much broader study of learning and teaching CDM, that used qualitative methodology based on Constructivist and Grounded Theory. Data was collected in individual interviews and focus groups. Using thematic analysis the data were analysed to identify key ideas. All participants worked in the Department of Surgery at one large regional hospital in Victoria.

RESULTS

For each stage there is a sequence of learning beginning from relying on external resources, gradually developing internal resources to guide and direct the learner's CDM. Those internal resources built through experience include multisensory and kinaesthetic memories that expand to facilitate the ability to cope with complexity.

DISCUSSION

Armed with the mind-map and rubric table included in this paper it should be possible for any senior clinician or teacher to diagnose their trainees' progression in Stage 4 CDM. This will enable them to tailor their teaching to best match the capabilities of the trainee and to enable to be more effectively targeted.

CONCLUSION

CDM can be taught and both trainees and senior clinicians can benefit from understanding the processes involved.

Tertiary Survey in the Days of Modern Imaging: Assessing the Detection Rate of Clinically Significant Injuries on Tertiary Survey in a Level 2 Trauma Centre

Aim: To determine the utility of tertiary survey (TS) in patients subjected to whole-body CT (WBCT) or selective CT (SCT) following trauma.

Methods: A retrospective analysis was performed on trauma patients admitted to a level 2 trauma centre following the introduction of a standardised TS form in 2017. The initial imaging protocol (WBCT versus selective CT versus x-ray), subsequently requested imaging, standardised injury data, and length of stay (LOS) were recorded. Clinically significant injuries were defined as those with an Injury Severity Score (ISS) of 1 on the Abbreviated Injury Scale (AIS).

Results: Five hundred and seven patients were included. The rate of additional significant injuries at the time of TS was 1.18% (n=6), each requiring conservative management only. There was no significant difference in injury detection based on the initial imaging protocol; however, there were three near-misses identified. Of these patients, two underwent selective CT and one was subjected to a plain film series, with clinically significant injuries identified early upon completion of trauma imaging. Overall, 2.9% (n=15) of patients had completed trauma imaging during the same admission. WBCT was associated with higher ISS and length of stay (p<0.05). After controlling for ISS, there was no difference in length of stay between imaging modalities except in those patients with an ISS of 0 (no clinically significant injuries), who appeared to have longer admissions if subject to WBCT (p<0.001).

Conclusion: The rate of missed injuries identified at TS is low. The imaging modality did not alter this. This may allow for the omission of the tertiary survey and earlier discharge in many trauma patients.

A systematic review of gut microbiota composition in observational studies of major depressive disorder, bipolar disorder and schizophrenia

The emerging understanding of gut microbiota as 'metabolic machinery' influencing many aspects of physiology has gained substantial attention in the field of psychiatry. This is largely due to the many overlapping pathophysiological mechanisms associated with both the potential functionality of the gut microbiota and the biological mechanisms thought to be underpinning mental disorders. In this systematic review, we synthesised the current literature investigating differences in gut microbiota composition in people with the major psychiatric disorders, major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SZ), compared to 'healthy' controls. We also explored gut microbiota composition across disorders in an attempt to elucidate potential commonalities in the microbial signatures associated with these mental disorders. Following the PRISMA guidelines, databases were searched from inception through to December 2021. We identified 44 studies (including a total of 2510 psychiatric cases and 2407 controls) that met inclusion criteria, of which 24 investigated gut microbiota composition in MDD, seven investigated gut microbiota composition in BD, and 15 investigated gut microbiota composition in SZ. Our syntheses provide no strong evidence for a difference in the number or distribution (α-diversity) of bacteria in those with a mental disorder compared to controls. However, studies were relatively consistent in reporting differences in overall community composition (β-diversity) in people with and without mental disorders. Our syntheses also identified specific bacterial taxa commonly associated with mental disorders, including lower levels of bacterial genera that produce short-chain fatty acids (e.g. butyrate), higher levels of lactic acid-producing bacteria, and higher levels of bacteria associated with glutamate and GABA metabolism. We also observed substantial heterogeneity across studies with regards to methodologies and reporting. Further prospective and experimental research using new tools and robust guidelines hold promise for improving our understanding of the role of the gut microbiota in mental and brain health and the development of interventions based on modification of gut microbiota.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background

The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods

Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings

Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation

Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

BACKGROUND

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

METHODS AND FINDINGS

The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.

CONCLUSIONS

To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

The influence of experience and expertise on how surgeons prepare to perform a procedure

BACKGROUND

There is a paucity of literature describing how surgeons (either novice or expert) mentally prepare to carry out a surgical procedure. This paper focuses on these processes, and is part of a larger piece of research based on the Royal Australasian College of Surgeons (RACS) Clinical Decision Making model.

METHODS

Interviews were conducted over a 3-year period with registrars, trainees, fellows and consultants in the Department of Surgery at one large regional hospital in Victoria. Analysis began from the first interview with no pre-conceived codes. Emerging themes were drawn from participants' interpretation of their experiences. Further information was obtained during discussions in theatre while patients were being prepared for surgery.

RESULTS

The findings show that the process of rehearsal changes as a surgeon gains more experience in a procedure. A 'novice' relies on external sources of information, for example textbooks and videos. After participating in a number of similar procedures their reliance gradually moves to their own sensory memories. Surgeons at all levels of experience discuss their preparations with peers, colleagues, senior clinicians, and where appropriate, with members of other disciplines.

CONCLUSION

These findings offer insight into how surgeons, at different levels of experience, prepare for a procedure. These understandings have the potential to improve the teaching and learning of this essential component of surgical practice.

Two-year outcomes from the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement pilot study

BACKGROUND

The aim of the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) pilot study was to determine (i) the outcomes of emergency laparotomy (EL) and (ii) the feasibility of a national, multi-disciplinary quality improvement (QI) project based on a bundle of evidence-based care standards.

METHODS

An online database was created using the Research Electronic Data Capture (REDCap) programme. National ethics approval with waiver of consent was obtained. Data were entered directly onto REDCap and extracted monthly for eight care standards (preoperative consultant radiologist reporting of computed tomography scans, preoperative mortality risk score, consultant presence in theatre, timely access to theatre and critical care commensurate with risk and involvement of aged care). Monthly QI run charts using 'traffic' light graphics (green ≥80%, amber ≥50% to <80% and red <50%) reported compliance with the standards.

RESULTS

Sixty hospitals indicated interest, but difficulties with site-specific ethics approval resulted in only 24 hospitals participating (2886 EL in 2755 patients). The overall in-hospital mortality was 7.1% (2.3%-13.3%) and average length of stay 15.5 (8.6-22.7) days. Both significantly declined. Preoperative risk assessment (overall 45%) improved almost three-fold during the study. Only 60% had timely access to theatre and only 70% with a predicted mortality risk of >10% were admitted to critical care.

CONCLUSION

Overall mortality compared favourably with similar international studies and declined in association with participation in the audit. Compliance with some care standards shows considerable scope to improve EL care using QI methodology.

Medical Students Can Learn Surgery Effectively in a Rural Longitudinal Integrated Clerkship

BACKGROUND

At Deakin University School of Medicine, compulsory formal teaching in Surgery occurs in year 3. This may occur as part of a rural longitudinal integrated clerkship (LIC), or in a traditional teaching hospital block rotation (BR). The purpose of this study was to compare these groups' exposure to surgical common conditions and their academic outcomes.

METHODS

Part I: This was a survey of students' encounters with patients with common surgical conditions between 2016 and 2018. Self-reported data were collected describing the nature of the encounters and their clinical settings. Part II: All third year Surgery MCQ and OSCE results from 2011 to 2017 were analyzed. Students were deidentified and grouped according to whether they were in the LIC or BR programme.

RESULTS

Part I: Thirty-eight third year students (20 LIC, 18 BR) submitted data for a total of 188 clinical encounters. Both groups encountered all nominated common surgical conditions, but the settings in which this occurred were different. BR students saw most patients as hospital inpatients whereas LIC student encounters were distributed across multiple clinical sites. Part II: A total of 942 (121 [26%] LIC and 821 [74%] BR) students' assessment results were analyzed. The groups performed similarly in the MCQ (p = 0.21) and OSCE (p = 0.16) examinations.

CONCLUSIONS

Students who were taught surgery in a LIC program performed similarly to on their final exams to their peers in traditional clerkships, with self-reported student data indicating both groups encountered a similar range of conditions.

Analysis of Financial Risk Protection Indicators in Myanmar for Paediatric Surgery

PURPOSE

To estimate proportion of Myanmar paediatric population at risk of impoverishment and catastrophic expenditure due to emergency surgical intervention.

METHODS

Prospective data were collected at two tertiary surgical centres including income, household expenses, expenses related to surgery. Data analysis was performed to estimate out-of-pocket (OOP) direct medical costs and OOP total costs. Catastrophic expenditure: expense exceeded 10% of household income. Risk of impoverishment: net income drops were below an impoverishment threshold (PPP-purchasing power parity): I$ 2.00 PPP/day, I$ 1.25/day PPP, national poverty line. Distribution of income was estimated using a gamma distribution. Comparison to an adult cohort was performed using Chi-square test with a p value of <0.05 being significant.

RESULTS

A total of 145 surveys were collected, and 119 (82.1%) contained sufficient data: Paediatric Centre (n = 99) and Adult Centre (n = 20). Overall average per patient direct medical and non-medical OOP costs was I$493: Centre 1: I$540 PPP (range I$41-6,588 PPP) and Centre 2: I$437 PPP (range I$ 36-1,405 PPP). 64% experienced catastrophic expense. There is no significant difference between the centres in the risks of impoverishment or catastrophic expenditure (p = 0.05). Up to 44% are at risk of catastrophic expenditure should surgery be required. Most of the risk (90%) is derived from direct non-medical costs. A high proportion were at the national poverty line threshold (36.1%). Seeking surgical treatment would imperil up to 37% at the national poverty line threshold, and up to 5.7% at the I$2 PPP per day limit.

CONCLUSIONS

A large proportion of the Myanmar population are at risk of impoverishment or catastrophic expenditure should they require surgery. Financial risk protection mechanisms are needed.

Who tolerates early enteral feeding after colorectal surgery?

BACKGROUND

Early enteral feeding and avoidance of routine nasogastric tube (NGT) placement have become standard care following colorectal surgery. However, some patients require NGT decompression post-operatively for vomiting or distension.

METHODS

This was a retrospective cohort study of all patients undergoing elective intra-abdominal colorectal surgery at University Hospital, Geelong, from 2014 to 2018. Failure of early feeding was defined by the placement of an NGT post-operatively, beyond the day of surgery.

RESULTS

A total of 754 patients were identified. Of these, 28 were excluded due to protocol violations (NGT was left in situ at the end of the operation), leaving 726 patients that were included in the analysis. Overall, 156/726 (21%) patients failed early feeding. The strongest independent predictor of failure was undergoing a total or subtotal colectomy compared with all other operations (15/28 (54%) failed versus 141/698 (20%); P < 0.001). Laparoscopic surgery was independently associated with a lower risk of failure compared with open surgery (43/278 (15%) versus 113/448 (25%); P = 0.002). Risk of failure was not associated with gender, age, American Society of Anesthesiologists score, indication for procedure, presence of anastomosis or duration of surgery.

CONCLUSION

Laparoscopic surgery is associated with a lower risk of failure of early feeding compared with open surgery. Patients undergoing subtotal or total colectomy have a high rate (54%) of failure. This may assist in selecting appropriate patients for early feeding after colorectal surgery.