467 Impact of the Coronavirus Pandemic on Acute Surgical Patients’ Discharge Summaries

Background

The emergence of the Coronavirus pandemic has placed increased demands on the NHS workforce, especially in medical and intensive care units. The subsequent redistribution of surgical house officers to accommodate this in a single centre has possibly negatively impacted on the effective discharge notification of acute surgical patients.

Methods:

Discharge summaries of all patients discharged from a Surgical Assessment Unit were collected and analysed, to identify the date of completion and grade of responsible clinician. Data collection was carried out over three weeks before the initiation of lockdown measures and continued for a further three weeks during the peak of the Coronavirus pandemic with a three-week interventional period in between.

Results

In the initial audit, 36.2% of the 246 patients had delayed discharge summaries with an average of 7 days to complete. On re-evaluation, 45.3% of the 223 patients had delayed discharge summaries, with an average of 12 days to complete. A survey conducted post-re-audit identified that the most common reason for this was due to time constraints.

Conclusions

The reallocation of surgical staff has affected communication between primary and secondary care. Given the potential repercussions of these delays, healthcare systems should be made aware of this consequence, especially in preparation for any future resurgences.

A109 LINKING PRIMARY AND SPECIALTY CARE FOR THE MANAGEMENT OF DIGESTIVE HEALTH CONDITIONS: AN EVALUATION OF GUT LINK IMPLEMENTATION

Background

Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions.

Aims

To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service.

Methods

This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%).

Results

A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%).

To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI.

Conclusions

The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways.

Funding Agencies

CAG

A85 THE CLINICAL IMPACT OF COVID-19 DELAYS ON PLASTIC BILIARY STENT REMOVAL IN NOVA SCOTIA

Background

The COVID-2019 pandemic continues to restrict access to endoscopy, resulting in delays or cancellation of non-urgent endoscopic procedures. A delay in the removal or exchange of plastic biliary stents may lead to stent occlusion with consensus recommendation of stent removal or exchange at three-month intervals [1–4]. We postulated that delayed plastic biliary stent removal (DPBSR) would increase complication rates.

Aims

We aim to report our single-centre experience with complications arising from DPBSR.

Methods

This was a retrospective, single-center, observational cohort study. All subjects who had ERCP-guided plastic biliary stent placement in Halifax, Nova Scotia between Dec 2019 and June 2020 were included in the study. DPBSR was defined as stent removal >=90 days from insertion. Four endpoints were assigned to patients: 1. Stent removed endoscopically, 2. Died with stent in-situ (measured from stent placement to documented date of death/last clinical encounter before death), 3. Pending removal (subjects clinically well, no liver enzyme elevation, not expired, endpoint 1 Nov 2020), and 4. Complication requiring urgent reintervention. Kaplan-Meier survival analysis was used to represent duration of stent patency (Fig.1).

Results

102 (47.2%) had plastic biliary stents placed between 2/12/2019 and 29/6/2020. 49 (48%) were female, and the median age was 68 (R 16–91). Median follow-up was 167.5 days, 60 (58.8%) subjects had stent removal, 12 (11.8%) died before replacement, 21 (20.6%) were awaiting stent removal with no complications (median 230d, R 30–332), 9 (8.8%) had complications requiring urgent ERCP. Based on death reports, no deaths were related to stent-related complications.

72(70.6%) of patients had stents in-situ for >= 90 days. In this population, median time to removal was 211.5d (R 91-441d). 3 (4.2%) subjects had stent-related complications requiring urgent ERCP, mean time to complication was 218.3d (R 94–441). Stent removal >=90 days was not associated with complications such as occlusion, cholangitis, and migration (p=1.0). Days of stent in-situ was not associated with occlusion, cholangitis, and migration (p=0.57). Sex (p=0.275), cholecystectomy (p=1.0), cholangiocarcinoma (p=1.0), cholangitis (p=0.68) or pancreatitis (p=1.0) six weeks prior to ERCP, benign vs. malignant etiology (p=1.0) were not significantly associated with stent-related complications.

Conclusions

Plastic biliary stent longevity may have been previously underestimated. The findings of this study agree with CAG framework recommendations [5] that stent removal be prioritized as elective (P3). Limitations include small sample size that could affect Kaplan-Meier survival analysis. Despite prolonged indwelling stent time as a result of COVID-19, we did not observe an increased incidence of stent occlusion or other complications.

Funding Agencies

None

A rare report on 18-month survival of a dog born with multiple anomalies including atresia ani

Long term survival of animals with major congenital anomalies is very rare. This report documents the 18-month survival of a dog with multiple anomalies including atresia ani. An 18-month-old black Cocker Spaniel bitch was presented for evaluation of prolapsed glands of the third eyelid involving both the eyes. Clinical examination revealed a single perineal opening, fecal matter in the vestibule, distended abdomen, hypoplastic vulva, and the absence of a tail without any neurological deficits. Abdominal contrast radiography revealed a distended colon with fecal stasis, rectovestibular fistula, termination of the rectum as a blind pouch, lumbar scoliosis due to block vertebrae, and the presence of only two hypoplastic coccygeal vertebrae. The case was diagnosed as atresia ani type II with rectovestibular fistula, hypoplastic vulva, lumbar scoliosis, and anury, in the global context of a caudal regression syndrome. The wide aperture fistula, connected to the vestibule, undamaged spinal cord and sacrum without any neurological deficits were the favorable prognostic factors that maintained continence and allowed the dog to survive to adult life with these anomalies. Thus, an appropriate bowel management program and specialty care can improve the quality of life and longevity of this animal.

Panniculitis at the Site of Injection: Infection or Foreign Body Reaction?

Introduction/Objective

A 63 year old diabetic female presented to the dermatology clinic with painful abdominal nodules. The nodules seemed to wax and wane every 1–2 weeks and appeared in different locations on the abdomen. The lesions were subcutaneous, tender, firm, and mobile with no discoloration. The patient had diabetes treated with injectable exenatide but no other significant medical or travel history.

Methods

The differential diagnoses included mycobacterial infection, mechanical insult from injectable diabetes medication, erythema nodosum, erythema induratum, and lupus panniculitis. Ultrasound was indicative of panniculitis. A biopsy of the active lesion was performed.

Results

The biopsy showed septal and lobular panniculitis with mixed inflammation and multinucleated giant cells. Small, circular, non-polarizable pink amphorous material was associated with the infiltrate. The amphorous material was strongly acid fast. The patient had a negative quantiferon-TB test. Scanning electron microscopy with energy dispersive x-ray analysis showed that the material contained more oxygen and less carbon than surrounding tissue, but no abnormal elements were identified. Infrared spectroscopy of the foreign material most closely matched poly(L- lactide-co-glycolide).

Conclusion

The diagnosis of exenatide induced granulomatous panniculitis was made. The patient had recently started using this injectable glucagon-like peptide-1 receptor agonist, which has been associated with panniculitis. The injectable formulation is loaded onto microspheres composed of poly (DL-lactic-co-glycolic acid), which is closely related to poly(L-lactide-co-glycolide). This material has been shown to stain strongly acid fast. This case of granulomatous panniculitis due to injectable diabetic medication highlights an important potential pitfall that pathologists should be aware of, especially in cases where mycobacterial infection is in the differential.

Does PD-L1 Positivity in Inflammatory Cells Correlate with PD-L1 Expression in Tumor Cells in Colorectal Adenocarcinoma?

Introduction/Objective

Drugs targeting the programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) checkpoint is an important type of novel immunotherapy. These checkpoint inhibitors are being used in a wide variety of cancers, including colorectal carcinoma (CRC). PD-L1 expression on tumor cells in CRC is predictive of good response to checkpoint inhibitor therapies. PD-L1 expression on tumor infiltrating immune cells (TIIC) is increasingly observed and independently portends good prognosis. The relationship between PD-L1 positivity in TIIC and tumor cells is not well established. In this study, the relationship and correlation of PD-L1 positivity in TIIC and tumor cells were retrospectively reviewed.

Methods

197 sections of CRC from 33 cases (mean of 6 sections/case) with heterogeneous expression of PD-L1 on tumor cells were stained for PD-L1 with immunohistochemistry. None of the patients had received neo-adjuvant therapy. The presence of tumor cells and immune cells with positive PD-L1 expression was noted for each section.

Results

Immune cells were positive in 79% of the sections examined. TIIC were positive in 56% of the sections examined. A Cohen’s correlation study showed correlation between tumor cells and TIIC in 77% of the cases (k=0.51, moderate agreement). There was at least one section with PD-L1 positive TIIC in 97% of cases.

Conclusion

This study shows that PD-L1 is expressed in TIIC in the vast majority of CRC cases designated PD-L1 positive and that PD-L1 is positive in TIIC at a higher rate than in tumor cells. The moderate correlation is interesting, perhaps suggesting that if TIIC are noted to be positive for PD-L1 and tumor cells are not, additional sections of tumor should be stained.

Heterogeneity and Geographical Patterns of PD-L1 Positive Tumor Infiltrating Immune Cells in Colonic Adenocarcinoma

Introduction/Objective

Programmed death-ligand 1 (PD-L1) status is an important prognostic and predictive biomarker. PD-L1 status is difficult to accurately assess in tumor cells (TCs) due to tumor heterogeneity and lack of standardized histologic evaluation. PD-L1 expression by tumor infiltrating immune cells (TIICs) is an independent prognostic marker and may provide fewer diagnostic challenges, as TIICs appear less heterogeneous. We examined the geographical patterns of PD-L1 expression in TCs and TIICs in order to evaluate heterogeneity and ease of histological evaluation.

Methods

197 blocks of colonic adenocarcinoma from 33 patients were retrospectively reviewed and stained for PD- L1. PD-L1 was interpreted as positive or negative in the TCs and TIICs. Geographical patterns of expression were recorded for the TCs and the TIICs at the surface, center of tumor, and invasive margin. Geographical patterns were compared using a chi-square test.

Results

56% of blocks had PD-L1 positive TCs. 42.7% showed positive TCs at the invasive margin. 38.2% had positive TCs at the invasive margin and surface. No blocks had positive TCs at the center of the tumor. 79% of blocks had PD-L1 positive TIICs. 20% showed positive TIICs at the invasive margin. 37.4% had positive TIICs at the surface and invasive margin. 15.5% of TIICs expressed PD-L1 throughout the tumor. There was a statistically significant difference in PD-L1 expression on TCs versus TIICs in 4 of the 7 geographic patterns.

Conclusion

PD-L1 expression on TCs of colonic adenocarcinoma is more heterogeneous than PD-L1 expression by TIICs. TIICs express PD-L1 more consistently throughout the tumor and are easier to identify and report. PD-L1 expression by TIICs is an independent prognostic indicator and may be more useful than TCs when evaluating the tumor microenvironment and determining PD-L1 status.

Health professional mobility and the Global Code of Practice: joint EUROSTAT/OECD/WHO survey data

Background

This study assesses the impact and continuing relevance of the Code of Practice on the International Recruitment of Health Personnel in the WHO Europe region by analysing trends over time in intra- and inter-regional health worker mobility.

Methods

Data from the joint EUROSTAT/OECD/WHO questionnaire are analysed to determine 1) the proportion of foreign-born and foreign-trained doctors and nurses working in WHO Europe Member States, 2) trends in health workforce mobility over time by country of origin and destination, and 3) how the Global Code has impacted mobility patterns.

Results

The size of the foreign-trained health workforce in Europe varies widely, with foreign-trained doctors comprising over a quarter of the workforce in Norway, Switzerland and the UK, but below 2% in Estonia and Serbia. While annual in-flows across the region have been stable since 2009, the share of foreign-trained doctors and nurses have both increased by over 30%. Mobility between The Commonwealth of Independent States has remained steady, but an increase in East-West and South-North migration is observed, driven by European Union expansion in 2004 and the economic crisis. Migration of health workers into Europe from developing countries covered by the Code has fluctuated, with increased numbers seen from some origin countries (e.g. Nigeria, Pakistan). Some Western countries remain reliant on a foreign-trained health workforce. This contributes to a high outward flow of health professionals from other European countries and creates challenges for sustainable workforce development.

Conclusions

The Global Code remains highly relevant, but other factors have more impact on migration flows, such as free movement in the EU. Health workforce mobility data can be improved to support a 'whole of workforce' approach to policy and planning by including more professional groups, and by adding qualitative indicators, e.g. individual perceptions and intention to leave.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The effect of a running training intervention on ankle power generation in children and adolescents with cerebral palsy: A randomized controlled trial

BACKGROUND

Children and adolescents with cerebral palsy who are classified as Gross Motor Function Classification Scale level I or II are usually able to run but lack ankle power generation for push-off. The aim of this study was to analyze the efficacy of a running training program in improving ankle power generation in children and adolescents with cerebral palsy.

METHODS

This randomized controlled trial compared kinematic and spatiotemporal data collected during running from 38 children and adolescents with unilateral or bilateral cerebral palsy before and after a 12-week running program. Normalized speed, stride length, cadence, foot strike pattern, peak ankle power generation, peak hip flexor power generation in swing and propulsion strategy were calculated. Linear mixed models were developed to analyze differences between groups.

FINDINGS

At follow-up the intervention group had increased normalized speed of running (t = -3.68 p < .01) while the control group got slower (t = 3.17 p < .01). In running, children in Gross Motor Function Classification Scale level II in the intervention group increased ankle power (t = 2.49 p = .01) while the control group did not change (t = 0.38 p = .71). In sprinting, children in Gross Motor Function Classification Scale levels I and II in the intervention group maintained ankle power (level I t = 0.32 p = .75; level II t = 1.56 p = .12) while those in the control group decreased ankle power (level I t = 4.69 p < .01; level II t = 2.52 p = .01). Most within-group differences did not result in significant between-group differences at follow-up.

INTERPRETATION

Power generation for running may be responsive to targeted intervention in children with cerebral palsy.

Safety of hospital discharge before return of bowel function after elective colorectal surgery

BACKGROUND

Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function.

METHODS

A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien-Dindo classification system.

RESULTS

A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4-7) and 7 (6-8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110).

CONCLUSION

Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients.

A152 FOREIGN BODY INGESTIONS AT A TERTIARY CARE CENTRE - A QUALITY ASSURANCE STUDY

Background

Foreign body ingestion and esophageal food bolus impaction are common emergencies encountered by gastroenterologists. If not treated in a timely fashion these can result in significant morbidity, or even mortality. The mainstay of diagnosis and therapy is endoscopy. Guidelines regarding timing of endoscopy have been published by both the American and European Societies of Gastrointestinal Endoscopy, and both suggest emergent endoscopy, meaning within 2 to 6 hours, for complete esophageal obstructions. There is relatively sparse data regarding the endoscopic techniques used in real world practice.

Aims

This is a quality assurance study looking at the endoscopic practices at an adult tertiary care hospital in Halifax, Nova Scotia with respect to foreign body and food impaction management.

Methods

The hospital records of all patients presenting with ingested foreign bodies or esophageal food bolus impactions between May 2018 and July 2019 were included. Patients were identified by searching the call-back forms used by our department which documents all on-call endoscopy cases. This was then cross-referenced by endoscopy nursing charting which documents every endoscopy performed. Information such as demographics, obstruction type, endoscopic method of removal, complications, time between consultation and endoscopy, underlying pathology, and others were analyzed.

Results

70 cases were identified. Average patient age was 51.3 years old (range 16–96). 18 (25.7%) were female and 52 (74.3%) were male. 64 cases (91.4%) were esophageal food impactions and 6 (8.57%) were foreign body ingestions. Of the food impactions, 39 cases (60.9%) were cleared by the push/slide-by technique only and 10 (16.7%) were relieved using instruments such as snares, forceps, or nets. 15 (23.4%) passed spontaneously prior to scope, of which 7 received glucagon. An overtube was used in 1 case (0.16%). Complications occurred in 5 (7.8%) cases and included 3 mucosal tears, 2 of which required therapeutic interventions, and 2 episodes of oxygen desaturation in which the procedure was aborted. Complete obstructions occurred in 42 (65.6%) cases with average time of consultation to endoscopy of 2.4 hours. However, 3 (7.1%) cases exceeded 6 hours. The most common pathology was eosinophilic esophagitis with 20 cases (31.3%).

Ingested foreign bodies included 2 long objects, 3 sharp objects, and a cylindrical battery, and all but one were in the stomach. 5 (83.3%) cases used an overtube. No complications occurred.

Conclusions

At our institution 67/70 (95.7%) cases were performed within the timelines recommended by society guidelines. No complications occurred in the cases not performed within those time limits. An overtube was used in only one case in which a food bolus was retrieved out of the esophagus. Overall this study suggests that our centre is meeting recommended targets, however there is room for improvement.

Funding Agencies

None

A269 EUS-GUIDED ROSE FNA AND CNB FOR THE DIAGNOSIS OF PANCREATIC CANCER: A COMPARATIVE ANALYSIS

Background

Endoscopic ultrasound-guided fine-needle aspiration with Rapid On Site Evaluation (ROSE EUS-FNA) and endoscopic ultrasound-guided core-needle biopsy (EUS-CNB) are widely used for the diagnosis of pancreatic tumors. There is no known published randomized control trial that compares between the two modalities. Given the aggressive nature of pancreatic cancer, it is crucial to make a prompt diagnosis in order to initiate treatment in a timely fashion.

Aims

This study compares the diagnostic performance of ROSE EUS-FNA and EUS-CNB for diagnosis of pancreatic cancer.

Methods

A retrospective review was performed for patients who underwent ROSE EUS-FNA and/ or EUS-CNB for solid pancreatic lesion. Diagnostic yield (defined as percentage of diagnostic samples), diagnostic accuracy (defined as percentage of correct diagnosis), sensitivity and specificity for malignancy were compared between ROSE EUS- FNA and EUS- CNB. Baseline characteristics for both patients and lesions were also obtained.

Results

A total of 82 patients with solid pancreatic lesions were reviewed. 84 EUS with 61 FNA and 74 CNB were performed. The diagnostic yield was 42/61 (69%) and 59/74 (79.7%) for FNA and CNB respectively (P 0.166). The diagnostic accuracy was 33/61 (54%) and 53/74 (71%) for FNA and CNB respectively (P 0.0326).

50 patients underwent both FNA and CNB during the same EUS. The calculated diagnostic yield among this subgroup was 33/50 (66%) and 39/50 (78%) for FNA and CNB respectively (P 0.265); with diagnostic accuracy of 26/50 (52%) for FNA and 34/50 (68%) for CNB (P 0.152). The diagnostic accuracy after combining both techniques was 40/50 (80%).

The incremental increase in diagnostic yield by combining both methods was 12/50 (24%) and 6/50 (12%) relative to FNA and CNB respectively.

The sensitivity for the diagnosis of malignancy for FNA and CNB was 60.8% and 92.7%, respectively. The specificity was 100% for both methods.

Conclusions

EUS-guided CNB is a superior method of assessing solid pancreatic lesion and pancreatic malignancy with better diagnostic yield and accuracy and higher sensitivity than ROSE EUS-FNA.

Funding Agencies

None

Safety and efficacy of non-steroidal anti-inflammatory drugs to reduce ileus after colorectal surgery

BACKGROUND

Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery.

METHODS

A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury.

RESULTS

A total of 4164 patients were included, with a median age of 68 (i.q.r. 57-75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1-3, of whom 1061 (92·0 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001).

CONCLUSION

NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

Infectious disease outbreaks in the African region: overview of events reported to the World Health Organization in 2018

The WHO African region is characterised by the largest infectious disease burden in the world. We conducted a retrospective descriptive analysis using records of all infectious disease outbreaks formally reported to the WHO in 2018 by Member States of the African region. We analysed the spatio-temporal distribution, the notification delay as well as the morbidity and mortality associated with these outbreaks. In 2018, 96 new disease outbreaks were reported across 36 of the 47 Member States. The most commonly reported disease outbreak was cholera which accounted for 20.8% (n = 20) of all events, followed by measles (n = 11, 11.5%) and Yellow fever (n = 7, 7.3%). About a quarter of the outbreaks (n = 23) were reported following signals detected through media monitoring conducted at the WHO regional office for Africa. The median delay between the disease onset and WHO notification was 16 days (range: 0-184). A total of 107 167 people were directly affected including 1221 deaths (mean case fatality ratio (CFR): 1.14% (95% confidence interval (CI) 1.07%-1.20%)). The highest CFR was observed for diseases targeted for eradication or elimination: 3.45% (95% CI 0.89%-10.45%). The African region remains prone to outbreaks of infectious diseases. It is therefore critical that Member States improve their capacities to rapidly detect, report and respond to public health events.

Measuring health and well-being with the help of the community

Issue

The Well North Programme is a multi-centre study focused on reducing inequalities in deprived communities through locally-led interventions and activities. As a locally driven project where the local stakeholders were involved in the programme of work, it was important to involve the community when deciding what to measure.

Description

As part of the evaluation there was a need to produce a tool to capture health and wellbeing information that was relevant to the specific communities involved in the project. In order to do this, we established that we needed local people to define what they wanted to measure, and we would use evidence synthesis techniques to identify tools that could be used to measure it within the community.

Results

We formulated the Well North Star, a bespoke spider diagram designed to capture individual level data. The Star is a quantitative tool used to collect individual-level data at an individual, organisational and geographical level. Each arm of the star represents an important theme, selected for measurement by local people. Identified local stakeholders (including residents, voluntary sector, police and councillors) were invited to workshops in order to decide what issues were important locally. After group discussions and thematic analysis, up to seven issues were highlighted as the most important in the community. Two of the main issues highlighted within local communities were aspiration and access to local information. After extensive literature search, tools to measure these were insufficient (e.g. aspiration tools focused on aspiration to become famous) and so bespoke tools needed to be created.

Lessons

When conducting community driven research, it is important to involve representatives from the community in identifying issues that are important to them. There is a gap between what academics and researchers consider important in local communities and what the communities themselves consider important.