508 Conservative Management of Small Bowel Obstruction: A Local Experience

Introduction

Post-operative intra-abdominal adhesions remain the leading cause of small bowel obstruction (SBO) representing one of the main diagnoses warranting emergency laparotomies. The National Audit in Small Bowel Obstruction advocates the use of water-soluble contrast agents (WSCA) as initial management of SBO. We aim to assess the role and outcomes of WSCA and its rate in successfully managing SBO non-operatively.

Method

We conducted a 2-year retrospective analysis including all patients admitted with adhesive SBO. Outcomes of patients who received WSCA were compared to those who hadn’t.

Results

118 patients were included, 27(23%) of which required immediate surgery while 91(77%) were initially managed conservatively. From the latter group, 53(58.2%) received WSCA whilst 38(41.8%) didn’t. Of the group that received WSCA, 36(39.5%) were successfully managed non-operatively, compared to 26(28.5%) that didn’t, this however lacked statistical significance. LOS didn’t differ between these two groups (5 days vs. 5.5 days, p = 0.805). 32% of the patients required eventual surgical intervention needing longer LOS regardless of receiving WSCA (6.6 days vs. 13.6 days p < 0.001).

Conclusions

Adhesive SBO can be managed conservatively in up to two-thirds of patients. WSCA usage has a positive impact but needs further assessment in larger studies.

P15: EVALUATING THE INTERNATIONAL USABILITY OF A LOW-COST LAPAROSCOPIC TRAINER IN LOW- AND HIGH-INCOME SETTINGS

Introduction

Limited access to equipment and trained personnel restrict the adoption of laparoscopic surgery globally. There are a wide range of laparoscopic trainers available; however, most of these are not affordable. We propose an ultra-low-cost laparoscopic trainer (Lap-Pack), designed for portability, ease of assembly and compatibility with smart devices. The study aims to evaluate the usability of Lap-Pack as a training tool in low- and high-income settings.

Method

An international usability study was conducted in India and the UK in 2019. The participants (n=60), consisting of senior surgeons (n=18), junior trainees (n=20) and medical students (n=22), were asked to complete two tasks using Lap-Pack. Participants then scored Lap-Pack in a 25-point questionnaire, including a pre-established Face-Validity Criteria and four major evaluation categories – Usability, Camera, View, Material.

Result

Lap-Pack scored highly in Face-Validity with a combined mean score of 4.63 (95%CI: 4.31, 4.95, p <0.05) of a possible 6. In both cohorts, the Usability and Camera categories scored highest, with combined values respectively of 6.10 (95%CI: 6.01, 6.19, p <0.05) and 6.09 (95%CI: 5.88, 6.31, p <0.05) of a possible 7. For both centres, the highest-scoring individual criteria were its light weight and portability.

Conclusion

Overall, Lap-Pack was received positively by medical students and consultants alike, suggesting it is a suitable device for development of skills as part of a larger laparoscopic training curriculum. Its ease of assembly, portability and versatility show promise of increasing access to training opportunities worldwide.

Take-home message

Lap-Pack is an ultra-low-cost, portable laparoscopic simulator featuring compatibility with smart devices designed to help increase access to laparoscopic training worldwide. An international usability study found medical students, junior trainees and senior surgeons rated its usability and camera features highly, suggesting its employability as a laparoscopic training tool on a global scale.

Prevalence of Loss of Smell and/or Taste and other Otorhinolaryngology Symptoms in COVID-19 Patients

Background Loss of smell and/or taste have been described in COVID-19 patients. Studies have not been conducted to evaluate the loss of smell and/or taste in the context of Nepal. Objective To investigate the prevalence of Ear, Nose and Throat related symptoms and assess smell and taste disorders in laboratory-confirmed SARS-CoV-2 patients. Method This prospective cross-sectional study evaluated patients from September 2020 to March 2021 with preceding COVID-19 diagnosis from a tertiary centre in Kathmandu. COVID-19 positive patients visiting out-patient department, quarantined or admitted were included. Patients were given questionnaire consisting of demographic data, history of smoking and evaluation of presenting symptoms. Loss of smell and taste were subjectively tested and followed up via telephone for ten weeks to evaluate for recovery time and degree of recovery. Result A total of 226 patients participated in the study, 18-92 years old (mean age, 36.77 ± 15.23 years; 53.5% males, 69% non-smokers). Majority of the patients had Myalgia (n = 128, 56.6%) as their presenting symptoms followed by fever (n = 122, 53.9%), loss of smell (n = 117, 51.7%), cough (n = 107, 47.34) and sore throat (n = 102, 45.1%). Loss of sense of smell and taste was reported in 51.8% and 42% respectively. The association between loss of sense of smell and taste was statistically significant (p < .001). All patients had some degree of recovery with 64.1% recovery of smell and 64.2% recovery of taste within 14 days of onset of symptoms. The mean recovery time for sense of smell and taste was 14.34 ± 9.82 days and 15.03 ± 10.06 days, respectively. Conclusion Olfactory and gustatory dysfunctions are cardinal features of COVID-19. They recover spontaneously along with other symptoms within few weeks. The absence of smell or taste in times of pandemic can be suggestive of potential COVID-19 infection and be used as a screening tool for early diagnosis and reduce transmission of the infection.

Filifactor alocis: Recent Insights and Advances

Filifactor alocis, a fastidious Gram-positive obligate anaerobic bacterium, is a newly appreciated member of the periodontal community that is now proposed to be a diagnostic indicator of periodontal disease. Its pathogenic characteristics are highlighted by its ability to survive in the oxidative stress-rich environment of the periodontal pocket and to significantly alter the microbial community dynamics by forming biofilms and interacting with several oral bacteria. Here, we describe the current understanding of F. alocis virulence attributes, such as its comparative resistance to oxidative stress, production of unique proteases and collagenases that can cause structural damage to host cells, and dysregulation of the immune system, which enable this bacterium to colonize, survive, and outcompete other traditional pathogens in the inflammatory environment of the periodontal pocket. Furthermore, we explore the recent advancements and future directions for F. alocis research, including the potential mechanisms for oxidative stress resistance and our evolving understanding of the interactions and mechanisms of bacterial survival inside neutrophils. We also discuss the current genetic tools and challenges involved in manipulating the F. alocis genome for the functional characterization of the putative virulence genes. Collectively, this information will expedite F. alocis research and should lead to the identification of prime targets for the development of novel therapeutics to aid in the control and prevention of periodontal disease.

Ultrasound imaging for the differential diagnosis of periapical lesions of endodontic origin in comparison with histopathology - a systematic review and meta-analysis

BACKGROUND

Differentiating periapical lesions is important for treatment planning and subsequent treatment outcome.

OBJECTIVE

To assess the diagnostic accuracy of ultrasound imaging for the differentiation of periapical lesions in comparison with histopathology.

METHODS

PubMed, Scopus, Embase, Web of Science and ProQuest databases were searched for clinical studies published until June 2020 that evaluated the use of ultrasound (US) imaging for differential diagnosis of periapical lesions and used histopathology as the reference standard. Animal studies, laboratory-based studies, reviews and clinical studies not using a reference standard were excluded. Risk of bias (RoB) assessment was performed using a modified Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The random effects model was used for quantitative analysis of the data, and the Deeks test was used for calculating publication bias. Quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Twelve articles were included in the systematic review, out of which ten articles were quantitatively assessed. All the articles had a high RoB and concerns regarding applicability in the patient selection domain. For the index test domain, seven articles had low and the remaining five had unclear RoB and concerns regarding applicability. In the reference standard domain, low RoB and concerns regarding applicability were observed for all the articles. The RoB was low in flow and timing domains in all the articles except for one, where it was high. Summary estimates of sensitivity and specificity of US to diagnose periapical granulomas were 0.94 and 0.98, whereas for periapical cysts it was 0.98 and 0.99, respectively. Area under the curve for diagnosis of both periapical granulomas and periapical cysts was 0.99. All the included articles had inherent publication bias. Quality of evidence using GRADE, for sensitivity, was moderate for periapical granulomas and high for periapical cysts, whereas for specificity, it was high for periapical granulomas and low for periapical cysts.

DISCUSSION

The available evidence is considered to be of low quality due to the observational nature of the studies and inherent publication bias.

CONCLUSION

Although the sensitivity and specificity for differentiating periapical cysts and periapical granulomas using US were high, taking the quality of evidence into consideration, it can serve as an additional tool in differential diagnosis of periapical lesions.

BCG as a game-changer to prevent the infection and severity of COVID-19 pandemic?

The impact of COVID-19 is changing with country wise and depend on universal immunization policies. COVID-19 badly affects countries that did not have universal immunization policies or having them only for the selective population of countries (highly prominent population) like Italy, USA, UK, Netherland, etc. Universal immunization of BCG can provide great protection against the COVID-19 infection because the BCG vaccine gives broad protection against respiratory infections. BCG vaccine induces expressions of the gene that are involved in the antiviral innate immune response against viral infections with long-term maintenance of BCG vaccine-induced cellular immunity. COVID-19 cases are reported very much less in the countries with universal BCG vaccination policies such as India, Afghanistan, Nepal, Bhutan, Bangladesh, Israel, Japan, etc. as compared to without BCG implemented countries such as the USA, Italy, Spain, Canada, UK, etc. BCG vaccine provides protection for 50–60 years of immunization, so the elderly population needs to be revaccinated with BCG. Several countries started clinical trials of the BCG vaccine for health care workers and elderly people. BCG can be uses as a prophylactic treatment until the availability of the COVID-19 vaccine.

Postpercutaneous Nephrolithotomy Ureteropelvic Junction Obstruction

Percutaneous endoscopic renal surgery such as percutaneous nephrolithotomy (PCNL) is a safe and effective treatment for patients with large and/or complex renal calculi. However, a unique set of complications can occur with this surgical approach that may involve the targeted kidney and surrounding structures. Renal collecting system obstruction after PCNL is rare, but may result from ureteral avulsion, stricture formation, transient mucosal edema, blood clot, or infundibular stenosis. Impaction of stone and trauma during PCNL could induce stricture formation and obstruction. Use of proper percutaneous and endoscopic techniques and instruments will help to reduce the chances of developing such strictures and obstruction.

Establishing core outcome sets for gastrointestinal recovery in studies of postoperative ileus and small bowel obstruction: protocol for a nested methodological study

INTRODUCTION

Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction.

METHOD

An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co-developed and may be combined to form a common output with disease-specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal-group stakeholder discussions; online-facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized.

DISSEMINATION AND IMPLEMENTATION

The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi-faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set.

Early Vaccination of Chickens Induces Suboptimal Immunity Against Infectious Bronchitis Virus

Infectious bronchitis virus (IBV) is highly prevalent in broiler chickens despite extensive vaccination commonly conducted early after hatch. The effects of early vaccination on immune responses were further investigated in chickens primed at increasing ages, followed by booster vaccination with an attenuated Arkansas (Ark) Delmarva Poultry Industry-type vaccine. Results show that vaccination on day 1 of age elicits significantly lower systemic and mucosal antibody responses compared with vaccination at later time points in the life of the chicken. The increase of IBV antibodies in serum from secondary responses after booster vaccination was more dramatic and significantly higher when measured by an Ark spike subunit 1 protein ELISA compared with measuring by non-Ark serotype whole-virus ELISA, which underlines the immunogenic importance of the virus spike at inducing antibodies. However, the levels achieved following boosting did not differ significantly between ages of priming. Thus, it seems that the booster vaccination mitigated the differences detected after prime immunization. In contrast to the continued rise of systemic antibodies after booster vaccination, the levels of mucosal IBV-specific immunoglobulin A decreased after booster vaccination. The recruitment or expansion of cluster of differentiation (CD)4⁺, CD8⁺, and CD4⁺/CD8⁺ T-cell populations in different immune effector sites was increased with age, but remained unaltered by IBV vaccination. In contrast, peripheral blood CD4⁺ cells showed a significant increase in IBV-vaccinated chickens compared with nonvaccinated age-matched controls both after primary and booster immunization. The results of the current study confirm that IBV vaccination on the day of hatch induces suboptimal IBV immune responses both in the systemic and mucosal compartments. This routine practice may be contributing to the immunologic escape of the virus and increased persistence of vaccine virus in vaccinated chickens. However, booster vaccination seems to overcome poor initial responses.

Effects of Drying, Lactic Acid, and an Antimicrobial Marinade on the Survival of Generic Escherichia coli on Biltong

ObjectivesThe objective of the experiment was to evaluate the effects of drying, lactic acid spray, and a certain marinade application on the survival of generic Escherichia coli on biltong.Materials and MethodsFrozen eyes of round (IMPS #171C) were obtained from a local beef purveyor. The eyes of round were thawed (at 4°C), trimmed of extra fat and connective tissues, and cut into strips (L × W × T; 6 in × 2 in × 0.75 in). The experiment was divided into 2 groups and replicated once. Experiment 1 was further sub-grouped into 3 treatments: (1) negative control (NC), (2) negative control for dip treatment (NCD), and (3) inoculated group (I). Experiment 2 was sub-grouped into 6 treatments: (1) negative control (NC), (2) negative control for dip treatment (NCD), (3) positive inoculated control (PIC), and inoculated treatments (4) marinated (M), (5) 2% lactic acid spray (LA), and (6) marinated and lactic acid spray (MLA). For both experiments 1 and 2, 12 strips of biltong were randomly selected for each treatment (n = 36 for experiment 1; n = 72 for experiment 2). The inoculated samples were dipped for 30 s in a cocktail (5-log) of 4 different strains of nalidixic adapted Escherichia coli (beef isolates) and allowed 2 h for attachment at 4°C. The lactic acid was sprayed to each side of the respective biltong and allowed a 10-min resting period. Marinade was applied to respective treatment groups by dipping, rubbing, and incubating overnight (at 4°C). All samples were kept in a smokehouse in a controlled environment with drying cycle at 78°F and 60% relative humidity. Experiment 1 was incubated in the smokehouse for a total of 12 d and experiment 2 was incubated for 9 d total. Samples from each treatment group were removed on Days 0, 2, 5, 7, 9, and 12 (experiment 1 only) for microbiological sampling and analysis. Samples were homogenized, serially diluted, enumerated on TSA plus 200 ppm nalidixic acid, and incubated at 35°C for 18–24 h. Colonies were counted after 24 h and colony counts were transformed into log10 CFU for reporting.ResultsThe data for experiment 2 showed that the treatments LA, M, MLA, and PIC were able to achieve a 2.5–3 log10 CFU reduction after 9 d of drying. The M and MLA treatments exhibited a 2–3 log10 CFU reduction after 2 d of drying as compared with LA and PIC that showed a similar reduction in microbial counts after 9 d of incubation. The NC and NCD treatment groups resulted in no microbial growth from Day 0 till Day 9 of incubation. The data for experiment 1 showed that there was a 1 log10 CFU reduction of E. coli in treatment group I. The NC and NCD groups did not show microbial growth from Day 0 till Day 9 of incubation. The water activity decreased overtime to 0.722 for experiment 1 and 0.711 for experiment 2. Overall, the M and the MLA samples appeared to have the greatest and quickest killing effect on generic E. coli.ConclusionResults from these experiments suggest that the combination of drying with a lactic acid spray and marinade application causes a decrease in the E. coli population on Biltong during incubation for 9 or 12 d. While the results show that there may be a small decrease from drying alone, the greatest decreasing effect appears to be the combination of the drying, lactic acid, and marinade. Future work will include additional replicates and experiments with pathogens such as E. coli O157:H7.

Primary adrenal teratoma: An unusual tumor - Challenges in diagnosis and surgical management

We report a rare case of a 25-year-old lady who presented with right hypochondriac pain associated with weakness for 3 months. Her hormonal evaluation was normal. Computed tomography scan revealed an adrenal mass for which a right open transperitoneal adrenalectomy was performed, and the lesion was diagnosed as mature teratoma on histopathological examination. Teratoma is an unusual neoplasm which arises from one or all the three germ layers. Extragonadal teratomas are rare in adults as compared to children and are mostly retroperitoneal in location, constituting only 4% of all primary teratomas. Primary adrenal teratomas are even rarer and to the best of our knowledge, only eight cases have been reported in adults in the past 10 years. Adrenal teratoma can pose a diagnostic challenge because radiologically it mimics myelolipoma, angiomyolipoma, liposarcoma, or pheochromocytoma. Mature teratomas are usually benign but may possess malignant potential, the chances of which are greater in adults as compared to children, making it an important entity requiring a proper diagnosis and management.

Effect of Wetting and Dewetting Dynamics on Atomic Force Microscopy Measurements

Water bridge dynamics between an atomic force microscopy (AFM) tip and a flat substrate is studied by using a multibody dissipative particle dynamics (MDPD) model. First, the numerical model is validated by comparing the present results of droplet contact angles and liquid bridges with those reported in the literature. Then, the ability of MDPD to capture the meniscus shape and behavior for different operating conditions and geometric parameters is examined for both static and dynamic cases. Hence, several parametric studies and analyses of the AFM tip configuration and its operating conditions are reported. It is found that a critical capillary number of about 0.001 is calculated based on 5% change on the force measurements between the static and dynamic results. It is also demonstrated that the hysteresis behavior in the capillary force exerted on the AFM tip can be successfully predicted by using the MDPD model when the tip approaches or retracts from the substrate. Moreover, there is an excellent agreement in the results of breakup distance for different water bridge volumes between the predictions of the MDPD model and the theory. Also, the hysteresis of capillary force exerted on an AFM tip composed of multibody design is studied. The prediction on the transition of the capillary force vs distance between the AFM tip and the substrate is in good agreement with the experimental results. Therefore, we demonstrate a validated MDPD model which can successfully capture liquid bridge dynamics. This model can be used as a powerful design tool for meniscus manipulation technology, such as dip-pen nanolithography, as well as for studying dynamic, e.g., tapping mode AFM tip, interactions with a liquid bridge.

P4599Strict versus no fasting prior to cardiac catheterization: a prospective evaluation of safety and clinical outcomes

Background/Methods

No studies have examined safety of a no fasting (NF) strategy as compared to current nil per os (NPO) practice in patients undergoing non emergent cardiac catheterization (CC). We compared these two strategies in this single center, prospective, randomized study. Fasting group was NPO for solids after midnight but could have clear liquids up to 2 hours prior to procedure. NF group had no restriction or oral intake.

Results

A total of 520 patients enrolled till December 2018 were included in this interim analysis. Both groups had similar baseline characteristics (figure 1). As compared to the fasting group (n=274), NF group (n=246) had similar rates of primary outcomes: CIN (0.02% in both groups), peri-procedural hypotension (0.02% vs 0.03%), aspiration pneumonitis (none vs 0.009%), nausea/vomiting (0.05 vs 0.07%), hypoglycemia (0.007% vs 0.008%) respectively [p=not significant for all].Secondary outcomes including patient's satisfaction and 30-day mortality were also similar in both groups. Cost of index hospitalization was significantly lower in NF group (table 1).

Outcome table Outcomes Fasting group (n=274) Non- Fasting group (n=246) p value Length of Stay (days)† 2.13±0.2 1.96±0.19 0.524 SBP post catheterization† 133.31±1.44 133.15±1.39 0.936 Hypotension peri procedurally 6 (2%) 7 (3%) 0.617 Fluid resuscitation required for hypotension 2 (0.7%) 3 (1%) 0.669 Pressor required for hypotension 1 (0.4%) 2 (0.8%) 0.603 Acute Kidney Injury 10 (4%) 9 (4%) 0.981 Contrast induced nephropathy 5 (2%) 6 (2%) 0.612 Hypoglycemia 2 (0.7%) 2 (0.8%) 1 Hyperglycemia 12 (4%) 4 (2%) 0.080 Symptomatic hypotension 1 (0.4%) 2 (0.8%) 0.603 Nausea/vomiting 12 (5%) 15 (7%) 0.344 Aspiration pneumonitis 0 (0%) 2 (0.9%) 0.219 Patient satisfaction score† 4.39±0.06 4.45±0.06 0.438 Alive on discharge 271 (98.9%) 240 (98%) 0.622 30-day mortality 4 (1.5%) 6 (2.4%) 0.417 30-day Cardiac readmission 32 (13%) 26 (11%) 0.557 Total Cost (US Dollars)† 10148.97±985.71 7710.914±648.33 0.040 Results are shown as number (%). †Expressed as mean ± standard error.

Conclusion

NF strategy is safe and cost effective as compared to traditional NPO practice in patients undergoing CC.

Acknowledgement/Funding

A financial grant of USD15,000 from Guthrie Research Foundation