317 Preoperative Fasting in Adults – A Quality Improvement Project at Macclesfield District General Hospital

Aim

Our primary endpoint was to evaluate staff awareness of preoperative fasting guidelines. Our secondary endpoint was to evaluate patient preoperative fasting times.

Method

Data were collected using online close-ended survey questions from surgical ward nurses and healthcare assistants before and after implementing a multimodal campaign to raise awareness. Data were collected for patient fasting times before and after the same interventions.

Interventions:

Results

Staff: Our interventions increased staff awareness of preoperative fasting guidelines for food by 20.6% (from 50% to 70.6%) and for clear fluids by 28.8% (30% to 58.8%).

Patients

Average preoperative fasting times for food before and after intervention were 12.7 and 12 hours respectively (p=0.736). For clear fluids, average fasting times before and after intervention were 6.2 hours and 4.5 hours (p=0.415).

Conclusions

Staff were generally unaware of the guidelines and viewed preoperative fasting solely as a safeguard against aspiration, causing adoption of a risk-averse attitude. The benefits of adequate hydration and nutritional support before surgery were overlooked. Our interventions helped raise awareness in the short term.

For our next cycle, we plan to assess the efficacy of implementing long-lasting changes such as local trust guidelines and improved staff training to drive a change in attitude and awareness of preoperative fasting.

310 Ethical Challenges Facing Autonomous Surgical Robots

Aim

Despite delays, automation is expected across all fields, with notable interest in surgical robotics. With this comes many of the ethical and moral dilemmas the industry is expected to face in bringing autonomation, to surgical robots, into clinical practice.

Method

A review of the available literature published on automation, machine ethics and surgical robotics.

Results

One of the key issues at the heart of autonomous surgical robotics lies the responsibility in the event of complications. Does it lie at the hand of the robotics manufacturer, the clinician or clinical organisation or possibly the patient? A question that remains unanswered despite the relative expectation of autonomous robotics into clinical practice in the coming years.

Furthermore, how should a robot proceed in an emergency? An automated surgical robot, which lacks a moral framework, may be unable to deal with emergencies especially within the context of fluctuating local environment where the needs of patients are distinct and everchanging.

In addition to this, a political and ethical concern is the expected number of job losses of highly skilled professionals and the training need to adapt to changing work. Can these professionals be employed in a different capacity? Moreover, data concerns have been highlighted, how best to use patient data to improve the technologies whilst preventing misuse of sensitive information.

Conclusions

Based on current literature, greater work is needed to be done to address the ethical issues before implementation of autonomous surgical robotics.

Novel therapeutic drug strategies to tackle immune-oncological challenges faced by cancer patients during COVID-19

INTRODUCTION

For the clinical treatment of cancer patients, coronavirus (SARS-CoV-2) can cause serious immune-related problems. Cancer patients, who experience immunosuppression due to the pathogenesis and severity of disease, may become more aggressive due to multiple factors such as age, comorbidities, and immunosuppression. In this pandemic era, COVID-19 causes lymphopenia, cancer cell awakening, inflammatory diseases, and a cytokine storm that worsens disease-related morbidity and prognosis.

AREAS COVERED

We discuss all the risk factors of COVID-19 associated with cancer patients and propose new strategies to use antiviral and anticancer drugs for therapeutic purposes. We bring new drugs, cancers and COVID-19 treatment strategies together to address the immune system challenges faced by oncologists.

EXPERT OPINION

The chronic inflammatory microenvironment caused by COVID-19 awakens dormant cancer cells through inflammation and autoimmune activation. Drug-related strategies to ensure that clinical treatment can reduce the susceptibility of cancer patients to COVID-19, and possible counter-measures to minimize the harm caused by the COVID-19 have been outlined. The response to the pandemic and recovery has been elaborated, which can provide information for long-term cancer treatment and speed up the optimization process.

Headspace solid-phase microextraction with 1-pyrenyldiazomethane in-fibre derivatisation for analysis of faecal short-chain fatty acids

Short chain fatty acids (SFCAs) are nutritionally important products of colonic bacteria. Their analysis in faeces is problematic. We report a headspace solid-phase microextraction procedure in which faecal SCFAs are derivatised on the fibre in-situ with 1-pyrenyldiazomethane. With this method sharp, well-resolved chromatographic peaks were obtained with no interferences. Inclusion of deuterated analogues enabled accurate quantification. Good linearity, recoveries and precision were achieved. Differences observed between the SCFA profiles of normal subjects and patients with cystic fibrosis indicate the potential of this new technique for clinical studies. 2-Methylbutyric acid was found in all faecal samples. Few have reported this before.

Quantitative determination of trimethylamine in urine by solid-phase microextraction and gas chromatography-mass spectrometry

Trimethylaminuria (fish odour syndrome) is diagnosed from an increase in urinary excretion of trimethylamine with decreased trimethylamine oxide. We report a new quantitative stable isotope dilution gas chromatography-mass spectrometry procedure for the analysis of these metabolites using solid-phase microextraction (SPME). Both polydimethylsiloxane and mixed Carboxen-polydimethylsiloxane SPME fibres were found to be suitable for the headspace extraction of TMA. This new sampling technique could have wide application for the analysis of volatile and semi-volatile compounds by metabolic screening laboratories.

Epidemiological profile, mineral metabolic pattern and crystallographic analysis of urolithiasis in Kuwait

This study was conducted to determine the epidemiological profile of urolithiasis in Kuwaiti patients and the associated metabolic abnormalities favouring stone formation in this patient population. Between 1986 and 1994, a total of 421 Kuwaiti patients were studied in Al-Amiri renal stone laboratory. The mineral composition of stones was determined using a combination of stereoscopic microscopy and infrared spectrophotometry. Mineral metabolic screen (MMS) was available in 306 (72.7%) of those patients. The average annual incidence of new stone formation in Kuwaiti patients was 23.9 per 100,000 population. The incidence was only 6.9 per 100,000 population in those from pediatric age group, 33.4 in adults and 73.6 in the elderly. The frequency of new stone formation was higher among males as compared to females at different age groups. Calcium oxalate (CaO) constituted 72.1% of renal stones encountered in adults as compared to only 52.1% and 40.7% in elderly and pediatric age groups. Eighty four patients had recurrent and/or high stone load. Detailed family history was available in 57 of those 84 patients and was suggestive of strong family aggregation of stone disease in 30 (53%) patients. The proportion of urate stones was 15.4% of all stones formed and constituted a major cause of renal stones in children (24.1%), adults (14.4%) and elderly (12.5%). Cystine stones were found in 10 patients (2.4%). Hyperuricemia was detected in 1/3 of patients from pediatric age group. In adults, 89 (38.4%) of 232 patients had abnormal MMS, of which hyperuricosuria with or without hyperuricemia accounted for 79.8% of those abnormalities. In elderly patients, metabolic disorders were detected in 7 (17.5%) of the 40 patients. In the latter group, all except one, had hyperuricosuria with or without hyperuricemia. Cystinuria, distal renal tubular acidosis (d-RTA) and hyperparathyroidism constituted 6.6% of metabolic abnormalities in the patients studied. Primary abnormalities of upper and lower urinary tract was detected in 6% of adult patients as compared to 47% in children and 30% in the elderly. In conclusion; the incidence rate of new stone former in Kuwait is significantly lower from that reported in Europe and USA. This latter finding and the high familial aggregation of urolithiasis in our area constitute a cogent argument against the role of hot climate in the pathogensis of urolithiasis and are in favour of genetic predisposition. Isolated hyperuricosuria was detected in 17% of idiopathic CaO stone formers. The latter finding is of practical importance since red-meat is a common food item in our area and restriction of purine-intake may help to decrease the frequency of urate and CaO stone formation in predisposed patients.

Towards improving care for children with diabetes in Kuwait

Presents the results of a medical audit of the records of 199 children diagnosed as diabetic and admitted to Al-Amiri Hospital, Kuwait. Uses the measurement of glycosylated haemoglobin (HbA1) to indicate the levels of control achieved. Finds that the degree of glycaemic control compares favourably with studies done in other hospitals, but unfavourably with specialized diabetic clinics. Proposes that glycaemic control could be improved by provision of the services of specialized support staff such as dietitian, educator, psychologist and health visitor.