Influence of different volumes and frequency of programmed intermittent epidural bolus in labor on maternal and neonatal outcomes: A systematic review and network meta-analysis

STUDY OBJECTIVE

In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined.

DESIGN

Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708).

SETTINGS

Labor.

PATIENTS

Pregnant patients.

INTERVENTIONS

Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool.

MAIN RESULTS

Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials.

CONCLUSIONS

Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.

Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery

STUDY OBJECTIVE

Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery.

DESIGN

Systematic review.

SETTINGS

Robot assisted abdominal surgery.

PATIENTS

Adults.

INTERVENTIONS

Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials.

MAIN RESULTS

We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent.

CONCLUSIONS

Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.

Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis

BACKGROUND

Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery.

METHODS

CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis.

RESULTS

We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs.

CONCLUSIONS

Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.

Increased complications rates and inferior patient reported outcomes following total knee arthroplasty due to post-traumatic osteoarthritis with previous fracture treatment: a systematic review

PURPOSE

This study aims to present the existing literature relating to patient-reported outcome measures (PROMs) and complications in patients undergoing total knee arthroplasty (TKA) due to posttraumatic osteoarthritis (PTOA) with prior fracture treatment around the knee compared with patients who underwent TKA because of primary osteoarthritis (OA).

METHODS

A systematic review was undertaken and synthesised in accordance with the PRISMA guidelines by searching existing literature in the following databases: PubMed, Scopus, Cochrane Library and EMBASE. A search string according to the PECO was used. After analysing 2781 studies, 18 studies (5729 PTOA patients/149,843 OA patients) were included for a final review. An analysis revealed that 12 (67%) were retrospective cohort studies, four (22%) were register studies and the remaining two (11%) were prospective cohort studies. The mean Critical Appraisal Skills Programme (CASP) score was 23.6 out of 28, signifying studies of moderate quality.

RESULTS

The most frequently reported outcome measure were postoperative complications, reported in all eighteen studies. Intraoperative complications were reported in ten (4165 PTOA/124.511 OA) and patient-reported outcome measures (PROMs) in six studies (210 PTOA/2768 OA). A total of nine different PROMs were evaluated. As far as PROMs were concerned, the scores were inferior for PTOA but did not differ statistically from OA, except for one study, which favoured the OA group. Across all studies, postoperative complications were higher in the PTOA group, reporting infections as the most common complication. Furthermore, a higher revision rate was reported in the PTOA group.

CONCLUSION

PROM analysis suggests that both patient groups benefit from a TKA in terms of functional outcome and pain relief, however, patient-reported outcomes could be inferior for PTOA patients. There is consistent evidence for increased complication rates following PTOA TKA. Patients undergoing TKA due to PTOA after fracture treatment should be informed about the risk for inferior results and refrain from comparing their knee function to patients with TKA after OA. Surgeons should be aware of the challenges that PTOA TKA poses.

LEVEL OF EVIDENCE

Level III.

Local anaesthetic adjuncts for peripheral nerve blockade

PURPOSE OF REVIEW

Moderate-to-severe pain is common and remains a significant problem. Compared with opioid analgesia alone, single-shot peripheral nerve blockade has been associated with improved pain relief and the potential of decreased side effects. Single-shot nerve blockade, however, is limited by its relatively short duration of action. In this review, we aim to summarize the evidence related to local anaesthetic adjuncts for peripheral nerve blockade.

RECENT FINDINGS

Dexamethasone and dexmedetomidine exhibit characteristics that most closely resemble the ideal local anaesthetic adjunct. In upper limb block, dexamethasone has been demonstrated to be superior to dexmedetomidine regardless of administration route for the duration of sensory and motor blockade as well as the duration of analgesia. No clinically significant differences between intravenous and perineural dexamethasone were found. Perineural and intravenous dexamethasone have the potential to prolong sensory blockade to a greater extent than motor blockade. The evidence indicates that the mechanism of action of perineural dexamethasone in upper limb block is systemic in nature. Unlike perineural dexmedetomidine, intravenous dexmedetomidine has not been shown to result in differences in the characteristics of regional blockade compared with local anaesthetic alone.

SUMMARY

Intravenous dexamethasone is the local anaesthetic adjunct of choice, increasing the duration of sensory and motor blockade as well as the duration of analgesia by 477, 289 and 478 min, respectively. In view of this, we recommend consideration of the intravenous administration of dexamethasone at a dose of 0.1-0.2 mg/kg for all patients undergoing surgery whatever the level of postoperative pain, mild, moderate or severe. Further research should focus on the potential synergism of action between intravenous dexamethasone and perineural dexmedetomidine.

9 MOG associated encephalitis presenting as idiopathic intracranial hypertension

A young Caucasian male (7y) with normal BMI was atypical for his provisional diagnosis of Idiopathic Intracranial Hypertension (IIH), that resolved following a Lumbar Puncture (LP). At 8y he presented with a 2-week history of headaches and vomiting that started some weeks after flu vaccination and an upper respiratory infection.Visual Acuity (VA) and colour vision were normal. Ocular motility was full. Fundoscopy and OCT showed recurrence of papilloedema, with enlarged blind spots on Kinetic perimetry.LP opening pressure was 30cm H2O and CSF white cells were elevated (23). Repeat brain and spine imaging showed new white matter signal changes in keeping with neuroinflammation, as well as enhancement of the left optic nerve extending to the chiasm and optic tract. VA, colour vision and pupillary reactions remained normal.Pattern VEP peak times were prolonged from the left eye compared to right eye to small check widths, consistent with relative macular-cortex pathway dysfunction. Hemifield PVEPs were slightly prolonged and reduced from the bitemporal fields indicating chiasmal dysfunction. Normal PERGs excluded PVEP delay associated with primary RGC disease.Further investigations showed oligoclonal band and serum-MOG antibody positivity.Management: Initial treatment with Acetazolamide 125mg bd for a week, following LP, was changed to IV methylprednisolone followed by oral prednisolone.Symptoms improved significantly following LP and steroid treatment. He will be followed in a Demyelination Clinic.MOG-associated disease has been reported with raised intracranial pressure and should be considered especially in children with atypical clinical phenotype for IIH.

High-level soccer players have a low rate of return to performance after hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

Femoroacetabular impingement syndrome (FAIS) is a known cause of impaired sports performance in athletes and the relationship between FAIS and soccer players has previously been described. Hip arthroscopy is a viable treatment option that can facilitate athletes' return to sport (RTS). The aim of this study was to evaluate the RTS and return to performance (RTP) with objective measurements in high-level soccer players after hip arthroscopy for FAIS.

METHOD

Soccer players, with a hip sports activity scale (HSAS) level of 7 or 8 before symptom onset and undergoing hip arthroscopy for FAIS between 2011 and 2019 were identified in the Gothenburg hip arthroscopic registry. A total of 83 high-level soccer players, with a mean age of 23.9 (SD 4.4) years at surgery, were included. To verify the activity level and further stratify players as elite or sub-elite, player statistics were collected from soccer-specific scout webpages and the Swedish national soccer association. The return to sport was defined as return to one game of soccer. Return to performance was defined as playing at the same level, or higher, and participating in at least 80% of the number of games played the season before symptom onset or the season before surgery either the first or second season after hip arthroscopy.

RESULTS

In total, 71 (85.5%, 95% confidence interval (CI) 76.1-92.3%) of the players returned to sport the first or second season after surgery. Compared to the season before symptom onset, 31 (37.3%, 95% CI 27.0-48.7%) players returned to performance the first or second season after surgery, and 32 (38.6%, 95% CI 28.1-49.9%) players returned to performance the first or second season after surgery compared to the season before surgery.

CONCLUSION

A high rate of elite and sub-elite soccer players return to soccer after hip arthroscopy for FAIS. However, less than half of the players RTP when evaluating performance through level of play and number of games played.

LEVEL OF EVIDENCE

Level IV.

Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis

PURPOSE

In labour, neuraxial analgesia is the standard in the provision of pain relief. However, the optimal mode of delivering epidural solution has not been determined, and some parturients may need an alternative to epidural analgesia. We sought to conduct a systematic review and network meta-analysis to compare continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, patient-controlled epidural bolus (PCEA), fentanyl patient-controlled analgesia (PCA), and remifentanil PCA, either alone or in combination.

METHODS

We searched CENTRAL, CINAHL, Ovid Embase, Ovid Medline, and Web of Science for randomized controlled trials that included nulliparous and/or multiparous parturients in spontaneous or induced labour. The maintenance epidural solution had to include a low concentration local anesthetic and an opioid. Specific subgroups in the obstetric population such as preeclampsia were excluded. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes are presented as mean differences and odds ratios, respectively, with 95% confidence intervals.

RESULTS

Overall, 73 trials were included. For the first coprimary outcome, the need for rescue analgesia, CEI was inferior to PIEB and PIEB + PCEA was superior to PCEA alone, with a low certainty of evidence given the presence of serious limitations and imprecision. The second coprimary outcome, the maternal satisfaction, was improved by PIEB + PCEA compared with CEI + PCEA and PCEA alone, with a low quality of evidence in view of the presence of serious limitations and imprecision. Fentanyl PCA increased the requirement for rescue analgesia and decreased maternal satisfaction relative to many methods of delivering epidural solution. In terms of secondary outcomes, PIEB increased analgesic efficacy compared with CEI, and PCEA reduced local anesthetic consumption at the expense of inferior analgesia relative to CEI and PIEB. PIEB + PCEA was superior to CEI + PCEA in regard to the pain score at 2 h and 4 h, consumption of local anesthetic, incidence of lower lower limb motor blockade and the rate of spontaneous vaginal delivery. Fentanyl and remifentanil PCA did not provide the same level of analgesia as all epidural methods, resulted in increasing analgesic ineffectiveness with time spent in labour, and predisposed to a higher incidence of side effects such as nausea and/or vomiting and sedation. Remifentanil PCA was superior to fentanyl PCA for analgesia at an early time point, and it increased the incidence of oxygen desaturation relative to other strategies of delivering epidural solution.

CONCLUSIONS

Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects. We interpret the findings of our systematic review and network meta-analysis as suggesting PIEB + PCEA to be the optimal delivery mode of epidural solution. Nevertheless, the potential differing importance of the various maternal, fetal, and neonatal outcomes in determining which is optimal has not, to our knowledge, been elucidated yet.

STUDY REGISTRATION

PROSPERO (CRD42021254978); registered 27 May 2021.

Cognitive aids in the management of clinical emergencies: a systematic review

Clinical emergencies can be defined as unpredictable events that necessitate immediate intervention. Safety critical industries have acknowledged the difficulties of responding to such crises. Strategies to improve human performance and mitigate its limitations include the provision and use of cognitive aids, a family of tools that includes algorithms, checklists and decision aids. This systematic review evaluates the usefulness of cognitive aids in clinical emergencies. Following a systematic search of the electronic databases, we included 13 randomised controlled trials, reported in 16 publications. Each compared cognitive aids with usual care in the context of an anaesthetic, medical, surgical or trauma emergency involving adults. Most trials used only clinicians in the development and testing of the cognitive aids, and only some trials provided familiarisation with the cognitive aids before they were deployed. The primary outcome was the completeness of care delivered to the patient. Cognitive aids were associated with a reduction in the incidence of missed care steps from 43.3% to 11% (RR (95%CI) 0.29 (0.15-0.16); p < 0.001), and the quality of evidence was rated as moderate. The use of cognitive aids was related to decreases in the incidence of errors, increases in the rate of correctly performed steps and improvement in the clinical teamwork skills scores, non-technical skills scores, subjective conflict resolution scores and the global assessment of team performance. Cognitive aids had an inconsistent influence on the time to first intervention and time to complete care of the patient's condition. It is possible that this was a reflection of how common or rare the crisis in question was as well as the experience and expertise of the clinicians and team. Sufficient thought should be applied to the development of the content and design of cognitive aids, with consideration of the pre-existing guideline ecosystem. Cognitive aids should be tested before their deployment with adequate clinician and team training.

NetCellMatch: Multiscale Network-Based Matching of Cancer Cell Lines to Patients Using Graphical Wavelets

Cancer cell lines serve as model in vitro systems for investigating therapeutic interventions. Recent advances in high-throughput genomic profiling have enabled the systematic comparison between cell lines and patient tumor samples. The highly interconnected nature of biological data, however, presents a challenge when mapping patient tumors to cell lines. Standard clustering methods can be particularly susceptible to the high level of noise present in these datasets and only output clusters at one unknown scale of the data. In light of these challenges, we present NetCellMatch, a robust framework for network-based matching of cell lines to patient tumors. NetCellMatch first constructs a global network across all cell line-patient samples using their genomic similarity. Then, a multi-scale community detection algorithm integrates information across topologically meaningful (clustering) scales to obtain Network-Based Matching Scores (NBMS). NBMS are measures of cluster robustness which map patient tumors to cell lines. We use NBMS to determine representative "avatar" cell lines for subgroups of patients. We apply NetCellMatch to reverse-phase protein array data obtained from The Cancer Genome Atlas for patients and the MD Anderson Cell Line Project for cell lines. Along with avatar cell line identification, we evaluate connectivity patterns for breast, lung, and colon cancer and explore the proteomic profiles of avatars and their corresponding top matching patients. Our results demonstrate our framework's ability to identify both patient-cell line matches and potential proteomic drivers of similarity. Our methods are general and can be easily adapted to other'omic datasets.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Is Not Superior to Anatomic Single-Bundle Reconstruction at 10-Year Follow-up: A Randomized Clinical Trial

BACKGROUND

The anatomic double-bundle (DB) technique is purported to be a superior technique due to its mimicking of the double-stranded anatomic formation of the anterior cruciate ligament (ACL). Previous studies with 2-, 5- and 10-year follow-up are conflicted as to whether this technique is superior to the previous gold standard method of ACL reconstruction, the anatomic single-bundle (SB) reconstruction.

PURPOSE/HYPOTHESIS

The aim of this prospective randomized study was to compare the outcomes of the anatomic DB technique and anatomic SB technique with independent drilling at 10 years after anterior cruciate ligament (ACL) reconstruction. We hypothesized that DB ACL reconstruction would result in a better outcome in terms of the pivot-shift test.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 105 patients (33 women, 72 men; median age, 27 years [range, 18-52 years]) were randomized and underwent ACL reconstruction (DB group: n = 53; SB group: n = 52). All reconstruction procedures were performed anatomically by identifying the ACL footprint, using the anteromedial portal for femoral tunnel drilling, and utilizing interference screws for tibial and femoral fixation. One blinded observer examined the patients both preoperatively and at follow-up (median, 120 months [range, 112-134 months]). Multiple subjective and objective clinical evaluations were used to assess the outcomes. Radiographic assessments of osteoarthritis were performed using the Ahlbäck, Kellgren-Lawrence, and Fairbank classification systems early postoperatively and at the final follow-up.

RESULTS

Preoperatively, no differences were found between the study groups. Overall, 70 patients (67%; DB group: n = 39; SB group: n = 31) were available for analysis at 10-year follow-up. No significant difference could be shown between the groups in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, single-leg hop test result, range of motion measurements, Lysholm knee score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score (KOOS) score. Correspondingly, no differences were found between the groups regarding the presence of radiographic osteoarthritis at follow-up. Both groups improved at follow-up compared with preoperatively in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, Lysholm knee score, and KOOS score (P < .05 [highest P value for any comparison]).

CONCLUSION

The anatomic DB technique was not superior to the anatomic SB technique with independent drilling at 10-year follow-up in regard to objective and subjective measurements. As such, one could argue that there is no need for the continued use of the anatomic DB technique in an unselected population.

Scent-delivery devices as a digital healthcare tool for olfactory training: A pilot focus group study in Parkinson's disease patients

Parkinson's disease (PD) patients display a combination of motor and non-motor symptoms. The most common non-motor symptom is scent (olfactory) impairment, occurring at least four years prior to motor symptom onset. Recent and growing interest in digital healthcare technology used in PD has resulted in more technologies developed for motor rather than non-motor symptoms. Human-computer interaction (HCI), which uses computer technology to explore human activity and work, could be combined with digital healthcare technologies to better understand and support olfaction via scent training - leading to the development of a scent-delivery device (SDD). In this pilot study, three PD patients were invited to an online focus group to explore the association between PD and olfaction, understand HCI and sensory technologies and were demonstrated a new multichannel SDD with an associated mobile app. Participants had a preconceived link, a result of personal experience, between olfactory impairment and PD. Participants felt that healthcare professionals did not take olfactory dysfunction concerns seriously prior to PD diagnosis. Two were not comfortable with sharing scent loss experiences with others. Participants expected the multichannel SDD to be small, portable and easy-to-use, with customisable cartridges to deliver chosen scents and the mobile app to create a sense of community. None of the participants regularly performed scent training but would consider doing so if some scent function could be regained. Standardised digital SDDs for regular healthcare check-ups may facilitate improvement in olfactory senses in PD patients and potential earlier PD diagnosis, allowing earlier therapeutic and symptomatic PD management.

First experience of implementing Candida auris real-time PCR for surveillance in the UK: detection of multiple introductions with two international clades and improved patient outcomes

BACKGROUND

Candida auris has been associated with rapid transmission and high mortality. A novel PCR-based surveillance programme was initiated at a London teaching hospital from January 2018. The results of this implementation until March 2019 are presented along with the clinical, transmission and phylogenetic characteristics encountered in that setting.

METHODS

A real-time PCR assay for C. auris was developed, validated, and implemented for direct use on skin swabs and urine. Environmental swabs were also tested by PCR as an emergency outbreak-control measure. Clinical risk factors and outcomes of patients were determined. Environmental dispersal was assessed using 24 h settle plate cultures around nine colonized patients followed by air sampling around one colonized patient during high- and low-turbulence activities. Sequencing was performed using Illumina HiSeq and maximum likelihood phylogenies were constructed using rapid bootstrap analysis.

RESULTS

Twenty-one C. auris colonized patients were identified. Median turnaround time of colonization detection reduced from 141 h (5.8 days) to approximately 24 h enabling rapid infection-control precautions. Settle plates detected 70-600 cfu/m² around colonized patients over 24 h and air sampling suggested dispersal during turbulent activities. C. auris DNA was detected from 35.7% environmental swabs. Despite being in a high-risk setting, no patients developed invasive infection. Sequencing analysis of isolates from this centre identified two introductions of the South Asian (Clade I) and one of the South African (Clade III) strain.

CONCLUSION

The PCR offers a rapid, scalable method of screening and supports clinical risk reduction in settings likely to encounter multiple introductions.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Protocol for a multicenter prospective cohort study evaluating arthroscopic and non-surgical treatment for microinstability of the hip joint

BACKGROUND

Microinstability of the hip joint is a proposed cause of hip pain and reduced function in young individuals. The underlying mechanism is thought to be extraphysiological hip motion due to bony deficiency and/or soft tissue deficiency or decreased soft tissue function. Recently, the condition has gained increased attention, and despite the fact that treatment today includes both non-surgical and surgical approaches, there is limited evidence on diagnostic specificity and treatment effects. The aim of this study is to evaluate clinical outcomes of both non-surgical and surgical treatment for microinstability of the hip joint.

METHODS

A multicenter prospective cohort study is planned to evaluating the outcome of physical therapy aimed at stabilizing the hip joint, as well as arthroscopic plication of the hip joint capsule, if the physical therapy fails. Outcomes will be evaluated using hip-specific patient-reported outcome measures: the short version of the International Hip Outcome Tool and the Copenhagen Hip and Groin Outcome Score, strength and function tests, health-related quality of life as determined using the European Quality of Life-5 Dimensions and the European Quality of Life-Visual Analog Scale, sports activity levels according to the Hip Sport Activity Scale, and reported complications. Patients will be evaluated at 6, 12 and 24 months after each treatment.

DISCUSSION

It is important to evaluate the clinical outcomes of both non-surgical and surgical treatment for suspected microinstability of the hip joint, and the planned prospective evaluation will contribute to the understanding of non-surgical as well as surgical treatment outcomes, including complications.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04934462 . Registered June 22 2021.

Modernising Orodispersible Film Characterisation to Improve Palatability and Acceptability Using a Toolbox of Techniques

Orodispersible films (ODFs) have been widely used in paediatric, geriatric and dysphagic patients due to ease of administration and precise and flexible dose adjustments. ODF fabrication has seen significant advancements with the move towards more technologically advanced production methods. The acceptability of ODFs is dependent upon film composition and process of formation, which affects disintegration, taste, texture and mouthfeel. There is currently a lack of testing to accurately assess ODFs for these important acceptability sensory perceptions. This study produced four ODFs formed of polyvinyl alcohol and sodium carboxymethylcellulose using 3D printing. These were assessed using three in vitro methods: Petri dish and oral cavity model (OCM) methods for disintegration and bio-tribology for disintegration and oral perception. Increasing polymer molecular weight (MW) exponentially increased disintegration time in the Petri dish and OCM methods. Higher MW films adhered to the OCM upper palate. Bio-tribology analysis showed that films of higher MW disintegrated quickest and had lower coefficient of friction, perhaps demonstrating good oral perception but also stickiness, with higher viscosity. These techniques, part of a toolbox, may enable formulators to design, test and reformulate ODFs that both disintegrate rapidly and may be better perceived when consumed, improving overall treatment acceptability.

Machine Learning and Machine Vision Accelerate 3D Printed Orodispersible Film Development

Orodispersible films (ODFs) are an attractive delivery system for a myriad of clinical applications and possess both large economical and clinical rewards. However, the manufacturing of ODFs does not adhere to contemporary paradigms of personalised, on-demand medicine, nor sustainable manufacturing. To address these shortcomings, both three-dimensional (3D) printing and machine learning (ML) were employed to provide on-demand manufacturing and quality control checks of ODFs. Direct ink writing (DIW) was able to fabricate complex ODF shapes, with thicknesses of less than 100 µm. ML algorithms were explored to classify the ODFs according to their active ingredient, by using their near-infrared (NIR) spectrums. A supervised model of linear discriminant analysis was found to provide 100% accuracy in classifying ODFs. A subsequent partial least square algorithm was applied to verify the dose, where a coefficient of determination of 0.96, 0.99 and 0.98 was obtained for ODFs of paracetamol, caffeine, and theophylline, respectively. Therefore, it was concluded that the combination of 3D printing, NIR and ML can result in a rapid production and verification of ODFs. Additionally, a machine vision tool was used to automate the in vitro testing. These collective digital technologies demonstrate the potential to automate the ODF workflow.

Medicine acceptability for older people in hospital and care home: the influence of setting

OBJECTIVE

Medicines acceptability is likely to have a significant impact on older people's adherence and, consequently, treatment effectiveness. The objective was to explore the influence of setting on medicines acceptability in older people.

METHODS

A multi-centre, prospective, cross-sectional, observational study was conducted in one care home and one elderly care hospital ward in London, UK, involving individuals on ≥1 medicine(s) and aged ≥65 years. Data-driven approach was applied using multiple observer-reported outcomes analysis tool to distinguish between positively and negatively accepted medicines.

KEY FINDINGS

263 observer reports from the care home (n = 97) and hospital ward (n = 166) involving 155 distinct medicinal products were assessed. Collectively, medicines appeared better accepted by patients at the hospital. Differences appeared to be driven by variations in solid oral dosage form (SODF) acceptability. Patients with dysphagia poorly accepted medicines in both settings, as expected. SODFs were unexpectedly better accepted in the hospital than in the care home in patients without dysphagia.

CONCLUSIONS

Medicines acceptability was affected by patient's characteristics, dosage form type and setting. Changes in care practices between care home and hospital may affect medicine administration and lead to variations in the ability and willingness of patients and carers to use the product as intended.

Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery

Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and she was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis.

METHODS

We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the  grading of recommendations, assessment, development, and evaluation system.

RESULTS

Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr.

CONCLUSIONS

Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr.

TRIAL REGISTRATION

PROSPERO (CRD42021238916); registered 25 February 2021.

1602 A Quality Improvement Project on The Management of Patients with Traumatic Head Injury Presenting to A District General Hospital

Introduction

Traumatic Brain Injury (TBI) is associated with morbidity and mortality. All District General Hospitals (DGH) in West Midlands liaise with Neurosurgery centres for management of these patients through a referral system (NORSe). The aim of this study was to assess outcomes in TBI following the implementation of vital interventions.

Method

A retrospective data was collected between 1/1/2019 and 1/12/2020. We included all patients admitted with traumatic brain injury over the age of 16. We accessed the data from the hospital database, clinical notes, and NORSe. A re-audit was performed following implementations of recommendations (proforma and care of elderly input). Further data were collected prospectively.

Results

Our cohort included n1=61 patients (first cycle) and n2= 29 (second cycle). The demographic age and gender were comparable in both cycles. The median time for Neurosurgery advice was 229 minutes (IQR 60-690) in the first cycle as compared to 80 minutes (IQR 40-120, P &lt; 0.05) and the main cause for delay was inadequate information transfer. The mortality rate was 24% (5 were attributed to sepsis), as compared to 14% in the second cycle. The median length of stay (LOS) was 4 days (IQR 3-13.5) in the first cycle, which translates to a cost of £26,815 per quarter. In comparison, LOS was 3 days (IQR 2-4), which translates to the cost of bed occupancy of £12,771 and saving of £14,043 per quarter, in the second cycle.

Conclusions

The introduction of simple interventions in a DGH can help to significantly improve patient outcomes in those admitted with Traumatic brain injury.

P–212 Mitochondrial DNA content shows a significant association with timing of human embryo development and fertility diagnosis in euploid embryos

Study question

Does mitochondrial DNA content (mtDNA) correlate with clinical parameters and embryo morphokinetics using advanced time-lapse technology?

Summary answer

mtDNA correlated with embryo morphokinetics and the growth trajectory of euploid embryos. Maternal age, anti-mullerian hormone level and fertility diagnosis were significantly associated with mtDNA.

What is known already

With the push towards single embryo transfers, laboratories are working to improve embryo selection. In addition to conventional microscopy, preimplantation genetic testing and time-lapse microscopy have been utilized to aid in embryo selection. More recently, as mtDNA may represent the energy potential of an embryo, some data have supported the use of mtDNA as an additional tool. Limited studies have suggested that a lower amount of mtDNA is associated with higher rates of implantation and improved embryo quality.

Study design, size, duration

This is a retrospective chart review. All embryos that underwent preimplantation genetic testing for aneuploidy (PGT-A) between January to December of 2020 were studied.

Participants/materials, setting, methods

Women undergoing in vitro fertilization (IVF) with intracytoplasmic sperm injection undergoing PGT-A were studied. All patients were from a single academic institution. This study exclusively examined the characteristics of euploid embryos. Mitochondrial DNA content was expressed as a ratio of mtDNA:nDNA (MitoScore). Time-lapse imaging was utilized to evaluate embryo development every 15 minutes in 5–7 focal planes. Chi square test and Spearman correlation analysis were performed with a p-value of &lt; 0.05 considered significant.

Main results and the role of chance

A total of 494 embryos from 52 women who underwent 58 IVF cycles were cultured to blastocyst and 331 embryos were biopsied for PGT-A evaluation. Of these, 132 embryos were diagnosed as euploid. A moderate positive correlation was found between MitoScore and time to morula, time to blast and time to expanded blast (correlation value 0.54, 0.50 and 0.54, respectively; p &lt; 0.001). Consistent with this trend, day 5 blastocysts had a significantly lower MitoScore values than day 6 blastocysts (20.2 v. 29.2; p &lt; 0.001). When examining all biopsied euploid embryos, no significant association was found between MitoScore, blastocyst maturity, trophectoderm or inner cell mass scores.

Our data also demonstrated a positive correlation between MitoScore and maternal age (correlation factor 0.33; p &lt; 0.001). A negative association between MitoScore and serum anti-mullerian hormone levels (correlation factor –0.20; p &lt; 0.021) was also noted. Of particular interest was the significant association between fertility diagnosis and mitochondrial score (p &lt; 0.001).

Even amongst euploid embryos, mtDNA content varied widely, potentially reflecting differences in embryo potential and quality. Additionally, the significant difference in MitoScore between that day 5 and day 6 blastocysts may reflect a fundamental difference in cytoplasmic characteristics and requires further study.

Limitations, reasons for caution

Due to the study cohort of euploid embryos undergoing PGT-A, this study was biased for the selection of high grade embryos. This limited diversity in embryo quality may have masked other potential associations between mitochondrial content and blastocyst quality.

Wider implications of the findings: mtDNA may be additional tool aiding in embryo selection as IVF labs work to improve pregnancy rates while minimizing the risks of transferring multiple embryos. To our knowledge, this is the largest study assessing the relationship of mtDNA content of blastocysts and the timing of embryo development using time-lapse imaging.

Trial registration number

None

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients: A systematic review with meta-analysis and trial sequential analysis of randomised controlled trials

BACKGROUND

Central neuraxial modalities can occasionally be challenging to perform, particularly if the underlying anatomy is altered or obscured.

OBJECTIVES

To compare the efficacy, efficiency and the safety of preprocedural ultrasound to landmark palpation in the nonobstetric adult population.

DESIGN

Systematic review of randomised controlled trials with meta-analysis and trial sequential analysis.

DATA SOURCES

Systematic search of Central, CINAHL, Embase, Global Health, MEDLINE, Scopus and Web of Science to 13th February 2020.

ELIGIBILITY CRITERIA

Randomised controlled trials of nonobstetric adult patients having diagnostic and/or therapeutic neuraxial procedures using standard preprocedural ultrasound interpreted by the operator as the intervention and conventional landmark palpation as the comparator.

KEY DEFINITIONS

A skin puncture was defined as the insertion or reinsertion of the needle through the skin; needle redirection was the backward followed by the forward movement of the needle without its removal from the skin; first skin puncture referred to a single skin puncture with or without needle redirections; and first pass was a single skin puncture with no needle redirection.

RESULTS

In all, 18 randomised controlled trials with 1800 patients were included. The first pass success rate was not different between landmark and ultrasound methods [risk ratio 1.46; 95% confidence interval (CI), 0.99 to 2.16; P = 0.06, I2 = 76%; moderate quality of evidence] and the trial sequential analysis demonstrated the futility of further randomisation of patients in modifying this finding. Preprocedural ultrasound increased the total time taken (mean difference 110.8 s; 95% CI, 31.01 to 190.65; P = 0.006; I2 = 96%; moderate quality of evidence). Subgroup analyses revealed no influence of the predicted difficulty of the neuraxial procedure on outcomes. Compared with the landmark method, ultrasound increased the first skin puncture success rate (risk ratio 1.36; 95% CI, 1.18 to 1.57; P < 0.001; I2 = 70%), and decreased the need for three or more skin punctures (risk ratio 0.46; 95% CI, 0.33 to 0.64; P < 0.001; I2 = 29%) and the number of needle redirections (mean difference -1.24; 95% CI, -2.32 to -0.17; P = 0.020; I2 = 83). The incidence of bloody tap was reduced with the use of ultrasound (risk ratio 0.61; 95% CI, 0.40 to 0.93; P = 0.020; I2 = 42%).

CONCLUSIONS

The use of preprocedural ultrasound for neuraxial procedures in the nonobstetric adult population did not enhance the first pass success rate and increased the total time taken to a clinically insignificant extent. Improvement in secondary outcomes, including other markers of efficacy, should be interpreted with caution.

Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis

BACKGROUND

Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised.

METHODS

CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced.

RESULTS

Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat.

CONCLUSIONS

Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.

Infiltration between the popliteal artery and the capsule of the knee (IPACK) block in knee surgery: a narrative review

BACKGROUND

The infiltration between the popliteal artery and the capsule of the knee (IPACK) block has been described as an alternative analgesic strategy for knee pain.

OBJECTIVE

Our aim was to perform a narrative review to examine the place and value that the IPACK block has in comparison to and in conjunction with other regional anesthesia modalities.

EVIDENCE REVIEW

Following an extensive search of electronic databases, we included anatomical studies, letters, comparative observational studies, and non-randomized and randomized controlled trials that examined the IPACK block in relation to surgery on the knee under general or neuraxial anesthesia.

FINDINGS

In all, 35 articles were included. Cadaveric studies demonstrated the potential for injected dye to spread to the nerves responsible for the innervation of the posterior as well as anteromedial and anterolateral aspects of the knee. Of the comparative observational studies (n=15) and non-randomized (n=1) and randomized controlled trials (n=13), 2 and 27 were conducted in the context of anterior cruciate ligament reconstruction and knee replacement surgery, respectively. The role of the IPACK block with each different permutation of regional anesthesia techniques was investigated by a small number of studies. Clinical studies, in the setting of knee replacement surgery, revealed variation in the manner in which the IPACK block was performed, and indicated the possible superiority of distal injection at the level of the femoral condyles for the management of posterior knee pain. Evidence suggested the following: the IPACK block in combination with single shot adductor canal block (ACB) may be beneficial for analgesic and functional outcomes; in conjunction with single shot or continuous ACB, the IPACK block might be superior to local infiltration analgesia (LIA); and functional outcomes may be improved with the supplementation of continuous ACB and LIA with the IPACK block. The IPACK block did not commonly result in the occurrence of foot drop. Relative to tibial nerve block (TNB), the IPACK block reduced the occurrence of foot drop and increased the proportion of patients who were able to be discharged on the third postoperative day.

CONCLUSIONS

The IPACK block was potentially complementary to the ACB and might be preferable to the TNB as a motor-sparing regional anesthesia technique in knee surgery. Definitive recommendations were not reached in the presence of the heterogeneous and limited evidence base.

822 Lessons Learnt During the COVID-19 Pandemic on Emergency Surgical Admissions in A District General Hospital

Introduction

Coronavirus disease (COVID-19) is an acute severe respiratory distress syndrome which resulted in an unprecedented impact on NHS service provision. We aimed to assess the impact of COVID-19 on general surgical services in a district general hospital.

Method

Electronic health care record data was retrospectively collected from 6th of April to 6th of May for both 2019 and 2020.

Results

Despite fewer referrals and admissions in 2020 (133 vs 177 admissions in 2019), there were more failed discharges (29 vs 17 in 2019) and higher associated costs. Higher numbers of biliary related pathologies and pancreatitis (50 in 2020 vs 25 in 2019), and fewer complaints of non-specific abdominal pain (10 in 2020 vs 22 in 2019) were observed. The use of outpatient investigations decreased by approximately 40% in 2020; however, utilisation of inpatient investigations was comparable.

Conclusions

Better utilisation of outpatient investigations and virtual clinic services may surmount pressures from further peaks of COVID-19. The increase in biliary related cases and pancreatitis may be consequent upon lifestyle changes during lockdown. This merits further investigation and if appropriate, public health intervention. In the absence of an efficacious vaccine, further research would be essential to streamline general surgical services based on clinical risk stratification.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

STUDY OBJECTIVE

Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery.

DESIGN

Systematic review and network meta-analysis.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients scheduled for breast surgery under general anesthesia.

INTERVENTIONS

Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced.

MEASUREMENTS

Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status.

MAIN RESULTS

In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques.

CONCLUSIONS

In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review

Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8-14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1-0.2 mg.kg^-1 for all patients undergoing surgery associated with significant postoperative pain.

Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis

PURPOSE

The incidence of difficult and failed intubation is higher in obstetrical patients than in the general population because of anatomic and physiologic changes in pregnancy. Videolaryngoscopy improves the success rate of intubation and reduces complications when compared with direct laryngoscopy in adults; however, it is not known whether this extends to obstetrical surgery. The aim of this study was to examine the efficacy, efficiency, and safety of videolaryngoscopy compared with direct laryngoscopy in obstetrics.

SOURCE

Central, CINAHL, Embase, MEDLINE and Web of Science databases were searched from inception to 27 May 2020 with no restrictions. Inclusion criteria included randomized-controlled trials (RCTs), observational studies, case series, and case reports that reported the application of videolaryngoscopy to intubate the trachea in pregnant patients having general anesthesia.

PRINCIPAL FINDINGS

Overall, four RCTs with 428 participants, nine observational studies, and 35 case reports/series with 100 participants were included. On meta-analysis of three trials, the co-primary outcomes of first-attempt success rate (risk ratio, 1.02; 95% confidence intervals [CI], 0.98 to 1.06; P = 0.29; I2 = 0%) and time to tracheal intubation (mean difference, 1.20 sec; 95% CI, -6.63 to 9.04; P = 0.76; I² = 95%) demonstrated no difference between videolaryngoscopy and direct laryngoscopy in parturients without difficult airways. Observational studies and case reports underline the role of videolaryngoscopy as a primary choice when difficulty with tracheal intubation is expected or as a rescue modality in difficult or failed intubations.

CONCLUSIONS

Evidence for the utility of videolaryngoscopy continues to evolve but supports its increased adoption in obstetrics where videolaryngoscopes should be immediately available for use as a first-line device.

TRIAL REGISTRATION

PROSPERO (CRD42020189521); registered 6 July 2020.

'Big Data' informed drug development: a case for acceptability

Data, which help inform various stages of drug product development, are increasingly being collected using newer, more novel platforms, such as mobile applications, and analysed computationally as much larger 'Big Data' data sets, revealing patterns relating to human behaviour and interactions. Medicine acceptability gauges the ability and willingness of patients to take their dosage forms. It has become a crucial human component of drug product design. Vouching for the age appropriateness of medicinal products, acceptability related data are now expected by regulatory bodies. Shifting from traditional paper-based to electronic data-gathering platforms will allow the pharmaceutical industry to collect real-world, real-time, clinically relevant data, capable of informing current and future drug product development, reducing time and cost, and setting foundations for patient-centric drug product design.

Incidence and outcomes of healthcare-associated COVID-19 infections: significance of delayed diagnosis and correlation with staff absence

BACKGROUND

The sudden increase in COVID-19 admissions in hospitals during the SARS-CoV-2 pandemic of 2020 led to onward transmissions among vulnerable inpatients.

AIMS

This study was performed to evaluate the prevalence and clinical outcomes of healthcare-associated COVID-19 infections (HA-COVID-19) during the 2020 epidemic and study factors which may promote or correlate with its incidence and transmission in a Teaching Hospital NHS Trust in London, UK.

METHODS

Electronic laboratory, patient and staff self-reported sickness records were interrogated from 1st March to 18th April 2020. HA-COVID-19 was defined as COVID-19 with symptom onset within >14 days of admission. Test performance of a single combined throat and nose swab (CTNS) for patient placement was calculated. The effect of delayed RNA positivity (DRP, defined as >48 h delay), staff self-reported COVID-19 sickness absence, hospital bed occupancy, and community incidence of COVID-19 was compared for HA-COVID-19. The incidence of other significant hospital-acquired bacterial infections (HAB) was compared with previous years.

RESULTS

Fifty-eight HA-COVID-19 (7.1%) cases were identified. When compared with community-acquired admitted cases (CA-COVID-19), significant differences were observed in age (P=0.018), ethnicity (P<0.001) and comorbidity burden (P<0.001) but not in 30-day mortality. CTNS-negative predictive value was 60.3%. DRP was associated with greater mortality (P=0.034) and incidence of HA-COVID-19 correlated positively with DRP (R = 0.7108) and staff sickness absence (R = 0.7815). For the study period HAB rates were similar to the previous 2 years.

CONCLUSIONS

Early diagnosis and isolation of COVID-19 patients would help to reduce transmission. A single CTNS has limited value in segregating patients into positive and negative pathways.

Mortality and readmission in non-ischemic compared with ischemic cardiomyopathies after implantable cardioverter-defibrillator implantation

Background/Introduction

Uncertainty remains regarding the benefit of primary prevention ICDs overall in contemporary practice, and particularly in those with NICM compared with ICM.

Purpose

To evaluate the contemporary risk of death and readmission following following implantable cardioverter-defibrillator (ICD) implantation in patients with non-ischemic cardiomyopathies (NICM) compared with ischemic cardiomyopathies (ICM) in a large nationally representative cohort in the United States.

Methods

We used data from the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ICD Registry linked with Medicare claims from April 1, 2010 to December 31, 2013 to establish a cohort of NICM and ICM patients with a left ventricular ejection fraction ≤35% who received a de novo, primary prevention ICD. We compared mortality, all-cause readmission, and heart failure readmission using Kaplan-Meier curves and Cox proportional hazard regressions models. We also evaluated temporal trends in mortality.

Results

Among 31,044 NICM and 68,458 ICM patients with a median follow up of 2.4 years, one-year mortality was significantly higher in ICM patients (12.3%) compared with NICM (7.9%, p&lt;0.001). The higher mortality in ICM patients remained significant after adjustment for covariates (hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.36 to 1.45), and was consistent in subgroup analyses. These findings were consistent across the duration of the study. ICM patients were also significantly more likely to be readmitted for all causes (adjusted HR 1.15, CI 1.12 to 1.18) and for heart failure (adjusted HR 1.25, CI 1.21 to 1.31).

Conclusions

The risks of mortality and hospital readmission after primary prevention ICD implantation were significantly higher in patients with ICM compared with NICM, and these findings were consistent across all patient subgroups tested and over the duration of the study.

Funding Acknowledgement

Type of funding source: None

Conventional landmark palpation vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetrics - a systematic review and meta-analysis with trial sequential analyses

The aim of this systematic review and meta-analysis was to examine the efficacy, time taken and the safety of neuraxial blockade performed for obstetric patients with the assistance of preprocedural ultrasound, in comparison with the landmark palpation method. The bibliographic databases Central, CINAHL, EMBASE, Global Health, MEDLINE, Scopus and Web of Science were searched from inception to 13 February 2020 for randomised controlled trials that included pregnant women having neuraxial procedures with preprocedural ultrasound as the intervention and conventional landmark palpation as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenszel method. In all, 22 trials with 2462 patients were included. Confirmed by trial sequential analysis, preprocedural ultrasound increased the first-pass success rate by a risk ratio (95%CI) of 1.46 (1.16-1.82), p = 0.001 in 13 trials with 1253 patients. No evidence of a difference was found in the total time taken between preprocedural ultrasound and landmark palpation, with a mean difference (95%CI) of 50.1 (-13.7 to 113.94) s, p = 0.12 in eight trials with 709 patients. The quality of evidence was graded as low and very low, respectively, for these co-primary outcomes. Sub-group analysis underlined the increased benefit of preprocedural ultrasound for those in whom the neuraxial procedure was predicted to be difficult. Complications, including postpartum back pain and headache, were decreased with preprocedural ultrasound. The adoption of preprocedural ultrasound for neuraxial procedures in obstetrics is recommended and, in the opinion of the authors, should be considered as a standard of care, in view of its potential to increase efficacy and reduce complications without significant prolongation of the total time required.

An Unusual Cause of Intraoperative Hemodynamic Instability Complicating Elective Mastectomy With Immediate Free Flap Reconstruction: A Case Report

Extrinsic compression of the heart consequent to intrapleural fluid is a rare cause of cardiac tamponade. Cases of massive hemothorax resulting in external cardiac tamponade due to injury of the internal thoracic artery (ITA) following blunt or penetrating trauma have been described in the literature. Here, we present a case of iatrogenic injury to the right ITA complicating mastectomy and deep inferior epigastric perforator flap reconstruction. It manifested as hemodynamic instability that persisted despite aggressive fluid resuscitation. Investigation with an intraoperative transesophageal echocardiogram demonstrated cardiac tamponade secondary to a massive hemothorax which resolved following surgical placement of an intercostal drain.

Caudal analgesia versus abdominal wall blocks for pediatric genitourinary surgery: systematic review and meta-analysis

Background

Caudal block is a well-established technique for providing perioperative analgesia in pediatric genitourinary surgery, but abdominal wall blocks such as ilioinguinal–iliohypogastric (II-IH) and transversus abdominis plane (TAP) block are increasingly being used.

Methods

Our protocol for this meta-analysis was registered on PROSPERO (CRD42020163497). Central, CINAHL, Embase, Global Health, LILACS, MEDLINE, Scopus and Web of Science were searched from inception to 11 December 2019 for randomized controlled trials that included pediatric patients having genitourinary surgery with II-IH or TAP block as the intervention and caudal analgesia as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenzel method.

Results

In all, 23 trials with 1399 patients were included. II-IH and TAP block were similar to caudal analgesia in the coprimary outcomes of the postoperative pain score at 0–2 hours (high-quality evidence) and the need for in-hospital rescue analgesia (moderate-quality evidence consequent to downgrading by publication bias). No subgroup differences in regard to the type of abdominal wall block or the method of block localization were demonstrated for these primary outcomes. Relative to caudal analgesia, II-IH and TAP block reduced the incidence of postoperative motor blockade and the time to micturition.

Conclusions

This meta-analysis was limited by unclear risk of selection and performance biases and significant heterogeneity. In summary, II-IH and TAP block are a non-invasive and reasonable alternative to caudal analgesia in pediatric genitourinary surgery.

Addressing a national crisis: the spine hospital and department's response to the COVID-19 pandemic in New York City

In a very brief period, the COVID-19 pandemic has swept across the planet leaving governments, societies, and healthcare systems unprepared and under-resourced. New York City now represents the global viral epicenter with roughly one-third of all mortalities in the United States. To date, our hospital has treated thousands of COVID-19 positive patients and sits at the forefront of the United States response to this pandemic. The goal of this paper is to share the lessons learned by our spine division during a crisis when hospital resources and personnel are stretched thin. Such experiences include management of elective and emergent cases, outpatient clinics, physician redeployment, and general health and wellness. As peak infections spread across the United States, we hope this article will serve as a resource for other spine departments on how to manage patient care and healthcare worker deployment during the COVID-19 crisis.