39 Virtual Clinics in Foot & Ankle Surgery: Patient and Clinician Perceptions and Review of The Literature

Aim

The COVID 19 worldwide pandemic has led to the popularisation of, “Virtual” clinics. Within orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

Method

A cross sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted from two weeks after their consultation by telephone with a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle also completed a 10-point questionnaire.

Results

100 patient responses were collected. Patient satisfaction with virtual clinics was positive, 65% were very happy (Likert scale rating 5). >90% of patients felt they received enough information, felt involved, felt it was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation. 22% would have preferred a video consultation. Clinician responses were more cautious, 60% were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

Conclusions

Virtual clinics may be more convenient for patients with high satisfaction levels but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow up patients. Virtual clinics are not appropriate for new patient referrals.

824 UK CoPACK Study: Health Care Workers Knowledge and Confidence in Using Personal Protective Equipment (PPE) And Related Anxiety Levels During The COVID-19 Pandemic

Aim

The COVID-19 pandemic has resulted in significant pressures on the NHS. Healthcare workers (HCWs) are at increased risk of infection. Personal protective equipment (PPE) lowers the risk of infection transmission. However, during the early phases of the pandemic, the information available regarding COVD-19 and the use of PPE has been unclear, with constantly changing guidelines. The aim of this study was to determine the knowledge and confidence about PPE usage among HCWs, in addition to measuring their anxiety levels during the COVID pandemic.

Method

A validated questionnaire was distributed among HCWs in as many UK hospitals as possible, during April 2020. The questionnaire consisted of 13 questions regarding demographics, knowledge on PPE guidance, HCW training and confidence levels in PPE usage and finally anxiety levels measured using the GAD-7 psychometric tool.

Results

1055 responses were received. Nurses (49%), Healthcare Assistants (HCA - 20%), Doctors (17%), Physios (8%) and other (6%). 99% of respondents indicated they were familiar with PPE guidance, but only 1.6% answered all 3 questions on PPE guidance accurately. 86.4% of respondents received mask-fitting checks. 79.7% received donning-doffing training. Despite this, only 46.8% were confident on their familiarity with PPE. 32.5% felt that their hospital communication regarding PPE policy during COVID-19 pandemic was poor or very poor. 30% HCWs experienced severe anxiety.

Conclusions

National guidance and local training on PPE usage during the COVID-19 pandemic has been unsatisfactory, leading to higher anxiety among HCWs. Improved information delivery and training are essential in preparation for the second wave and future pandemics.

Virtual clinics in foot and ankle surgery: patient and clinician perceptions

BACKGROUND

The worldwide COVID-19 pandemic has led to the popularisation of 'virtual' clinics. In orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

METHODS

A cross-sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted by telephone from two weeks after their consultation and asked to complete a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle completed a 10-point questionnaire.

RESULTS

One hundred patient responses were collected. Patient satisfaction with virtual clinics was positive, with 65% of respondents reporting they were very happy (Likert scale rating 5). More than 90% of patients felt they received enough information, felt involved, felt the virtual clinic was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation, and 22% would have preferred a video consultation. Clinician responses were more cautious, with 60% stating they were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

CONCLUSIONS

Virtual clinics may be more convenient for patients, with high satisfaction levels reported, but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow-up. Virtual clinics are not appropriate for new patient referrals.

145 THE INFLUENCE OF PROPYLENE GLYCOL DRENCHING ON THE SUPEROVULATORY RESPONSE AND EMBRYO QUALITY IN HIGH-YIELDING DAIRY COWS

Genetic improvement of dairy cows increased markedly over the last decades; this has marked increased milk yield, which has been associated with reduced fertility parameters. The objective of this study was to determine the effects of feeding propylene glycol (PG) on superovulatory responses of 50 dairy cows and on their embryo quality and quantity. Starting at 1 week before the application of superovulatory regimen, each cow received once daily an oral dose of 150 g of PG (PG group) or water (control group). All cows were superovulated with a total dose of 400 mg of FSH administrated twice daily in decreasing doses over 4 consecutive days. Embryos were recovered nonsurgically 7.5 days after the onset of oestrus using a 2-way catheter. Evaluation of embryo quality was done according to the IETS manual based on 1 to 4 grades. Grade 1 embryos were transferred after freezing; grade 2 and 3 embryos were freshly transferred. The results showed that the number of total ova/embryos recovered, grade 1 embryos, and the number of transferable embryos were significantly higher (P = 0.048, 0.015, and 0.014, respectively) in the PG group (10.33 ± 1.9, 7.08 ± 1.7, and 7.92 ± 1.6, respectively) when compared with control group (6.09 ± 0.9, 2.11 ± 0.45, and 3.92 ± 1.25, respectively). Insignificant increase in grade 2 and grade 3 embryos was indicated in the control group (1.37 ± 0.3 and 0.51 ± 0.18, respectively) when compared with PG group (0.75 ± 0.28 and 0.25 ± 0.13, respectively). On the other hand, the results indicated that there was an increase in the number of degenerated embryos and unfertilized ovum in the PG group (2.33 ± 0.85) compared with control group (2.09 ± 0.6). In conclusion, these results suggested that administration of PG has the ability to positively improve the superovulatory response and embryo quality in high-yielding dairy cows.

Approaching the community about screening children for a multicentre malaria vaccine trial

Community sensitisation, as a component of community engagement, plays an important role in strengthening the ethics of community-based trials in developing countries and is fundamental to trial success. However, few researchers have shared their community sensitisation strategies and experiences. We report on our perspective as researchers on the sensitisation activities undertaken for a phase II malaria vaccine trial in Kilifi District (Kenya) and Korogwe District (Tanzania), with the aim of informing and guiding the operational planning of future trials. We report wide variability in recruitment rates within both sites; a variability that occurred against a backdrop of similarity in overall approaches to sensitisation across the two sites but significant differences in community exposure to biomedical research. We present a range of potential factors contributing to these differences in recruitment rates, which we believe are worth considering in future community sensitisation plans. We conclude by arguing for carefully designed social science research around the implementation and impact of community sensitisation activities.

A new surgical strategy for breast conservation in locally advanced breast cancer that achieves a good locoregional control rate: preliminary report

The scope of breast conserving surgery has recently expanded to include locally advanced breast cancer (LABC) patients who are downstaged following neoadjuvant chemotherapy (NACT). However, the efficacy of this approach in achieving adequate locoregional control of disease is in doubt. Some reports have attributed the failure to the association of NACT-induced tumour downstaging which can leave multifocal in situ and invasive lesions around the main tumour mass. In the present study, in order to eradicate all possible tumour satellites, a very wide local excision that included the whole original tumour-bearing area was performed regardless of the expected wide defect. This defect was then immediately reconstructed by an ipsilateral pedicled latissimus dorsi myocutaneous (LDM) flap. The study included 26 patients with LABC without evidence of primary tumour-multicentricity. Tumours were downstaged following NACT. The early cosmetic outcome was good in the majority of cases. Early complications were minimal. Twenty-two patients had a mean follow up period of 30.2 (range 7-50) months. In those evaluable cases, locoregional control of the disease was excellent (100%) but distant metastases occurred in seven cases (31.8%).

Severe jaundice in Sweden in the new millennium: causes, investigations, treatment and prognosis

BACKGROUND

The aims of the study were to assess the causes of jaundice in Gothenburg, Sweden, to study the types of investigations applied in cholestatic and hepatocellular types of jaundice and treatment and to evaluate the prognosis of these patients up to a year from the diagnosis.

METHODS

Over a 3-month period, all adult patients with bilirubin > 100 micromol/l were identified by the clinical chemistry laboratory serving all three hospitals in Gothenburg. Relevant clinical information was obtained from medical records. Follow-up was performed 9-12 months later.

RESULTS

A total of 173 patients were identified; 40% were under surgical care while 38% were in the care of internists. The most common cause of jaundice was malignancy in 58 patients, liver metastases in 20, cholangiocarcinoma in 16, pancreatic cancer in 13, cancer of papilla Vateri in 2 and primary liver cancer in 7. Alcoholic liver disease was the second most common cause, found in 29 patients, followed by bile duct stones (28 patients). Only 3% had viral hepatitis. Ultrasound and/or CT were performed in 95% of those with cholestasis and ultrasound had been performed in 75% of those with hepatocellular type and CT in almost 50%. Thirty-two patients were operated on, 27 patients were treated endoscopically and 17 patients required liver transplantation. Total mortality was 51% and in malignancy 82%.

CONCLUSION

Malignancy and alcoholic liver disease are the most common causes of severe jaundice, whereas viral hepatitis is a rare cause. Many patients are under surgical care, probably due to historical reasons as surgery is rarely indicated.

A review of Hib epidemiology in Asia

Meningitis due to an invasive Haemophilus influenzae type b (Hib) infection, has been previously perceived to be relatively uncommon in Asia. However, the incidence of disease and its impact may have been underestimated. In addition to a lack of microbiological facilities in some hospitals, difficulties in culturing the organism and the widespread use of antibiotics may have hidden the true incidence of the disease in some countries. Furthermore, the reported disease burden probably underestimates the incidence of Hib pneumonia. The epidemiology of invasive Hib disease for various Asian nations is reviewed in this paper. Hospital-based studies show that Hib is a major cause of bacterial meningitis and/or pneumonia in the Philippines, India, Thailand, Malaysia, Indonesia and Vietnam. Singapore and Hong Kong have a low incidence of infection compared with Western and other Asian nations. This low incidence is not due to a higher level of natural protective antibodies, but may be related to an interaction between environmental and genetic factors. Therefore the widespread belief that Hib infection is unimportant in Asia does not refer to Asia as a whole and possibly to Chinese patients only, and failure to recognize this has serious implications. The inclusion of Hib vaccine in the routine infant immunization schedule in many industrialized nations has significantly reduced the incidence of invasive disease. Recent studies have shown Hib vaccination is also effective in preventing invasive disease in children in developing countries. While population-based data may be required to confirm the need for public-funded infant Hib immunization in Asia, its introduction in countries with a high incidence of Hib meningitis and/or pneumonia has the potential to significantly improve pediatric health and survival.

The efficacy of phenobarbital in controlling epilepsy in children

Most of the new anti epileptic drugs are hard to find and expensive to be used in developing countries. We prefer phenobarbital as the first line drug because it is easily available and quite cheap. In 1986 we had 117 cases of epilepsy, excluding infantile spasms, that were treated with phenobarbital as the first line drug and had been followed up regularly from 6 months to 10 years. The cases consisted of 54 boys and 63 girls; the age of the initial visit varied between 5 months and 12 years. Overall, good results were obtained in 73 cases (62.40%), fair result in 9 cases (7.69%) and poor in 35 cases (29.91%). In relation to the type of seizures, good results occurred in 72.60% of grand-mal type, 60% of absences, 43.75% of complex partial seizures and 47.05% of partial seizures secondarily generalized. The results in myoclonic and akinetic types were poor to fair. Better results were also found in group with normal neurological status and in group without spikes in EEG examination. In only 2 cases had their phenobarbital discontinued due to its intolerable side effects. Otherwise, the only indication to change phenobarbital to other anticonvulsant was the persistence of seizures for more than 75%. We concluded that in spite of its disadvantages, phenobarbital is still good to be used as the first line drug in the treatment of epilepsy, especially in developing countries.

Guillain Barre syndrome in children: clinical manifestations, laboratory findings, and the results of steroid treatment

We report 28 cases diagnosed as GBS in the Department of Child Health, Medical School, University of Indonesia, DR. Cipto Mangunkusumo General Hospital in 7 years period. There were 17 males and 11 females with a ratio of 1.5:1. The age ranged from 9 months to 9.5 years, with a mean age of 4.57 +/- 2.36 years. Twelve (42.86%) cases were preceded by acute respiratory infection, 8 (28.57%) cases by non specific fever, 1 (9.57%) case by gastrointestinal tract infection and 7 (25%) cases did not have any history of acute infection. The clinical manifestations were motor weakness (100%), cranial nerves involvement (14.29%) and disturbance of sensation (17.80%). Most cases (92.86%) showed albuminocytologic dissociation feature with the CSF protein content more than 40 mg/dl. The number of cells was less than 10 cells/mm3 in 96.43% of cases. The specific NCV feature (peripheral NCV decrease) was found in 96.15% of patients and only 1 patient (3.85%) showed normal peripheral NCV. The severity of the disease was in accordance with the prognosis later. Corticosteroid was not beneficial in the treatment of GBS.

Some clinical aspects of periventricular-intraventricular hemorrhage (PVH-IVH) in the newborns

Twenty seven cases of neonatal intracranial PVH-IVH were studied. Twenty-three (83.3%) cases were born with birth weight of less than 2,500 grams; out of which 8 (29.7%) had birth weight of less than 1,500 grams. Twenty (74.1%) cases were born after less than 37 weeks gestation, and 7 (25.9%) were born after more than 37 weeks of gestation. Out of the 18 cases with known Apgar scores, 11 (61.1%) were born with asphyxia. We could not make any conclusion on the correlation between mortality of newborn infants with PVH-IVH and severity of the bleeding, as most of them had other associated illness as well, which may directly or indirectly affect the mortality.

A case of Rett syndrome

A case of Rett syndrome in a-3 1/2 year-old girl is presented. The patient had normal pre and perinatal period and normal psychomotor development till the age of 14 months, followed by behavioural, social and psychomotor regression. Physical examination revealed a below normal head circumference, loss of eye and psychic contact, stereotypic hand movements and gait disturbance. No laboratory test can confirm the diagnosis of Rett syndrome, therefore the diagnosis was established by virtue of history of illness and clinical manifestations. This is the first case of Rett syndrome found and reported in Indonesia.

Longterm follow-up on patients with subdural effusions

Seventy-two patients with subdural effusions who had been hospitalized in the Department of Child Health, Dr. Cipto Mangunkusumo General Hospital, Jakarta, were followed up for at least one year. Of the 72 patients, 35 were included nn this evaluation. Of the 35 patients, 16 were caused by purulent meningitis, and 19 by other diseases. On follow up examination comparison was made between the prognosis of patients with subdural effusions which dried in less than 2 weeks and subdural effusions which dried in more than 2 weeks or the patient who was asked to be discharged before the subdural effusions dried. The conclusion is that the former group has less neurological deficit, epileptic seizures, motoric and mental retardation than the latter. The prognosis is worse in patients with subdural effusions of long duration.

Subdural effusion complicating purulent meningitis

The purpose of this paper is toevaluate the incidence, sex, age, nut-ritional condition, finding the effusi-on, mortality and, clinical signs andsymptoms which can support the di-agnosis of subdural effusion.

Post-encephalitis treatment with encephabol

The purpose of this investigation is to evaluate the effect of encephabol as seen from the clinical, psychological and electroencephalographical points of view on patients suffering from post-encephalitis and also whether side effects may occur. For comparison and as a control vitamins of the B-complex group which are related to encephabol are given to some patients.

Some aspects of neonatal convulsions

The purpose of this paper is to review and evaluaute the clinical dataon incidence, sex, body-weight, morbidity and mortality and the possible etiology of convulsions occurring in the neonatal period (i.e. the first 30 days of life) and to study the outcome in follow up examination at the age of more than 6 months. The age of 6 months is taken as a limit because previous experiences and those of other authors (Billing, 1964) have shown that only after the age of 6 months neurological and mental disorders remain evident and permanent.