Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

EP.TH.447Simultaneous repair of bilateral Inguinal hernia under Local Anaesthetic - is it feasible?

Introduction

Local Anaesthetic repair of unilateral Inguinal hernia is well reported in the literature, as a safe, well tolerated and effective operation. However, there is not much literature on simultaneous repair of bilateral inguinal hernias under local anaesthetic. We are reporting our experience with simultaneous repair of bilateral inguinal hernias under local anaesthetic.

Methods

We did a retrospective analysis of prospectively collected data of patients, who had bilateral inguinal hernia repaired under local anaesthetic over a period of 2009 - 2019, looking at the patient demographics, patient reported pain score, operating time, volume of local anaesthetic used, patient satisfaction and complication rates.All the patients had Lichtenstein's hernioplasty. The LA mixture was made up of 30ml 0.5% Bupivacaine with adrenaline, 20 ml 2% Lignocaine with adrenaline, 50 ml of 0.9% Saline and 6 ml of 8.6% Sodium Bicarbonate. All these surgeries were performed on a day case basis.

Results

There were 24 patients, who underwent local anaesthetic repair of bilateral inguinal hernias, 22 Males and 2 Females. Age range was 35 - 81 years. The BMI varied from 18 - 30, with a mean of 24. The average operating time was 66.8 minutes (38 - 120 minutes, median 60 min). The mean pain score was 24, on a 0-100 scale. Patient satisfaction scores varied from 50-100 (Median 90, Mean 88.1)

Conclusion

We conclude that successful simultaneous repair of bilateral inguinal hernia under local anaesthetic is feasible, with a low level of patient discomfort, high satisfaction rate and using safe quantities of local anaesthetic

TP1.2.7The stuck colonoscope

Background

With the increased awareness and push for earlier diagnosis of colorectal cancer, the number of patients undergoing colonoscopy is increasing. Being a common condition, a number of these patients will have herniae. We describe a rare complication during a Sigmoidoscopy in a patient with an Inguinal hernia.

The case

A 75-year-old man was booked for a flexible sigmoidoscopy for rectal bleeding. The scope was successfully inserted to the Splenic flexure. During withdrawal, the scope stopped moving. It was still possible to advance the scope, but not to withdraw. The patient confirmed the presence of a left inguinal hernia. Physical examination and the position on magnetic scope imager confirmed the loop in the hernia.

Various manoeuvres to withdraw the scope were unsuccessful. A colleague was called for a second opinion. We came up with a plan to maintain a ‘long loop‘ position in the hernia, by holding the scope through the scrotum and allowing it to slide on withdrawal. This was successful and the patient was discharged.

Discussion

Incarceration of the scope in the hernia occurs when the hernial defect permits entry and exit of the scope, leaving a loop in the hernia, in a long loop position. During withdrawal, the configuration changes to a short loop, crowding the hernial defect, preventing the scope from sliding. On searching literature, we found that this technique has been described by Koltun et al and is known as the “Pulley” technique. We suggest that colonoscopists are familiar with this technique.

EP.WE.453Impact of COVID 19 pandemic on colorectal rapid access investigations

Aim

The impact of the COVID-19 pandemic on delays in diagnosis of cancer has been highlighted at a national level. Such a delay represents an ongoing source of mortality and morbidity missing from the COVID-19 statistics. This study examines the delay in investigation of patients referred to the urgent colorectal cancer referral service at a single centre.

Method

Retrospective data was collated from prospective database for all 1,894 referrals to the urgent colorectal cancer referral service for the period 21 January to 24 December 2020. The time to appointment (TTA) was compared by date of referral and outcome type (endoscopy, CT abdomen pelvis (CT-AP), CT colonography (CT-C), clinic appointment).

Results

Across 2020, fewer than 25% of patients met the NICE recommendation of appointment within 14 days (median TTA 30 days, first quartile 19). TTA increased dramatically in the first months of the pandemic (February median: 19; March: 80.5). TTA remained high, not falling below a median wait of 28 days until November. CT-C tests were particularly delayed (median TTA: 86) due to concerns regarding aerosol generation and COVID-19 transmission. Patients were offered CT-AP tests while awaiting their delayed CT-C, as CT-AP had a significantly better wait of 15 days.

Conclusion

COVID-19 was a major disruptor of colorectal cancer diagnosis in 2020, with patients waiting more than twice as long as NICE recommends. This will likely continue into 2021, with further research required to assess the impact of this disruption on mortality and morbidity.

EP.TU.465Role of CT scan as initial investigation in colorectal rapid access patients

Background

We looked into CT colonoscopies and CT abdomen and pelvis which were booked as initial investigation in patients referred via the colorectal rapid access pathway. These tests were directly booked following the referral after a nurse led triage.

As per our colorectal straight to test protocol (STT) any patients over the age of 75 or unfit individuals will have a CT colonoscopy (virtual colonoscopy) instead of colonoscopy. CT trunk was used during COVID pandemic as the initial investigation when the aerosol generating procedures were stopped. CT trunks are also the initial investigation as per the STT protocol when patients are referred with suspected abdominal mass, weight loss or abdominal pain.

Methods

Retrospective analysis of prospective electronic data base of colorectal STT referrals from Feb 2020 to end of October 2020.

Results

Conclusion

CT colonoscopies and CT trunks form part of initial diagnostic tool in the colorectal rapid access patients. They are particularly useful in high risk patients who cannot tolerate colonoscopy. These investigations complement the lower GI endoscopy. These scans also identify non-colorectal malignancies and retroperitoneal pathology such as AAA.CT trunks were useful tools during COVID 19 Pandemic.

EP.TU.440Managements of blood thinning medications in elderly populations presenting with rectal bleeding: Are we doing it right?

Purpose

Rectal bleeding is a common adverse effect of blood thinners in elderly patients resulting in admission. Our aim is to review the management of bold thinning medications in populations.

Methods

A retrospective analysis of patients admitted with per-rectal bleed from 2018 to December 2020 was performed. All patients above the age of 60 years on blood-thinning medications were analyzed in terms of management and discharge.

Results

A total of 93 (54.71%) patients out of 170 were included in the study. The median age was 83 years. The majority of them were on Direct Oral-Anticoagulants (DOAC) (35.4%), Clopidogrel (26.8%) and Aspirin (32.5%) with remaining on warfarin (14%) and dual anti-platelets (3.2%). On admission DOAC and warfarin was stopped in all the patients and antiplatelets was stopped in 76% of them. Identical percentage of patients in all the groups required blood transfusion. At discharge, DOAC was restarted in 33% of the patients with similar percentage discontinued. 6% were switched to alternative and the rest were due to outpatient review. Warfarin and antiplatelets was restarted in 61% and 62% of the patients respectively. Alternative medications were initiated on 7.6% of patients on warfarin and 5.4% on antiplatelets. Readmissions were mainly seen in patients on antiplatelets (10%). No patients in the study developed thrombotic complications.

Conclusion

Individual patient circumstances lead to variations in the management of blood thinning medications with per-rectal bleed. Larger trials are needed to ensure uniformity. Readmissions were mostly seen in patients on antiplatelets.

SP10.1.6 Benefit of Two week colorectal cancer referrals of patients who had colonic imaging within the last 5 years: do they improve the colorectal cancer outcome?

Purpose

There has been a significant rise in the number of colorectal rapid access referrals. These referral results in additional demand for hospital services as well as delays assessment and management of other patients. We analyzed the outcome of colorectal fast tract clinic re- referrals on bowel cancer outcome in patients with recent colonic imaging.

Methods

We retrospectively analyzed 1000 consecutive colorectal rapid access pathway referrals in 2019.Patients with complete colonic imaging within the preceding 5 years were included. We assessed their clinical outcome and colonic imaging when performed.

Results

In total, 82 (8.2%) patients out of 1000 met the selection criteria. Among these 12 patients (14%) did not need any further colonic investigations. A further 12 patients (14%) were already on the colorectal surveillance program, including a patient with recently diagnosed rectal cancer. Hence 24 patients (29.2%) referral was not indicated. 58 patients had further colonic imaging in the form of colonoscopy or virtual colonoscopy following clinic consultation. 32 (55.17%) of them had normal colonic imaging. 14 patients (24.1%) were identified with colorectal polyps with only one identified as tubular adenoma. The remaining 12 patients had non neoplastic pathology.

Conclusion

No new significant colorectal pathology was identified in this group of patients. We suggest that symptomatic patients who had complete colonic imaging within 5 years be referred to routine colorectal clinic in order to make the colorectal rapid access referral pathway more effective especially during these unprecedented times.

Synthesis of the First Sialic Acid Analogue Containing a y-Pyrone Moiety

Oxidation of the two DANA (2-deoxy-2,3-didehydro-N-acetylneuraminic acid) derivatives (3) and (4) by using several reagents has led to the isolation of the first sialic acid derivative (1) containing a γ-pyrone moiety.

Membrane localization of the kinase which phosphorylates p34cdc2 on threonine 14

The key regulator of entry into mitosis is the serine/threonine kinase p34cdc2. This kinase is regulated both by association with cyclins and by phosphorylation at several sites. Phosphorylation at Tyr 15 and Thr 14 are believed to inhibit the kinase activity of cdc2. In Schizosaccharomyces pombe, the wee1 (and possibly mik1) protein kinase catalyzes phosphorylation of Tyr 15. It is not clear whether these or other, as yet unidentified, protein kinases phosphorylate Thr 14. In this report we show, using extracts of Xenopus eggs, that the Thr 14-directed kinase is tightly membrane associated. Specifically, we have shown that a purified membrane fraction, in the absence of cytoplasm, can promote phosphorylation of cdc2 on both Thr 14 and Tyr 15. In contrast, the cytoplasm can phosphorylate cdc2 only on Tyr 15, suggesting the existence of at least two distinctly localized subpopulations of cdc2 Tyr 15-directed kinases. The membrane-associated Tyr 15 and Thr 14 kinase activities behaved similarly during salt or detergent extraction and were similarly regulated during the cell cycle and by the checkpoint machinery that delays mitosis while DNA is being replicated. This suggests the possibility that a dual-specificity membrane-associated protein kinase may catalyze phosphorylation of both Tyr 15 and Thr 14.

Cdc25M2 activation of cyclin-dependent kinases by dephosphorylation of threonine-14 and tyrosine-15

Recent evidence has suggested that human cyclin-dependent kinase 2 (CDK2) is an essential regulator of cell cycle progression through S phase. CDK2 is known to complex with at least two distinct human cyclins, E and A. The kinase activity of these complexes peaks in G1 and S phase, respectively. The vertebrate CDC2/cyclin B1 complex is an essential regulator of the onset of mitosis and is inhibited by phosphorylation of CDC2 on Thr-14 and Tyr-15. In vitro, CDC2/cyclin B1 is activated by treatment with the members of the Cdc25 family of phosphatases. We found that, like CDC2, CDK2 is also phosphorylated on Thr-14 and Tyr-15 and that treatment of cyclin A or cyclin E immunoprecipitates with bacterially expressed Cdc25M2 (the mouse homolog of human CDC25B) increased the histone H1 kinase activity of these immune complexes 5- to 10-fold. Tryptic peptide mapping demonstrated that Cdc25M2 treatment of cyclin A or cyclin B1 immune complexes resulted in the specific dephosphorylation of Thr-14 and Tyr-15 on CDK2 or CDC2, respectively. Thus, we have confirmed that Cdc25 family members comprise a class of dual-specificity phosphatases. Furthermore, our data suggest that the phosphorylation and dephosphorylation of CDKs on Thr-14 and Tyr-15 may regulate not only the G2/M transition but also other transitions in the cell cycle and that individual cdc25 family members may regulate distinct cell cycle checkpoints.

A mouse cdc25 homolog is differentially and developmentally expressed

The timing and activation of the p34cdc2 kinase in mammals is associated with dephosphorylation of phosphotyrosine and phosphothreonine residues on the p34cdc2 kinase. For fission yeast, the timing of mitosis is regulated by cyclic accumulation of cdc25, which promotes dephosphorylation of p34cdc2 and concomitant protein kinase activation. We report the identification and characterization of a structural and functional mouse homolog, Cdc25M2, of the cdc25 phosphatase. Cdc25M2 shows high sequence identity to the previously reported human homolog cdc25Hu2. Cdc25M2 can functionally complement for a Schizosaccharomyces pombe cdc25ts mutation, and when expressed in Escherichia coli and purified, Cdc25M2 is an active phosphatase. cdc25M2 mRNA shows variation in expression in different tissues in the mouse embryo and is expressed in a developmental and cell-cycle-dependent fashion. We suggest that the expression and accumulation of the cdc25 mitotic inducer may play a critical role in the regulation of mouse development.

[Sarcoidosis of the larynx]

Report on 9 patients with laryngeal sarcoidosis. 7 patients showed a very typical picture with a diffuse enlargement of the epiglottis, the aryepiglottic folds and the arytenoid region. In one patient a tumour like lesion of the vocal cord appeared and in another subglottical structures were diffusely swollen. Including a review of the literature, the clinical aspects, diagnostic problems and therapeutical possibilities of this rare disease are described.

[Invasion of thyroid gland tumors in the larynx and trachea]

Intraluminal involvement of larynx or trachea in thyroid cancer causes extraordinary therapeutical problems. Surgical or medical treatment fails in most of these advanced tumours. Only carcinomas of low-grade malignancy--especially follicular and papillary type--can be cured by operation if involved parts of larynx or trachea are resected with the tumour. Surveying 85 cases reported in literature and 9 observations of our own we present the clinical, diagnostical and therapeutical aspects of this disease.

[Treatment of laryngeal hemangiomas in children]

Based on 3 observations of our own and a survey of 171 cases reported in the literature, the clinical, diagnostical and therapeutical aspects of subglottic haemangioma in infants are presented. By obstructing subglottic air passage these tumours can threaten life and often require tracheostomy. Mortality rate reported in literature is still high (19%). Because of their spontaneous regression capillary subglottic haemangiomas do not require further active treatment.