Ten-year territory-wide trends in the utilisation and clinical outcomes of extracorporeal membrane oxygenation in Hong Kong

INTRODUCTION

The utilisation of extracorporeal membrane oxygenation (ECMO) has been rapidly increasing in Hong Kong. This study examined 10-year trends in the utilisation and clinical outcomes of ECMO in Hong Kong.

METHODS

We retrospectively reviewed the records of all adult patients receiving ECMO who were admitted to the intensive care units (ICUs) of public hospitals in Hong Kong between 2010 and 2019. Temporal trends across years were assessed using the Mann-Kendall test. Observed hospital mortality was compared with the Acute Physiology and Chronic Health Evaluation (APACHE) IV-predicted mortality.

RESULTS

The annual number of patients receiving ECMO increased from 18 to 171 over 10 years. In total, 911 patients received ECMO during the study period: 297 (32.6%) received veno-arterial ECMO, 450 (49.4%) received veno-venous ECMO, and 164 (18.0%) received extracorporeal cardiopulmonary resuscitation. The annual number of patients aged ≥65 years increased from 0 to 47 (27.5%) [P for trend=0.001]. The median (interquartile range) Charlson Comorbidity Index increased from 1 (0-1) to 2 (1-3) [P for trend<0.001] while the median (interquartile range) APACHE IV score increased from 90 (57-112) to 105 (77-137) [P for trend=0.003]. The overall standardised mortality ratio comparing hospital mortality with APACHE IV-predicted mortality was 1.11 (95% confidence interval=1.01-1.22). Hospital and ICU length of stay both significantly decreased (P for trend=0.011 and <0.001, respectively).

CONCLUSION

As ECMO utilisation increased in Hong Kong, patients put on ECMO were older, more critically ill, and had more co-morbidities. It is important to combine service expansion with adequate resource allocation and training to maintain quality of care.

Systematic review and meta-analysis of ketamine-associated uropathy

INTRODUCTION

This systematic review and meta-analysis focused on the literature regarding ketamine-associated uropathy to summarise its clinical manifestations, the results of urological assessments, and current management.

METHODS

A literature search was conducted using keywords and MeSH terms related to ketamine abuse, urinary tracts, and urological examinations. Databases including Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched up to 26 June 2020.

RESULTS

In total, 1365 articles were retrieved; 45 articles (4921 patients) were included in the analysis of patient demographics, clinical manifestations, examination results, and treatments. Frequency was the most common manifestation (pooled prevalence 77.1%, 95% confidence interval [CI]=56.9%-92.2%), followed by urgency (69.9%, 95% CI=48.8%-87.3%) and suprapubic pain (60.4%, 95% CI=35.3%-82.9%). Upper urinary tract involvement was less common; the pooled prevalence of hydronephrosis was 30.2% (95% CI=22.0%-39.2%). Further workup revealed a pooled functional bladder capacity of 95.23 mL (95% CI=63.57-126.88 mL), pooled voided volume of 113.31 mL (95% CI=59.44- 167.19 mL), and pooled maximum urine flow rate of 8.69 mL/s (95% CI=5.54-11.83 mL/s). Cystoscopic examinations and bladder biopsy revealed frequent urothelial denudation, inflammatory changes, and inflammatory cell infiltration. Treatments included oral medications for symptomatic relief, intravesical therapy, and surgery (eg, hydrodistension and bladder reconstruction), but ketamine abstinence was necessary for improvement.

CONCLUSION

Ketamine-associated uropathy frequently involves frequency, urgency, and suprapubic pain; upper urinary tract involvement is less common. Affected patients showed reductions in bladder capacity and urine flow rate. Endoscopic and histological analyses often revealed cystitis. Despite variations in treatment, ketamine abstinence is important for all patients with ketamine-associated uropathy.

455 The Changing Trends of Image Guided Biopsy of Small Renal Masses Before Intervention- an Analysis of European Multinational Prospective EuRECA Registry

Aim

To evaluate the use of pre-cryoablation biopsy for small renal masses (SRMs) and the effects of increasing up take on histological results of treated SMRs.

Method

From 2015 to 2019, patients with sporadic T1N0M0 SRMs undergoing percutaneous, laparoscopic or open cryoablation from 14 European institutions within the European Registry For Renal Cryoablation (EuRECA) were included for the retrospective analysis. Univariate and multivariate logistic models were used to evaluate the trends, histological results and the factors influencing use of pre-cryoablation biopsy.

Results

871 patients (Median [IQR] age, 69[14], 298 women) undergoing cryoablation were evaluated. The use of pre-cryoablation biopsy has significantly increased from 42% (65/156) in 2015 to 72% (88/122) in 2019 (p&lt;0.001). Patients treated for a benign histology are significantly more likely to have presented later in the trend, where pre-cryoablation biopsy is more prevalent (OR: 0.64, 95% CI 0.51–0.81, p&lt;0.001). Patients treated for undiagnosed histology are also significantly less likely to have presented in 2018 compared to 2016 (OR 0.31, 95% CI 0.10–0.97, p=0.044). Patients aged 70+ are less likely to be biopsies pre-cryoablation (p&lt;0.05). R.E.N.A.L. nephrometry score of 10+ and a Charlson Comorbidity Index &gt;1 are factors associated with lower likelihood to not have received a pre-cryoablation biopsy (p&lt;0.05).

Conclusion

An increased use of pre-cryoablation biopsy was observed and cryoablation patients treated with a benign histology is more likely to have presented in periods where pre-cryoablation biopsy is not as prevalent. Comparative studies are needed to draw definitive conclusions on the effect of pre-cryoablation biopsy on SRM treatments.

1637 Ablative Therapies Versus Partial Nephrectomy for Small Renal Masses: A Systematic Review and Meta-Analysis

Introduction

The optimal management of small renal masses is unclear. Ablative therapies (AT) have been advocated as a potential alternative due to lower complication rates and non-inferior oncological outcomes. We performed a systematic review to compare AT and partial nephrectomy (PN) in patients with T1aN0M0 renal masses.

Method

This review is registered on PROSPERO (CRD42020199099). A search was performed on Medline, EMBASE, and Cochrane CENTRAL to identify studies comparing AT and PN. Different modalities and approaches were analysed as subgroups. Outcomes include cancer-specific survival (CSS), overall survival (OS), recurrence-free survival (RFS), metastatic-free survival (MFS), postoperative complications, and change in renal function.

Results

From 1,351 identified records, 30 studies incorporating 85,837 patients were included for meta-analysis. Patients receiving AT were found to have significantly worse CSS, OS, RFS when compared to patients receiving PN (p &lt; 0.05). Patients undergoing AT have a non-inferior MFS and significantly fewer overall complications (HR: 0.79, 95% CI 0.41-1.51, p = 0.48; RR: 0.71, 95% CI 0.53-0.96, p = 0.03). Patients undergoing AT have a smaller decline in renal function post-operatively (SMD: 0.30, 95% CI 0.11-0.50). When limited to studies with propensity score matching, CSS and RFS are no longer significantly different between the two groups (HR: 1.54, 95% CI 0.67-3.52, p = 0.31, HR: 1.72, 95% CI 0.90-3.28, p = 0.10). Subgroup analyses did not show significant differences between different modalities and approaches of AT in all outcomes.

Conclusions

AT is potentially non-inferior to PN when managing small renal masses, and more high-quality propensity score-matched studies with long follow-up time are needed to confirm the non-inferiority.

1459 Intravesical Chemohyperthermia Versus Bacillus Calmette-Guerin Instillation for Intermediate- And High-Risk Non-Muscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis

Introduction

Traditional intravesical chemotherapy instillations under room temperature post trans-urethral resection (TUR) of non-muscle invasive bladder cancer (NMIBC) have lower efficacies than maintenance BCG installations. Intravesical chemo-hyperthermia (CHT) at higher temperatures is developed to improve the efficacy of chemotherapy instillation. This systematic review aims to compare the use of CHT and BCG instillation post-TUR.

Method

The protocol of this review is registered on PROSPERO(CRD42020223277). A comprehensive literature search was performed on Medline, EMBASE, and Cochrane CENTRAL to identify studies comparing CHT and BCG post-TUR for intermediate- or high-risk NMIBC. Primary outcomes include recurrence-free survival (RFS) and progression-free survival (PFS). Secondary outcomes include adverse events (AE).

Results

From 2,375 identified records, four randomised control trials incorporating 327 patients were included for meta-analysis. The use of CHT was found to be non-inferior to BCG in RFS, PFS and AEs (Grades 1-3) (p &gt; 0.05). Sensitivity analysis, excluding patients with BCG failures, show 24-36 months recurrence rate to be significantly lower in CHT group (RR 0.64, 95% CI 0.42-0.98, p = 0.04) compared to the BCG group. In patients without carcinoma in situ (CIS), RFS is also significantly better in CHT patients (HR 0.52, 95% CI 0.32- 0.85, p &lt; 0.01). Safety profile remains non-inferior to the BCG group in sensitivity analyses. Quality of evidence across all outcomes ranged from moderate to low.

Conclusions

In well-selected patients, intravesical CHT has superior oncological outcomes and non-inferior safety profile when compared to BCG maintenance therapy for patients with intermediate- and high-risk NMIBC. CHT is a possible alternative treatment during BCG shortage.

1160 LEARN (Urological Teaching in British Medical Schools Nationally): A Multicentre Cross-Sectional Study

Introduction

Urology is a common rotation for UK Foundation Year (FY) doctors, and accounts for &gt;25% of acute surgical referrals. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology to be covered during medical school. However, its national uptake remains unknown. LEARN aims to assess undergraduate urology teaching across UK medical schools.

Method

LEARN is the largest ever multicentre cross-sectional study of undergraduate urology teaching. Year 2-5 medical students and FY1 doctors were invited to complete a survey between 3rd October-20th December 2020. The primary objective is to compare current undergraduate urology teaching against the BAUS syllabus. Secondary objectives investigate the type and quantity of teaching provided, the reported performance rate of GMC mandated urological procedures, and the proportion of those considering urology as a career.

Results

A total of 7,611/8,346 (91.2%) responses from 39 medical schools that met the inclusion criteria were analysed. 16.5% of responses were newly appointed FY1 doctors. In their undergraduate training, the most commonly taught topics were urinary tract infection, acute kidney injury and haematuria; the least taught topics were male urinary incontinence, male infertility and erectile dysfunction. 90.6% and 86.3% had reported performing catheterisation as undergraduates on male and female patients respectively, and 16.9% had considered a career in urology.

Conclusion

LEARN provides the largest evaluation of any undergraduate specialty teaching. It has identified areas to improve teaching, to equip the future workforce with the competencies to manage urological pathology, irrespective of future career choice.

979 Delayed Surgery for Localised and Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis for the COVID-19 Pandemic

Introduction

COVID-19 have delayed treatments for cancer; hence we performed a systematic review on the oncological effects of active surveillance (AS), delayed intervention (DI) and sequencing of cytoreductive nephrectomy (CN) and target therapy (TT) on localised and metastatic renal cell carcinoma (RCC). PROSPERO: CRD42020190882

Method

Both randomised controlled trials and observational studies related to the study were included in this review after a comprehensive search and screening.

Results

A total of 2065 potential eligible records were identified. 23 studies were included for quantitative analysis. In meta-analysis, no significant difference was found between the patients who underwent AS/DI and PN/RN for overall survival (OS) (HR 1.36, 95% CI 0.99-1.87, p = 0.06), while cancer-specific survival is significantly worsened (CSS) (HR 1.67, 95% CI 1.23-2.27, p &lt; 0.01) in AS/DI patients. In other localised stages, results are contradicting amongst literature. Upfront TT followed by deferred CN is associated with better OS when compared to upfront CN followed by deferred TT (HR 0.53, 95% CI 0.41-0.69, p = 0.00) in metastatic patients.

Conclusions

Based on low quality evidence, AS and DI is no inferior to immediate surgical intervention in well selected T1a patient’s OS but not CSS. Upfront TT followed by deferred CN improves OS and progression free survival.

P73 LEARN: uroLogical tEAching in bRitish medical schools Nationally - a national retrospective multi-centre audit of urology teaching across British medical schools

Introduction

Urological conditions account for approximately 25% of acute surgical referrals and 10-15% of general practitioner appointments. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology that must be covered during undergraduate medical training. However, its uptake nationally remains unknown. This project aims to assess undergraduate urology teaching across UK medical schools.

Methods

A targeted advertising drive using social media, medical school societies, websites and newsletters was performed over 4 weeks. Collaborators are responsible for recruiting survey respondents (year 2 medical students to foundation year 1 (FY1) doctors). Survey respondents will complete a REDCap survey retrospectively assessing their urology teaching to date. The primary objective is to compare current urology teaching in medical schools across the United Kingdom with the BAUS undergraduate syllabus.

Results

Currently, 522 collaborators have registered from 36 medical schools nationally. Of these collaborators, 6.32% (33/522) are FY1s and 93.68% (489/522) are medical students. Each collaborator will be responsible for recruiting at least 15 survey respondents to be eligible for PubMed-indexed collaborator authorship.

Conclusion

LEARN has recruited successfully to date, with all collaborators from the medical student and FY1 cohort. With the role of collaborators to further recruit survey respondents, LEARN will provide the most representative and thorough evaluation of UK undergraduate urological teaching to date. It will provide evidence to support changes in the medical school curriculum, and allow re-evaluation of the current national undergraduate BAUS syllabus.

Effects of acute controlled changes in end-tidal carbon dioxide on the diameter of the optic nerve sheath: a transorbital ultrasonographic study in healthy volunteers

Transorbital ultrasonographic measurement of the diameter of the optic nerve sheath is a non-invasive, bed-side examination for detecting raised intracranial pressure. However, the ability of the optic nerve sheath diameter to predict acute changes in intracranial pressures remains unknown. The aim of this study was to examine the dynamic changes of the optic nerve sheath diameter in response to mild fluctuations in cerebral blood volume induced by changes in end-tidal carbon dioxide. We studied 11 healthy volunteers. End-tidal carbon dioxide was controlled by a model-based prospective end-tidal targeting system (RespirAct™). The volunteers' end-tidal carbon dioxide was targeted and maintained for 10 min each at normocapnia (baseline); hypercapnia (6.5 kPa); normocapnia (baseline 1); hypocapnia (3.9 kPa) and on return to normocapnia (baseline 2). A single investigator repeatedly measured the optic nerve sheath diameter for 10 min at each level of carbon dioxide. With hypercapnia, there was a significant increase in optic nerve sheath diameter, with a mean (SD) increase from baseline 4.2 (0.7) mm to 4.8 (0.8) mm; p < 0.001. On return to normocapnia, the optic nerve sheath diameter rapidly reverted back to baseline values. This study confirms dynamic changes in the optic nerve sheath diameter with corresponding changes in carbon dioxide, and their reversibly with normocapnia.

Real-time ultrasound-guided spinal anesthesia in patients with a challenging spinal anatomy: two case reports

Spinal anesthesia may be challenging in patients with poorly palpable surface landmarks or abnormal spinal anatomy. Pre-procedural ultrasound imaging of the lumbar spine can help by providing additional anatomical information, thus permitting a more accurate estimation of the appropriate needle insertion site and trajectory. However, actual needle insertion in the pre-puncture ultrasound-assisted technique remains a 'blind' procedure. We describe two patients with an abnormal spinal anatomy in whom ultrasound-assisted spinal anesthesia was unsuccessful. Successful dural puncture was subsequently achieved using a technique of real-time ultrasound-guided spinal anesthesia. This may be a useful option in patients in whom landmark-guided and ultrasound-assisted techniques have failed.

Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review

Total hip arthroplasty (THA) is amenable to a variety of regional anaesthesia (RA) techniques that may improve patient outcome. We sought to answer whether RA decreased mortality, cardiovascular morbidity, deep venous thrombosis (DVT) and pulmonary embolism (PE), blood loss, duration of surgery, pain, opioid-related adverse effects, cognitive defects, and length of stay. We also questioned whether RA improved rehabilitation. To do so, we performed a systematic review of the contemporary literature to compare general anaesthesia (GA) and RA and also systemic and regional analgesia for THA. To reflect contemporary surgical and anaesthetic practice, only randomized controlled trials (RCTs) from 1990 onward were included. We identified 18 studies involving 1239 patients. Only two of the 18 trials were of Level I quality. There is insufficient evidence from RCTs alone to conclude if anaesthetic technique influenced mortality, cardiovascular morbidity, or the incidence of DVT and PE when using thromboprophylaxis. Blood loss may be reduced in patients receiving RA rather than GA for THA. Our review suggests that there is no difference in duration of surgery in patients who receive GA or RA. Compared with systemic analgesia, regional analgesia can reduce postoperative pain, morphine consumption, and nausea and vomiting. Length of stay is not reduced and rehabilitation does not appear to be facilitated by RA or analgesia for THA.

The post-operative analgesic efficacy and tolerability of lumiracoxib compared with placebo and naproxen after total knee or hip arthroplasty

BACKGROUND

Lumiracoxib is a novel selective cyclooxygenase-2 (COX-2) inhibitor in development for the treatment of chronic and acute pain.

METHODS

This randomized, double-blind multicentre study enrolled 180 patients (aged 18-80 years) with moderate-to-severe pain (>or=2 on a 4-point categorical scale) within 48 h of unilateral total knee or total hip arthroplasty. Patients were randomized to receive lumiracoxib 400 mg once daily (n = 60), placebo (n = 60) or naproxen 500 mg twice daily (n = 60). The study consisted of a 12-h single-dose phase followed by a multiple-dose phase (up to 96 h or until discontinuation). The primary efficacy measure was the summed (time-weighted) pain intensity difference over 0-8 h after the first dose (SPID-8).

RESULTS

Lumiracoxib and naproxen were comparable and both treatments were superior to placebo for the primary efficacy measure, SPID-8. Both treatments were generally similar and also superior to placebo for the secondary efficacy measures during both the single- and multiple-dose phases for up to 96 h. Both active treatments were well tolerated.

CONCLUSION

Lumiracoxib is an effective alternative to traditional non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of post-operative pain.

Ultrasound guidance for a lateral approach to the sciatic nerve in the popliteal fossa

Descriptions of the use of ultrasound for nerve location have focused on upper limb blocks. We present a case in which ultrasound imaging was used for a lateral approach to the sciatic nerve in the popliteal fossa. Ultrasound images taken proximal to the popliteal crease showed tibial and common peroneal nerves as round hyperechoic structures superficial and lateral to the tibial artery. Under direct ultrasound guidance, we placed a block needle close to the tibial nerve and confirmed its position with nerve stimulation. Injected local anaesthetic was seen on ultrasound as it spread around both tibial and common peroneal nerves.