Patient characteristics,anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey

Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3–4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient-level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non-obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4–69.1) to 52.8 (32.1–69.2) years. The median (IQR) BMI increased from 24.9 (21.5–29.5) to 26.7 (22.3–31.7) kg.m^–2. The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID-19 pandemic on the anaesthetic population, though patients with confirmed COVID-19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri-operative services significantly.     

Peri-operative tobacco cessation interventions: a systematic review and meta-analysis

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20–1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29–2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.     

A Novel Y319H Substitution in CYP51C Associated with Azole Resistance in Aspergillus flavus

This study aimed to explore any mutation in the CYP51 gene conferring azole resistance in Aspergillus flavus. Two voriconazole-resistant and 45 voriconazole-susceptible isolates were included in the study. Sequence analysis demonstrated a T1025C nucleotide change in CYP51C, resulting in the Y319H amino acid substitution in one resistant isolate. However, the earlier described T788G mutation in CYP51C conferring voriconazole resistance in A. flavus isolates was present in all isolates, irrespective of their susceptibility status.     

Combining VITEK® 2 with colistin agar dilution screening assist timely reporting of colistin susceptibility

ObjectivesThe rise in carbapenem resistance among Gram-negative bacteria has renewed interest in colistin. Recently, the EUCAST-CLSI Polymyxin Breakpoints Working Group declared that broth microdilution (BMD) is the only valid method for colistin susceptibility testing. BMD is not easily incorporated into the routine work of clinical laboratories, and usually this test is incorporated serially, resulting in delayed susceptibility reporting. We tested a strategy of combining VITEK^® 2 with a 2 μg/mL colistin agar dilution (VITEK^® 2/AD) screening plate to improve performance and time to reporting of colistin susceptibility.MethodsColistin susceptibility for 364 clinical isolates was determined by VITEK^® 2/AD and compared with the reference standard BMD according to the ISO 20776-1:2007 and CLSI guidelines. The EUCAST colistin susceptibility breakpoint of ≤2 μg/mL was used. Escherichia coli NCTC 13846 served as quality control strain. Agreement, very major error (VME) and major error rates were determined using ISO 20776-2:2007.ResultsThe VME rate for VITEK^® 2 alone was 30.6% (15/49, 95% CI 18.3–45.4%), and was reduced to 10.2% (5/49, 95% CI 3.4–22.2%) using the VITEK^® 2/AD combined testing. The combined testing had categorical agreement with BMD of 97% (354/364, 95% CI 95.0–98.7%), and a major error (ME) rate of 1.6% (5/315, 95% CI 0.5–3.7%). Using the combined testing, even against challenging strains, 349 (95.8%, 95% CI 93.3–97.7%) colistin susceptibility results could be reported, and only 15 isolates required further analysis by BMD.DiscussionOur method is simple to apply and allows rapid reporting of colistin susceptibility.     

Diagnostic disparity and identification of two TNNI3 gene mutations,one novel and one arising de novo,in South African patients with restrictive cardiomyopathy and focal ventricular hypertrophy

Identifying disease and making sophisticated diagnoses at a specialist level is dependent on opportunity. Effective and accurate diagnosis starts with persons presenting to medical concern, their subsequent funneling, levels of awareness and expertise encountered, and available technology. In this article we describe a young woman (index case) with classic features of restrictive cardiomyopathy (RCM) who was referred to us with hypertrophic cardiomyopathy (HCM). Cascade screening identified the same disease in four relatives, in whom the diagnosis for some has changed from tuberculosis (TB) as a cause for pleural effusions, to cor pulmonale, constrictive pericarditis (CP) and RCM as the cause of sarcoidosis or amyloidosis. At the same time, an unrelated young boy presented with a disease profile similar to our index case, but without a history of disease in any other first-degree relative.In view of the associated focal hypertrophy, we speculated that it could be caused by a mutation in troponin I [I type 3 (TNNI3; Genbank accession no. {"type":"entrez-nucleotide","attrs":{"text":"X90780.1","term_id":"4071059","term_text":"X90780.1"}}X90780.1)], which has been implicated in cases of unexplained RCM and/or HCM with ‘restrictive features’.1-3 Mutations in this gene have been described to cause RCM, HCM and dilated cardiomyopathy and specific mutations have on occasion been associated with more than one of these phenotypes.4 We focused on screening TNNI3 in a South African panel of HCM-affected probands for mutations, which included these two probands, using a high-resolution melt (HRM) approach.     

In vitro activities of pentamidine,pyrimethamine, trimethoprim,and sulfonamides against Aspergillus species

The susceptibilities of 70 strains of Aspergillus species were tested against seven different sulfa drugs and pentamidine by a microdilution method with RPMI 1640 and yeast nitrogen base media. Sulfamethoxazole, sulfadiazine, and pentamidine were active in vitro. The MICs obtained with RPMI 1640 were significantly higher than those with yeast nitrogen base. More studies are needed to further elucidate the action of these drugs.