The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience

IntroductionWith the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic.Materials and methodsA protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 ‘clean’ site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff.ResultsA total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive.ConclusionThis study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.     

Rheumatoid Arthritis (RA) associated interstitial lung disease (ILD)

Rheumatoid Arthritis (RA) is the most common Connective Tissue Disease (CTD) and represents an increasing burden on global health resources. Interstitial lung disease (ILD) has been recognised as a complication of RA but its potential for mortality and morbidity has arguably been under appreciated for decades. New studies have underscored a significant lifetime risk of ILD development in RA. Contemporary work has identified an increased risk of mortality associated with the Usual Interstitial Pneumonia (UIP) pattern which shares similarity with the most devastating of the interstitial pulmonary diseases, namely Idiopathic Pulmonary Fibrosis (IPF). In this paper, we discuss recent studies highlighting the associated increase in mortality in RA–UIP. We explore associations between radiological and histopathological features of RA–ILD and the prognostic implications of same. We emphasise the need for translational research in this area given the growing burden of RA–ILD. We highlight the importance of the respiratory physician as a key stakeholder in the multidisciplinary management of this disorder. RA–ILD focused research offers the opportunity to identify early asymptomatic disease and define the natural history of this extra articular manifestation. This may provide a unique opportunity to define key regulatory fibrotic events driving progressive disease. We also discuss some of the more challenging and novel aspects of therapy for RA–ILD.     

Qualitative analysis by interviews and video recordings to establish the components of a skilled low-cavity non-rotational vacuum delivery

Objectives  The objectives of this study were to define the components of a skilled low-cavity non-rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45-degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians.
Design  Qualitative study using interviews and video recordings.
Setting  Two university teaching hospitals (St Michael's Hospital, Bristol, and Ninewell's Hospital, Dundee).
Participants  Ten obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries.
Methods  Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low-cavity vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and compared for consistency of interpretation. The experts reviewed the coded interviews and video data for respondent validation and clarification. The themes that emerged following the final coding were used to formulate a list of skills.
Main outcome measures  Key technical skills of a low-cavity non-rotational delivery.
Results  The final list included detailed technical skills required for conducting a low-cavity vacuum delivery. The combination of semi-structured interviews and simulation videos allowed the formulation of a comprehensive skills tool for future evaluation.
Conclusion  This explicitly defined skills list could aid trainees understanding of the technique of low-cavity vacuum delivery. This is an important first step in evaluating clinical competence in intrapartum procedures.     

妊娠糖尿病妇女使用门冬胰岛素或常规人胰岛素在疗效、安全性方面的比较

在一项随机、平行分组的开放试验中，27例妊娠糖尿病妇女（年龄30．7±6．3岁，HbA1c〈7％）随机分为门冬胰岛素治疗组（餐前5分钟注射）和常规人胰岛素治疗组（餐前30分钟注射）。试验时间为从诊断妊娠糖尿病（18～28周）至产后6周。研究期间两组的总体血糖水平均控制良好（试验开始和结束时HbA1c≤6％）。进餐试验时，试验6周时的平均血糖水平（门冬胰岛素组4．2±0．57mmol／L，常规人胰岛素组4．8±0．86mmol／L）略低于试验0周时（门冬胰岛素组4．9±0．59mmol／L，常规人胰岛素组5．1±0．36mmol／L）。     

Visual acuity and visual field development after cryocoagulation in infants with retinopathy of prematurity

Visual development was studied in 10 very-low-birth-weight infants (less than 1500 g) with retinopathy of prematurity (ROP) stage 3+ who had been treated with cryocoagulation in both eyes. Binocular visual acuity (acuity cards method) and binocular visual fields (kinetic perimetry) were assessed repeatedly in the first year of life. At 12 months corrected age, visual acuity was normal in seven and impaired in three infants, who appeared to be severely myopic. Normal visual fields were found in eight infants at this age. The results indicate that cryotherapy in cases of ROP stage 3+ does not interfere with visual acuity development. The effect on visual field development needs further investigation.     

Survey of arthroscopy performed by rheumatologists

OBJECTIVE: To determine the international distribution and practice of arthroscopy performed by rheumatologists and to evaluate proposed guidelines on minimum standards for training in arthroscopy in the context of current clinical practice. METHODS: A questionnaire was sent to all rheumatology centres identified as practising arthroscopy, by (i) searching Medline from 1966 to 1999, (ii) searching the abstract books of the annual general meetings of ACR, BSR and EULAR from 1980 to 1999, and (iii) correspondence with all the centres identified. RESULTS: Thirty-six rheumatology centres were confirmed as performing arthroscopy (24 in Europe, 10 in USA and two in Australia) and 33 (92%) centres completed the questionnaire. Twenty-five (76%) of the 33 centres performing arthroscopy had started to perform it since 1990 and 72 rheumatologists are now trained in arthroscopy. A total of 16532 arthroscopies had been performed (median=220 arthroscopies/centre, range 20-5000); 50.5% of the arthroscopies had a primary clinical indication and 49.5% had a primary research indication. Most centres fulfilled the minimum standards for arthroscopic facilities and the proposed minimum standards in training were acceptable to 76% of respondents. Complication rates were calculated for 15682 arthroscopies where routine follow-up data were available [joint infection, 16 (0.1%); wound infection, 17 (0.1%); haemarthrosis, 141 (0.9%); deep venous thrombosis, 31 (0.2%); neurological damage, 3 (0.02%), thrombophlebitis, 12 (0.08%), other, 8 (0.06%)]. Irrigation volume correlated with wound infection rate (r=0.41, P=0.03) and centres performing cartilage biopsy had a higher rate of haemarthrosis (P=0.007). CONCLUSION: The last decade has seen rapid growth in arthroscopy performed by rheumatologists in an out-patient setting under local and regional anaesthesia. Proposed minimum standards for training in rheumatological arthroscopy reflect current practice accurately and are acceptable to the majority of arthroscopists. Complication rates of rheumatological arthroscopy are similar to those reported in the orthopaedic literature.