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.     

ATRX encodes a novel member of the SNF2 family of proteins: mutations point to a common mechanism underlying the ATR-X syndrome

It was shown recently that mutations of the ATRX gene give rise to a severe, X-linked form of syndromal mental retardation associated with alpha thalassaemia (ATR-X syndrome). In this study, we have characterised the full-length cDNA and predicted structure of the ATRX protein. Comparative analysis shows that it is an entirely new member of the SNF2 subgroup of a superfamily of proteins with similar ATPase and helicase domains. ATRX probably acts as a regulator of gene expression. Definition of its genomic structure enabled us to identify four novel splicing defects by screening 52 affected individuals. Correlation between these and previously identified mutations with variations in the ATR-X phenotype provides insights into the pathophysiology of this disease and the normal role of the ATRX protein in vivo.      

Identification of non-amplifying CYP21 genes when using PCR-based diagnosis of 21-hydroxylase deficiency in congenital adrenal hyperplasia (CAH) affected pedigrees

Steroid 21-hydroxylase deficiency is among the most common inborn errors of metabolism in man. Characterization of mutations in the 21- hydroxylase gene (CYP21) has permitted genetic diagnosis, facilitated by the polymerase chain reaction (PCR). The most common mutation is conversion of an A or C at nt656 to a G in the second intron causing aberrant splicing of mRNA. Homozygosity for nt656G is associated with profoundly deficient adrenal cortisol and aldosterone synthesis, secondary hypersecretion of adrenal androgens, and a severe form of congenital adrenal hyperplasia (CAH) characterized by ambiguous genitalia and/or sodium wasting in newborns. During the course of genetic analysis of CYP21 mutations in CAH families, we and others have noticed a number of relatives genotyped as nt656G homozygotes, yet showing no clinical signs of disease. A number of lines of evidence have led us to propose that the putative asymptomatic nt656G/G individuals are incorrectly typed due to dropout of one haplotype during PCR amplification of CYP21. For prenatal diagnosis, we recommend that microsatellite typing be used as a supplement to CYP21 genotyping in order to resolve ambiguities at nt656.      

Complete Genomic Sequence of Viral Hemorrhagic Septicemia Virus,a Fish Rhabdovirus

The complete nucleotide sequence of the fish rhabdovirus viral hemorrhagic septicemia virus (VHSV) has been determined. The genome comprises 11158 bases and contains six long open reading frames encoding the nucleoprotein N, phosphoprotein P, matrix protein M, glycoprotein G, nonstructural viral protein NV, and polymerase L. Genes are arranged in the order 3-N-P-M-G-NV-L-5. The exact 3 and 5 ends were determined after RNA-oligonucleotide ligation or RACE. They show inverse complementarity as in other rhabdovirus genomes. Nucleotide and deduced amino acid sequences exhibit significant homology to corresponding sequences in the related fish rhabdovirus infectious hematopoietic necrosis virus.     

Toltrazuril treatment of cystoisosporosis in dogs under experimental and field conditions

Coccidia of the genus Cystoisospora cause mild to severe diarrhoea in dogs. The effects of toltrazuril treatment on cystoisosporosis were studied under experimental and field conditions. Twenty-four puppies were experimentally infected each with 4 × 10⁴ oocysts of the Cystoisospora ohioensis group. Three groups of six puppies were treated 3 dpi with 10, 20 or 30 mg/kg body weight of toltrazuril suspension (5%); the remaining six puppies served as non-treated controls. Toltrazuril suspension or microgranulate were given once in a dose of 10 or 20 mg/kg body weight, respectively, to naturally infected puppies in conventional dog breeding facilities, depending on the coproscopical evidence of infection. Oocyst excretion and clinical data were recorded. Under experimental conditions, the non-treated puppies excreted oocysts beginning at 6 dpi and suffered from catarrhalic to haemorrhagic diarrhoea. On 12 dpi, four of six non-treated puppies died. Irrespective of the dose, toltrazuril treatment totally suppressed oocyst excretion and no diarrhoea or other signs of disease were observed in the treated groups. Natural Cystoisospora infections were regularly found during the 3rd or 4th week of age in dog breeding facilities although not always associated with diarrhoea. A single oral application of toltrazuril abrogated oocyst shedding and the treated puppies remained generally coproscopically negative during the following 2–4 weeks. Cystoisospora is pathogenic for puppies and can induce severe disease. Natural infections are common in conventional dog breeding facilities. Toltrazuril treatment is suitable for controlling cystoisosporosis under experimental and field conditions. A single oral treatment for puppies in the 3rd or 4th week of age is recommended. Received: 2 February 2000 / Accepted: 4 February 2000