Small bowel obstruction caused by a fibrotic bow-string appendix: a consequence of non-operative management of acute appendicitis.

A 73-year-old woman presented with small bowel obstruction that failed to settle with conservative management. Over the previous 2 years she had presented twice with computed tomography scan-proven acute appendicitis with localised perforation of the appendix tip. In view of medical comorbidities, she was treated non-operatively with clinical and radiological resolution on each occasion, but on the third presentation laparoscopy was undertaken for non-resolving small bowel obstruction and the non-inflamed appendix itself was identified as a fibrous band causing compression of the distal ileum and complete small bowel obstruction. Following division and appendicectomy, the patient made an uneventful recovery. This case illustrates the potential consequence of repeated appendiceal inflammation and non-operative management and may be seen increasingly as this approach is widely adopted during the COVID-19 pandemic.

A nurse led telephone clinic is a safe and effective service for assessment of patients with breast pain

Introduction: Breast pain as an isolated symptom, with a normal clinical examination, is rarely associated with sinister pathology. In our service we manage these patients out with the one stop clinic (OSC), as most do not require breast imaging and / or biopsy. COVID19 has forced reduction in face-to-face outpatient appointments. We developed an advanced nurse practitioner-led telephone clinic (TC) to manage patients referred with breast pain. Here we describe the outcomes of this service. Methods: Retrospective single centre review of breast pain TC January - October 2021. Electronic patient records for all appointments were reviewed. Attendance, referral information, previous breast history, re-referrals to service and clinic outcomes were recorded. Data was compared with the same clinic performed in person, prior to COVID19. Results: 208 patients were assessed. A proportion were previous breast cancer patients (28/208, 13.5%). 18/208 (8.7%) required assessment in OSC after TC, because of patient concern about a lump. None were diagnosed with cancer. This is a higher proportion of patients needing OSC assessment after an in person pain clinic assessment (2/210, 1%), but remains low. 11/208 (5.3%) patients were re-referred from primary care following discharge from TC, comparable to in person pain clinic (11/210, 5%). Conclusion: TC is a valid way to manage patients referred with breast pain as an isolated symptom. There is a low incidence of cancer in this cohort and no need for OSC assessment. Most patients are reassured and discharged following a normal clinical examination in primary care and TC assessment.

Chloroquine/ hydroxychloroquine prevention of coronavirus disease (COVID-19) in the healthcare setting;protocol for a placebo-controlled prophylaxis study (COPCOV)

There is no proven preventative therapy or vaccine against COVID-19. Theinfection has spread rapidly and there has already been a substantial adverse impact on the global economy. Healthcare workers have been affected disproportionately in the continuing pandemic. Significant infection rates in this critical group have resulted in a breakdown of health services in some countries. Chloroquine, and the closely related hydroxychloroquine, are safe and well tolerated medications which can be given for years without adverse effects. Chloroquine and hydroxychloroquine have significant antiviral activity against SARS-CoV-2, and despite the lack of benefit of hydroxychloroquine treatment in patients hospitalised with severe COVID-19, these drugs could still work in prevention. The emerging infection paradigm of an early viral peak, and late inflammation where there is benefit from corticosteroids. If these direct actiing antivirals are to work, they have the best chance given either early in infection infection occurs. We describe the study protocol for multi-centre, multi-country randomised, double blind, placebo controlled trial to answer the question can chloroquine/ hydroxychloroquine prevent COVID-19. 40,000 participants working in healthcare facilities or involved in the management of COVID-19 will be randomised 1:1 to receive chloroquine/ hydroxychloroquine or matched placebo as daily prophylaxis for three months. The primary objective is the prevention of symptomatic, virological or serologically proven coronavirus disease (COVID-19). The study could detect a 23% reduction from an incidence of 3% in the placebo group for either drug with 80% power. Secondary objectives are to determine ifchloroquine/hydroxychloroquine prophylaxis attenuates severity, prevents asymptomaticCOVID-19 and symptomatic acute respiratory infections of another aetiology (non-SARS-CoV-2). © 2020. Schilling WH et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.