Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting. Method: 2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates. Results: Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote. Conclusion: Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

Mathematical model for the novel coronavirus (2019-nCOV) with clinical data using fractional operator.

Coronavirus infection (COVID-19) is a considerably dangerous disease with a high demise rate around the world. There is no known vaccination or medicine until our time because the unknown aspects of the virus are more significant than our theoretical and experimental knowledge. One of the most effective strategies for comprehending and controlling the spread of this epidemic is to model it using a powerful mathematical model. However, mathematical modeling with a fractional operator can provide explanations for the disease's possibility and severity. Accordingly, basic information will be provided to identify the kind of measure and intrusion that will be required to control the disease's progress. In this study, we propose using a fractional-order SEIARPQ model with the Caputo sense to model the coronavirus (COVID-19) pandemic, which has never been done before in the literature. The stability analysis, existence, uniqueness theorems, and numerical solutions of such a model are displayed. All results were numerically simulated using MATLAB programming. The current study supports the applicability and influence of fractional operators on real-world problems.

Synthesis and Molecular Docking Study of Novel Pyrimidine Derivatives against COVID-19.

A novel series of pyrido[2,3-d]pyrimidines; pyrido[3,2-e][1,3,4]triazolo; and tetrazolo[1,5-c]pyrimidines were synthesized via different chemical transformations starting from pyrazolo[3,4-b]pyridin-6-yl)-N,N-dimethylcarbamimidic chloride 3b (prepared from the reaction of o-aminonitrile 1b and phosogen iminiumchloride). The structures of the newly synthesized compounds were elucidated based on spectroscopic data and elemental analyses. Designated compounds are subjected for molecular docking by using Auto Dock Vina software in order to evaluate the antiviral potency for the synthesized compounds against SARS-CoV-2 (2019-nCoV) main protease M pro. The antiviral activity against SARS-CoV-2 showed that tested compounds 7c, 7d, and 7e had the most promising antiviral activity with lower IC50 values compared to Lopinavir, "the commonly used protease inhibitor". Both in silico and in vitro results are in agreement.

Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting. Method: 2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates. Results: Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote. Conclusion: Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

MEMBRANOUS DEHISCENCE AFTER TRACHEAL RESECTION AND RECONSTRUCTION HEALED SPONTANEOUSLY WITH CONSERVATIVE TREATMENT

SESSION TITLE: Rare Cases in Cardiothoracic Surgery SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Membranous dehiscence after tracheal resection is an uncommon but deadly complication. It may present acutely with loss of airway, insidiously with progressive stridor, infection or subcutaneous emphysema, or asymptomatically. Treatment may be conservative if the separation is minimal but may require re-exploration if the defect is more severe. The extent of dehiscence amenable to conservative treatment is not well described in the literature. This case report describes the conservative treatment of a posterior membrane dehiscence. CASE PRESENTATION: A 50-year-old woman suffered from stridor due to tracheal stenosis after prolonged intubation from COVID-19. Endobronchial treatments were unsuccessful because of a malacic segment of airway. Via a cervical approach, approximately 2cm of malacic trachea was resected. Reconstruction was performed with a running suture of the posterior membrane and interrupted, figure-of-eight sutures of the anterior trachea. On postoperative day 5, the patient developed subcutaneous emphysema. A CT scan was obtained (Figure 1A), demonstrating disruption of the membranous portion of the anastomosis. As the patient's breathing was not affected, conservative treatment was preferred. She was encouraged to maintain her neck in a flexed position while continuously monitored with a pulse oximeter and treated with intravenous and aerosolized antibiotics. A repeat CT scan was obtained one week after (Figure 1B), showing no residual tracheal wall defect. Postoperative bronchoscopy showed that the posterior membrane had healed entirely. She remains asymptomatic on follow-up visits. DISCUSSION: Wound dehiscence after tracheal resection and reconstruction occurs in about 1-4% of the cases (1, 2), and it is associated with a significant morbidity and a 0.6% chance of mortality (1). We believe the membranous anastomosis failed because the posterior membrane was inflamed and adhered to the esophagus during the index operation. We did not want to perform a bronchoscopy in this situation, as positioning and coughing could exacerbate the dehiscence. As her breathing was unaffected at this point, we debated between a conservative or invasive approach. Conservative management is preferred for small defects and mild symptoms (3), but there is sparse further elaboration in the literature. Because the cartilaginous anastomosis appeared intact and she was breathing spontaneously, we decided to treat conservatively with expectant management. This included aggressive treatment with antibiotics to avoid infection and further anastomotic breakdown. More examples are needed to establish the likelihood of success with conservative treatment versus revisional surgery for partial dehiscence. CONCLUSIONS: Dehiscence after tracheal resection increases morbidity and mortality significantly. This is an example of a posterior membrane dehiscence that resolved spontaneously with conservative measures. Reference #1: Stock C, Gukasyan N, Muniappan A, Wright C, Mathisen D. Hyperbaric oxygen therapy for the treatment of anastomotic complications after tracheal resection and reconstruction. J Thorac Cardiovasc Surg. 2014;147(3):1030-5. Reference #2: Young A, Bigcas JLM. Tracheal Resection. [Updated 2022 Feb 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563234/. Reference #3: Auchincloss HG, Wright CD. Complications after tracheal resection and reconstruction: prevention and treatment. J Thorac Dis. 2016;8(Suppl 2):S160-7. DISCLOSURES: No relevant relationships by Rocio Castillo-Larios No relevant relationships by Magdy El-Sayed Ahmed No relevant relationships by Sebastian Fernandez-Bussy No relevant relationships by daniel hernandez No relevant relationships by Samuel Jacob No relevant relationships by Ian Makey No relevant relationships by Sai Priyanka Pulipaka No relevant relationships b Mathew Thomas No relevant relationships by Alejandra Yu Lee-Mateus

Unlocking the benefits of the Baveno VI guidance when screening for varices: an audit of clinical practice across London.

Background: The Baveno VI consensus identifies patients with compensated advanced chronic liver disease (cACLD) who can safely avoid screening endoscopy. However, concordance in clinical practice with this guidance is unknown. We audited clinical practice and the provision of transient elastography (TE) aiming to identify potential cost savings and benefits. Methods: Retrospective data collection from 12 sites across London over 6 months by reviewing oesophagogastroduodenoscopy (OGD) reports, platelet count and TE results as well as information on site-specific provision of TE. Results: Three-hundred and fifty-one screening procedures were identified; 177 (50.43%) had a TE test performed within the preceding 12 months; 142 (80.23%) patients with a recent TE test did not meet criteria for screening OGD. TE provision varied widely between sites. Conclusion: Improving concordance with the Baveno criteria through improved provision of TE would have benefits for patients, healthcare systems and the environment and would help to address the challenges of moving on from the COVID-19 pandemic.

Restricted Use of Echocardiography in Suspected Endocarditis during COVID-19 Lockdown: A Multidisciplinary Team Approach.

BACKGROUND: Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes. METHODS: All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study. RESULTS: In total, 38 patients were referred for ET review (71% male, median age 54 [interquartile range 48, 65.5] years). At the time of ET discussion, 21% had no echo imaging, 16% had point-of-care ultrasound only, and 63% had formal TTE. In total, only 16% underwent TOE. The ability of echocardiography, in those where it was performed, to affect IE diagnosis according to the Modified Duke Criteria was significant (p=0.0099); however, sensitivity was not affected. All-cause mortality was 17% at 30 days and 25% at 12 months from ET discussion in those with confirmed IE. CONCLUSION: Limiting echocardiography in patients with a low pretest probability (not probable or definite IE according to the Modified Duke Criteria) did not affect the diagnostic ability of the Modified Duke Criteria to rule out IE in this small study. Moreover, restricting nonessential echocardiography, and importantly TOE, in patients with suspected IE through use of the ET did not impact all-cause mortality.

P16 Transient elastography is underutilised in London hospitals and results in unnecessary endoscopic screening for oesophageal varices: a multi-site audit of practice

IntroductionThe Baveno VI consensus provides guidance on using non-invasive methods to identify patients with compensated advanced chronic liver disease (cACLD) who are unlikely to have clinically significant portal hypertension (CSPH). Patients with a platelet count of 150,000/Litre and a liver stiffness of 20kPa, assessed using transient elastography (TE), have a sufficiently low risk of variceal bleeding that they do not require variceal screening endoscopy to examine for oesophageal varices (OV) costing approximately £342 per procedure. This identifies potential substantial cost savings to healthcare systems and reduces risk to patients from unnecessary investigations. However, concordance with these guidelines, availability of TE and number of avoidable endoscopies is unknown.MethodRetrospective data collection from 10 sites across London, 6 teaching hospitals and 4 district general hospitals (DGH), over a 6 month period from 1st January to 30th June 2019 by reviewing oesophagogastroduodenoscopy (OGD) requests and analysing those with indications of ‘variceal screening’, ‘cirrhosis’, ‘liver disease’ or ‘variceal surveillance’. Patient platelet count and TE result within a year of OGD was recorded.ResultsData was collected for 353 endoscopies, 7 were excluded due to incomplete data and 89 due to decompensation at the time of endoscopy. 141 screening procedures were included. Endoscopic findings included: 74.5% no OV, 16.3% grade I OV and 9.2% ≥grade II OV or high risk stigmata. 49.7% did not have a recent TE (48.5% in teaching hospitals vs 52.4% in DGH). Of those who did have a recent TE result, 54 (76.1%) met the Baveno criteria for absence of CSPH, of whom 5 (9.3%) were found to have clinically significant varices. Median follow-up was 350.5 days and 0 of these patients subsequently bled. The performance of the Baveno criteria in this study was: sensitivity 64.3%, specificity 85.9%, positive predictive value 52.9% and negative predictive value 90.7%. Avoiding OGD in patients meeting Baveno criteria in this cohort would have potentially saved over £18000.DiscussionOur study shows that TE is not widely used for risk stratifying patients with cACLD across London prior to screening OGD. These simple non-invasive markers can achieve substantial cost savings, avoid exposing patients to unnecessary investigations and relieve pressure on endoscopy departments under increased strain due to the Coronavirus pandemic. Whilst a small proportion of OV will be missed, the bleeding risk in these is low with adequate follow-up. Availability and utilisation of TE for risk stratification in cACLD should be improved.