Virtual or face to face modified Constraint Induced Movement Therapy (mCIMT) or CIMT – real world service transformation considerations

Keywords: Virtual;CIMT;Service Purpose: Upper limb weakness is a common complaint post stroke. Motor impairment and learned non-use can lead to secondary complications such as muscle atrophy, weakness, stiffness and contractures, which reduce function. Constraint induced movement therapy (CIMT) is a daily intensive rehabilitation treatment for upper limb weakness post stroke shown to improve activity of the weaker limb by constraining the non-affected hand and undertaking repetitive task and motor learning exercises. However CIMT is sometimes difficult to implement due to the length of time of the programme (daily attendance for 2–3 weeks) and the therapy staff and time needed. COVID-19 and the global pandemic halted face to face therapy and our aim was to redesign and deliver CIMT virtually. The objective was to consider the practicalities of virtual programmes and use patient reported outcomes to determine any difference between virtual and face to face. Methods: From September 2020 to March 2021 patients referred for CIMT were assessed using established criteria. Programmes were individually tailored to include daily supervised and independent practice. The virtual programme was established to align with the face to face programme as closely as possible. The main requirements for the virtual programme were patients’ acceptance and ability to undertake a virtual programme and access to technology that supported video consultation. Patients were supported via email/telephone and a member of the therapy team monitored progress daily in a 45 min video consultation. The ArmA (Arm Activity Measure) was completed pre and post programme for both virtual and face to face. ArmA consists of two parts;ArmA-A asks whether the patient is able to care for their arm themselves or with a carer and ArmA-B asks how easy or hard it is to use their affected arm in functional tasks. Lower scores indicate better ability. Results: Four patients completed a CIMT programme face to face and 6 virtually. ArmA scores for the whole group pre CIMT;ArmA-A, range 1–18 (maximum score 32) and ArmA-B, range 8–43 (maximum score 52). Post CIMT;ArmA-A range 0–15 with 4 patients scoring 0 or 1 and ArmA-B range 4–31. Virtual versus face to face ArmA scores reduced in both groups with change scores of between 4–14 points on ArmA-A and 3–22 points on ArmA-B. Conclusion(s): This is a small service evaluation of CIMT delivery methods in an outpatient service. Both groups showed improvements in caring for and functional use of their arm. Patients found CIMT delivered virtually or face to face as acceptable and all adhered to the programme. Impact: There are clear advantages to virtually delivered therapy programmes with the impact of flexibility and choice for patients and a ‘Greener NHS’ service due to decreased daily travel and reduction in carbon footprint that could transform physiotherapy practice and contribute to greater accessibility for many. Services that have been traditionally thought of as face to face delivery are showing commensurate benefit that needs further evaluation and research. Funding acknowledgements: No funding received.

COVID-19 and the emergency presentation of colorectal cancer

Introduction: The COVID-19 pandemic led to widespread disruption of colorectal cancer services during 2020. Cancer referral pathways were modified in response to reduced diagnostic availability. Our aim was to assess the impact of COVID-19 on colorectal cancer referral, presentation and stage. Methods: This single centre, retrospective cohort study was performed at a tertiary referral centre. Patients diagnosed and managed with colorectal adenocarcinoma between January to December 2020 were compared with patients from 2018 and 2019 in terms of demographics, mode of presentation and pathological cancer staging. Results: 272 patients were diagnosed with colorectal adenocarcinoma during 2020 compared with 282 in 2019 and 257 in 2018. Patients in all years were comparable for age, gender, and tumour location (P = >0.05). There was a significant decrease in Urgent Suspected Cancer (USC) referrals, diagnostic colonoscopy and radiological imaging performed between March to June 2020 compared with previous years. More patients presented as emergencies (P = 0.03) with increased rates of large bowel obstruction in 2020 compared with 2018/19 (P = 0.01). The distribution of TNM grade was similar across the 3 years but more T4 cancers were diagnosed in 2020 versus 2018/19 (P = 0.03). Conclusion: This study demonstrates that a relatively short-term impact on the colorectal cancer referral pathway can have significant consequences on patient presentation leading to higher risk emergency presentation and surgery at a more advanced stage. It is critical that efforts are made to make this pathway more robust to minimise the impact of other future adverse events and to consolidate the benefits of earlier diagnosis and treatment.

Where have all the appendicectomies gone?

INTRODUCTION: The COVID-19 pandemic stimulated a national lockdown in the UK. The public were advised to avoid unnecessary hospital attendances and health professionals were advised to avoid aerosol-generating procedures wherever possible. The authors hypothesised that these measures would result in a reduction in the number of patients presenting to hospital with acute appendicitis and alter treatment choices. METHODS: A multicentred, prospective observational study was undertaken during April 2020 to identify adults treated for acute appendicitis. Searches of operative and radiological records were performed to identify patients treated during April 2018 and April 2019 for comparison. RESULTS: A total of 190 patients were treated for acute appendicitis pre-lockdown compared with 64 patients treated during lockdown. Patients treated during the pandemic were more likely to have a higher American Society of Anesthesiology (ASA) score (p = 0.049) and to have delayed their presentation to hospital (2 versus 3 days, p = 0.03). During the lockdown, the use of computed tomography (CT) increased from 36.3% to 85.9% (p < 0.001), the use of an antibiotic-only approach increased from 6.2% to 40.6% (p < 0.001) and the rate of laparoscopic appendicectomy reduced from 85.3% to 17.2% (p < 0.001). The negative appendicectomy rate decreased from 21.7% to 7.1% during lockdown (p < 0.001). CONCLUSIONS: The COVID-19 lockdown was associated with a decreased incidence of acute appendicitis and a significant shift in the management approach. The increased use of CT allows the identification of simple appendicitis for conservative treatment and decreases the negative appendicectomy rate.

Correction to: The management of adult appendicitis during the COVID‑19 pandemic: an interim analysis of a UK cohort study (Techniques in Coloproctology, (2020), 10.1007/s10151-020-02297-4)

Unfortunately, few of the collaborators names were incorrectly published in the original publication. The correct names of the collaborators are given below. Talal Majeed Mina Mesri Hannah Byrne Eduardo Raimundo Da Silva Bento Fadzlien Zahari Farah Roslan John R O’Neil Dimitrios Damaskos Jamaal Jackman The original article has been updated.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study.

BACKGROUND: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Safe management of surgical smoke in the age of COVID-19.

BACKGROUND: The COVID-19 global pandemic has resulted in a plethora of guidance and opinion from surgical societies. A controversial area concerns the safety of surgically created smoke and the perceived potential higher risk in laparoscopic surgery. METHODS: The limited published evidence was analysed in combination with expert opinion. A review was undertaken of the novel coronavirus with regards to its hazards within surgical smoke and the procedures that could mitigate the potential risks to healthcare staff. RESULTS: Using existing knowledge of surgical smoke, a theoretical risk of virus transmission exists. Best practice should consider the operating room set-up, patient movement and operating theatre equipment when producing a COVID-19 operating protocol. The choice of energy device can affect the smoke produced, and surgeons should manage the pneumoperitoneum meticulously during laparoscopic surgery. Devices to remove surgical smoke, including extractors, filters and non-filter devices, are discussed in detail. CONCLUSION: There is not enough evidence to quantify the risks of COVID-19 transmission in surgical smoke. However, steps can be undertaken to manage the potential hazards. The advantages of minimally invasive surgery may not need to be sacrificed in the current crisis.