Venous thromboembolism chemical prophylaxis after skull base surgery.

PURPOSE: There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis. METHODS: Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons. RESULTS: One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM. CONCLUSION: Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Advancing neurosurgery education in junior doctors and medical students - A neurosurgery virtual lecture series.

BACKGROUND: Exposure to neurosciences, especially neurosurgery, in UK medical schools is limited and variable. This combined with the fact that neurology and neurosurgery have been perceived as notoriously difficult subjects could negatively affect confidence and efficiency in junior doctors when assessing and managing patients with neurosurgical conditions. This study aims to assess the impact of a neurosurgery virtual lecture series on foundation doctors' and medical students' confidence and knowledge in the assessment and management of neurosurgical patients. METHODS: Six virtual lectures were delivered via Zoom weekly between October and November 2020 covering lesion localisation, neuroradiology, neurosurgical emergencies, trauma assessment, and neuro-ICU. Data was collected relating to participants' pre- and post-lecture self-perceived confidence levels and performance of five SBA questions, lecture series satisfaction, and feedback. RESULTS: 31 participants in a district general hospital attended the virtual lecture series (17 foundation doctors and 14 medical students). Pre-lecture, foundation doctors felt significantly more confident than medical students in trauma assessment, spinal emergencies and neurointensive care medicine. In all lectures, participants' median confidence levels improved significantly post-lecture (p < 0.05). There was no significant difference in the performance of pre-lecture SBA questions between foundation doctors and medical students in all but one lecture, which was the neuro-ICU lecture where foundation doctors scored better (3.0 vs 1.0, p = 0.012). In both cohorts, the participants' median scores in SBA questions (objective marker of knowledge improvement) increased significantly post-lecture in all lectures. CONCLUSION: This study has shown that this neurosurgery virtual lecture series that was focused and low-cost was well received, improved knowledge and confidence of junior doctors and medical students in assessing and managing neurosurgical patients. Future expansion of this lecture series into regional or national initiative can further increase exposure to neurosurgery, ultimately improving the care of neurosurgical patients.

Takotsubo cardiomyopathy with low ventricular ejection fraction and apical ballooning predicts mortality: a systematic review and meta-analysis.

Takotsubo cardiomyopathy (TCM) is characterized by temporary wall motion abnormality of the left ventricle. There is much debate upon the prognostic parameters. We conducted a systematic review and meta-analysis to investigate whether LVEF and the presence of apical ballooning predict long-term mortality in TCM. PubMed and Embase were searched through to October 30, 2017 without language restrictions, followed by an additional search through to February 2, 2020. Our search identified 18 studies that met the inclusion criteria, with a total of 5168 patients. Reduced LVEF as a categorical variable was associated with more than threefold increase in mortality risk in TCM patients (HR 3.10; 95% CI 1.78-5.42; P < 0.0001; I2 = 57%). Further subset analyses with the exclusion of studies consisting of patients with coronary artery disease revealed another significant relationship between LVEF and mortality (HR 3.13; 95% CI 1.392-7.031; P < 0.006; I2 = 58%). LVEF as a continuous variable was also found to be associated with increased mortality risk. However, this relationship only retained significance when computing odds ratios instead of hazard ratios (OR 0.95; 95% CI 0.93-0.98; P < 0.001; I2 = 0%). Finally, the existence of apical ballooning failed to demonstrate any link with an increased risk of mortality (HR 1.26; 95% CI 0.97-1.64; P = 0.09; I2 = 34%). LVEF and apical ballooning are both potential prognostic markers for mortality.

A single-centre observational cohort study to evaluate volume and severity of emergency general surgery admissions during the COVID-19 pandemic: Is there a "lockdown" effect?

INTRODUCTION: The COVID-19 pandemic has led to changes in NHS surgical service provision, including reduced elective surgical and endoscopic activity, with only essential emergency surgery being undertaken. This, combined with the government-imposed lockdown, may have impacted on patient attendance, severity of surgical disease, and outcomes. The aim of this study was to investigate a possible 'lockdown' effect on the volume and severity of surgical admissions and their outcomes. METHODS: Two separate cohorts of adult emergency general surgery inpatient admissions 30 days immediately before (February 16, 2020 to March 15, 2020), and after UK government advice (March 16, 2020 to April 15, 2020). Data were collected relating to patient characteristics, severity of disease, clinical outcomes, and compared between these groups. RESULTS: Following lockdown, a significant reduction in median daily admissions from 7 to 3 per day (p < 0.001) was observed. Post-lockdown patients were significantly older, frailer with higher inflammatory indices and rates of acute kidney injury, and also were significantly more likely to present with gastrointestinal cancer, obstruction, and perforation. Patients had significantly higher rates of Clavien-Dindo Grade ≥3 complications (p = 0.001), all cause 30-day mortality (8.5% vs. 2.9%, p = 0.028), but no significant difference was observed in operative 30-day mortality. CONCLUSION: There appears to be a "lockdown" effect on general surgical admissions with a profound impact; fewer surgical admissions, more acutely unwell surgical patients, and an increase in all cause 30-day mortality. Patients should be advised to present promptly with gastrointestinal symptoms, and this should be reinforced for future lockdowns during the pandemic.

Expanding the role of medical retina virtual clinics using multimodal ultra-widefield and optical coherence tomography imaging.

BACKGROUND: An increasingly elderly population with a corresponding increase in ophthalmic conditions has led to increased pressure on hospital eye services (HES). In this study, we evaluated the use of a medical retina virtual clinic (MRVC), which has expanded into assessing all new medical retina referrals, where the need for urgent treatment was not clear. METHODS: Retrospective analysis of all new patients who were seen in the MRVC between April 2016 and May 2018. Pro forma sheets were used in the MRVC to record the patient history, visual acuity, and type of imaging required. Two consultants reviewed the completed pro formas and images and provided a final diagnosis and management plan. These results and reasons for face-to-face (F2F) clinic appointment requests were analyzed. RESULTS: Six hundred ten new referrals were enrolled in the virtual clinic. The most common diagnosis was diabetic eye disease (59.9%). In the virtual clinic 44.1% were followed up, 28.1% were discharged, and 27.8% were booked an F2F clinic appointment (urgent/routine). The main reason for F2F clinic was to offer treatment. Urgent F2F appointments took place on average 11.9 days after virtual clinic attendance. In only two cases was the image quality felt to be inadequate to assess the retina. CONCLUSIONS: MRVC is an effective way of triaging medical retina referrals to allow those patients needing treatment to be seen promptly in the medical retinal service. The use of multimodal ultra-widefield and optical coherence tomography imaging allows assessment of a wide range of retinal pathologies and is a promising solution to alleviate the burden on HES.

Intra-tumoural regulatory T cells: a potential new target in cancer immunotherapy.

We hypothesised that T(reg) cells preferentially expand/infiltrate inside murine mesotheliomas. Immunotherapy based on the manipulation of T(reg) cell populations should therefore be targeted to the tumour site. The AE17 murine mesothelioma model was used for this study. Both intra-tumoural T(reg) cells and those in the periphery of tumour-bearing mice were identified by flow cytometry. The effect on tumour growth of intra-tumoural depletion of T(reg) cells using the PC61 anti-CD25 mAb was then examined. We identified CD4+ T(reg) cells co-expressing both the CD25 cell surface marker and the transcription factor Foxp3 within murine mesotheliomas. These intra-tumoural T(reg) cells increase significantly as a percentage of total CD4+ T cells within the tumour as it grows. We showed that the depletion of intra-tumoural T(reg) cells with anti-CD25 mAb injected directly into the tumours can cause significantly reduced tumour growth. Localised, intra-tumoural depletion of T(reg) cells is a new, clinically relevant treatment option for established tumours.