Postoperative Pulmonary Complications in the ENIGMA II Trial: A Post Hoc Analysis.

BACKGROUND: Nitrous oxide promotes absorption atelectasis in poorly ventilated lung segments at high inspired concentrations. The Evaluation of Nitrous oxide In the Gas Mixture for Anesthesia (ENIGMA) trial found a higher incidence of postoperative pulmonary complications and wound sepsis with nitrous oxide anesthesia in major surgery compared to a fraction of inspired oxygen of 0.8 without nitrous oxide. The larger ENIGMA II trial randomized patients to nitrous oxide or air at a fraction of inspired oxygen of 0.3 but found no effect on wound infection or sepsis. However, postoperative pulmonary complications were not measured. In the current study, post hoc data were collected to determine whether atelectasis and pneumonia incidences were higher with nitrous oxide in patients who were recruited to the Australian cohort of ENIGMA II. METHODS: Digital health records of patients who participated in the trial at 10 Australian hospitals were examined blinded to trial treatment allocation. The primary endpoint was the incidence of atelectasis, defined as lung atelectasis or collapse reported on chest radiology. Pneumonia, as a secondary endpoint, required a diagnostic chest radiology report with fever, leukocytosis, or positive sputum culture. Comparison of the nitrous oxide and nitrous oxide-free groups was done according to intention to treat using chi-square tests. RESULTS: Data from 2,328 randomized patients were included in the final data set. The two treatment groups were similar in surgical type and duration, risk factors, and perioperative management recorded for ENIGMA II. There was a 19.3% lower incidence of atelectasis with nitrous oxide (171 of 1,169 [14.6%] vs. 210 of 1,159 [18.1%]; odds ratio, 0.77; 95% CI, 0.62 to 0.97; P = 0.023). There was no difference in pneumonia incidence (60 of 1,169 [5.1%] vs. 52 of 1159 [4.5%]; odds ratio, 1.15; 95% CI, 0.77 to 1.72; P = 0.467) or combined pulmonary complications (odds ratio, 0.84; 95% CI, 0.69 to 1.03; P = 0.093). CONCLUSIONS: In contrast to the earlier ENIGMA trial, nitrous oxide anesthesia in the ENIGMA II trial was associated with a lower incidence of lung atelectasis, but not pneumonia, after major surgery.

Total knee arthroplasty: does ultra-early physical therapy improve functional outcomes and reduce length of stay? A retrospective cohort study.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) Society recommends that after total knee arthroplasty (TKA), patients should be mobilized early. However, there is no consensus on how early physical therapy should be commenced. We aim to investigate whether ultra-early physical therapy (< 12 h postoperatively) leads to better outcomes. METHODS: This is a retrospective cohort study of 569 patients who underwent primary TKA from August 2017 to December 2019 at our institution. We compared patients who had undergone physical therapy either within 24 h or 24-48 h after TKA. Further subgroup analysis was performed on the < 24 h group, comparing those who had undergone PT within 12 h and within 12-24 h. The outcomes analyzed include the Oxford Knee Scoring System score, Knee Society Scores, range of motion (ROM), length of stay (LOS) and ambulatory distance on discharge. A student's t test, chi-squared test or Fisher's exact test was used where appropriate, to determine statistical significance of our findings. RESULTS: LOS in the < 24 h group was shorter compared to the 24-48 h group (4.87 vs. 5.34 days, p = 0.002). Subgroup analysis showed that LOS was shorter in the ultra-early PT (< 12 h) group compared to the early PT (12-24 h) group (4.75 vs. 4.96 days, p = 0.009). At 3 months postoperatively, there was no significant difference in ROM, ambulatory distance or functional scores between the < 24 h group and 24-48 h group, or on subgroup analysis of the < 24 h group. CONCLUSION: Patients who underwent physical therapy within 24 h had a shorter length of stay compared to the 24-48 h group. On subgroup analysis, ultra-early (< 12 h) physical therapy correlated with a shorter length of stay compared to the 12-24 h group (4.75 vs. 4.96 days, p = 0.009) - however, the difference is small and unlikely to be clinically significant. Ultra-early (< 12 h) physical therapy does not confer additional benefit in terms of functional scores, ROM or ambulatory distance. These findings reinforce the importance of early physical therapy after TKA in facilitating earlier patient discharge.

Surgical caps displaying team members' names and roles improve effective communication in the operating room: a pilot study.

BACKGROUND: Teamwork in the operating theatre is a complex emergent phenomenon and is driven by cooperative relationships between staff. A foundational requirement for teamwork is the ability to communicate effectively, and in particular, knowing each other's name. Many operating theatre staff do not know each other's name, even after formal team introductions. The use of theatre caps to display a staff member's name and role has been suggested to improve communication and teamwork. METHODS: We hypothesized that the implementation of scrub hats with individual team members' names and roles would improve the perceived quality and effectiveness of communication in the operating theatre. A pilot project was designed as a pre-/post-implementation questionnaire sent to 236 operating room staff members at a general hospital in suburban Melbourne, Victoria, Australia, between November 6 to December 18, 2018. Participants included medical practitioners (anaesthetists, surgeons, obstetricians and gynaecologists), nurses (anaesthetic, scrub/scout and paediatric nurses), midwives and theatre technicians. The primary outcome was a change in perceived teamwork score, measured using a five position Likert scale. RESULTS: Of 236 enrolled participants, 107 (45%) completed both the pre and post intervention surveys. The median perceived teamwork response of four did not change after the intervention, though the number of low scores was reduced (p = 0.015). In a pre-planned subgroup analysis, the median perceived teamwork score rose for midwives from three to four (p < 0.001), while for other craft groups remained similar. The median number of staff members in theatre that a participant did not know the name of reduced from three to two (p < 0.001). Participants reported knowing the names of all staff members present in the theatre more frequently after the intervention (31% vs 15%, p < 0.001). The reported rate of formal team introductions was not significantly different after the intervention (34.7% vs 47.7% p = 0.058). CONCLUSIONS: In this study, we found that wearing caps displaying name and role appeared to improve perceived teamwork and improve communication between staff members working in the operating theatre.

A Two Components Approach for Long Range Remote Raman and Laser-Induced Breakdown (LIBS) Spectroscopy Using Low Laser Pulse Energy.

The remote detection of chemicals using remote Raman spectroscopy and laser-induced breakdown spectroscopy (LIBS) is highly desirable for homeland security and NASA planetary exploration programs. We recently demonstrated Raman spectra with high signal-to-noise ratio of various materials from a 430 m distance during daylight with detection times of 1-10 s, utilizing a 203 mm diameter telescopic remote Raman system and 100 mJ/pulse laser energy at 532 nm for excitation. In this research effort, we describe a simple two-components approach that helps to obtain remote Raman and LIBS spectra of targets at distance of 246 m with 3 mJ/pulse in daytime. The two components of the method are: (1) a small spectroscopy system utilizing 76 mm diameter collection optics; and (2) a small remote lens near the target. Remote Raman spectra of various chemicals are presented here with detection time of 1 s. Remote LIBS spectra of minerals using single laser pulse of 3 mJ/pulse energy from a distance of 246 m are also presented. This research work demonstrates a simple approach that significantly improves remote Raman and LIBS capabilities for long range chemical detection with compact low laser power Raman and LIBS systems.

Spontaneous pneumocephalus from nasal continuous positive airway pressure in a patient with ventriculo-peritoneal shunt.

Pneumocephalus in patients receiving positive airway pressure ventilation commonly occurs in the setting of trauma or surgery. We report a case of atraumatic pneumocephalus in a patient with a ventriculoperitoneal (VP) shunt on nasal continuous positive airway pressure (CPAP) for obstructive sleep apnoea. The patient presented with a 1-week history of "gurgling" sensation in his head and ataxia, with CT scan findings of a significant pneumocephalus. As extensive work up did not reveal any cause for his pneumocephalus, the nasal CPAP was thought to be the source. The CPAP was discontinued with improvement of the pneumocephalus, and resolution of his symptoms. He subsequently represented with recurrence of his symptoms, and increasing pneumocephalus on imaging. This was successfully managed by increasing his shunt pressure.

Periodontitis and type II diabetes: a two-way relationship.

For many years an association between diabetes and periodontitis has been suspected. In more recent times this relationship has been suggested to be bidirectional with each condition being able to influence the other. In this review the two-way relationship between diabetes and periodontitis is considered. For this narrative review a very broad search strategy of the literature was developed using both EMBASE and MEDLINE (via PubMed) databases. The reference lists from the selected papers were also scanned, and this provided an additional source of papers for inclusion and further assessment. The data available suggest that diabetes is a risk as well as a modifying factor for periodontitis. Individuals with diabetes are more likely to have periodontitis and with increased severity when diabetes is uncontrolled/poorly controlled. Possible mechanisms of how diabetes affects periodontitis include adipokine-mediated inflammation, neutrophil dysfunction, uncoupling of bone and advanced glycation end-products-receptor for advanced glycation end-products interaction. Evidence is accruing to support how periodontitis can affect diabetes and complications associated with diabetes. There is some evidence demonstrating that periodontal therapy can result in a moderate improvement in glycaemic control. Available evidence indicates that diabetes and peridontitis are intricately interrelated and that each condition has the capacity to influence clinical features of each other.

Adhesives for the restoration of non-carious cervical lesions: a systematic review.

OBJECTIVES: To establish whether simplified adhesives (self-etch) are as clinically effective as conventional adhesives (etch-and-rinse) with multiple application steps for treatment of non-carious cervical lesions (NCCLs). NULL HYPOTHESIS: there is no difference in the clinical effectiveness of the four different bonding strategies: Three-step etch-and-rinse; Two-step etch-and-rinse; Two-step self-etch; One-step self-etch for treatment of NCCLs. SOURCES: Electronic databases were searched including: Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. In addition, studies were identified by handsearching of selected journals. STUDY SELECTION: Randomised controlled trials (RCTs) comparing at least two adhesives in non-carious cervical lesions (NCCLs), with at least 18 months follow-up were selected. The primary outcome was loss of retention/restoration loss, with marginal adaptation and marginal discolouration as secondary outcomes. Criteria for quality assessment included: random sequence generation; allocation concealment; blinding of outcome assessment; and information on withdrawals. Twenty six studies were identified that met the inclusion criteria. In general, studies were not of sufficient quality to fully address the objectives of this review. CONCLUSION: There is not enough evidence to support one adhesive or bonding strategy over another for treatment of NCCLs. Consequently, the null hypothesis of no difference cannot be supported or rejected with the data currently available. There is a need for better standardisation and reporting of randomised controlled trials investigating adhesive performance. CLINICAL SIGNIFICANCE: Studies with low overall risk of bias demonstrated good clinical performance for adhesives with all four bonding strategies. However, included studies showed wide variation between adhesives of the same category.