Acute kidney injury after gynaecological surgery - a systematic review and meta-analysis.

INTRODUCTION: Acute kidney injury (AKI) is an abruptly occurring loss of renal function, which includes both kidney injury and kidney impairment. It is associated with mortality and morbidity due to the increased risk of developing chronic kidney disease. The aim of this systematic review and meta-analysis was to determine the incidence of post-operative AKI in gynaecological patients without pre-existing kidney injury. METHODS: Systematic searches were made for studies examining the association between AKI and gynaecological surgery published between 2004 and March 2021. The primary outcome was to compare two subgroups of studies; a screening group where AKI was diagnosed by systematic clinical screening and a non-screening group where AKI was diagnosed randomly. RESULTS: Among the 1,410 records screened, 23 studies met the inclusion criteria, reporting AKI in 224,713 patients. The pooled incidence for post-operative AKI after gynaecological surgery in the screening subgroup was 7% (95% confidence interval (CI): 0.04-0.12). The overall pooled result for post-operative AKI after gynaecological surgery in the non-screening subgroup was 0% (95% CI: 0.00-0.01). CONCLUSION: We found a 7% overall risk of post-operative AKI after gynaecological surgery. We found a higher incidence of AKI in the studies screening for kidney injury, illustrating that the condition is underdiagnosed when not screened for. An important risk exists of healthy women developing severe renal damage as AKI is a common post-operative complication with a potentially severe outcome that may be prevented in early diagnosis.

[Mental health after ectopic pregnancy].

Ectopic pregnancy results in an urgent, sometimes lifethreatening condition and always leads to pregnancy loss. We conducted a literature search on mental health after ectopic pregnancy. The level of anxiety, depression, posttraumatic stress and grief was high, comparable to the level after miscarriage. Several interventions such as good communication, information or follow-up counselling sessions improved mental health. We recommend that clinicians focus on these aspects during admission and follow-up at the general practitioners.

Microbreaks in Laparoscopic Appendectomy have No Effect on Surgeons' Performance and Well-being.

BACKGROUND: Musculoskeletal fatigue and pain as a consequence of performing surgery is found in 70%-87% of surgeons. The aim of this study was to examine the effect of microbreaks on surgeons' performance and well-being during laparoscopic appendectomy. MATERIALS AND METHODS: The study was a blinded randomized crossover trial. Twelve surgeons were tested at three time points: Before surgery (baseline), after surgery without intervention, and after surgery where microbreaks were used every 10 min for 10 s. The musculoskeletal endurance test was used as the primary outcome. Performance was assessed by procedure length and a manual precision test. The surgeons' well-being was measured by level of exhaustion rated on the Borg CR10 scale and visual analog scale ratings for musculoskeletal discomfort in the neck, shoulders, back, wrists, and legs. RESULTS: No significant differences were found in musculoskeletal endurance, procedure time, or the manual precision test. The level of exhaustion was significantly increased after both normal procedures (P = 0.01) and procedures with microbreaks (P = 0.03). However, no significant difference was found between the two (P = 0.25). There was a significant increase from baseline regarding self-reported musculoskeletal discomfort in the back, shoulders, and legs after surgery but no significant differences between procedures with and without microbreaks. CONCLUSIONS: This study did not find a positive effect of microbreaks on laparoscopic appendectomy. Exhaustion and discomfort were present after surgery, demonstrating that short surgical procedures (less than 60 min) can result in fatigue in surgeons.

[Posterior reversible encephalopathy syndrome - an MRI diagnosis often missed in pregnancy].

Posterior reversible encephalopathy syndrome (PRES) is a complex clinical condition with a wide clinical spectrum. In this report two cases illustrate two different onsets. The first patient presented with general seizures, whereas the other presented with symptoms of pre-eclampsia, which developed into sudden blindness. Both patients had uneventful caesarean sections performed, with delivery of healthy children. Due to CT scans of the cerebrum, correct treatment and diagnosis were delayed in both cases, but subsequently, PRES was confirmed by MRI. Both patients were discharged in good health.

[The use of chewing gum stimulates bowel motility after gynaecological surgery]. / Brug af tyggegummi fremmer tarmmotiliteten efter gynækologisk-obstetrisk kirurgi.

Post-operative ileus is a condition which occurs after abdominal surgery. The incidence of post-operative ileus after gynaecological surgery is estimated to be 10-15% (range: 5-25%). The highest rates occur after laparotomy. Chewing gum stimulates bowel motility after gynaecological surgery and reduces time to first flatulence and faeces. Data on reduction in ileus symptoms and reduced hospital stay are not sufficient. Chewing gum is well tolerated and this article recommends it for post-operative optimization.

No Circadian Variation in Surgeons' Ability to Diagnose Acute Appendicitis.

OBJECTIVE: To examine if there were circadian variations in surgeons' ability to diagnose acute appendicitis. DESIGN: Retrospective database study of all patients admitted to an acute surgical procedure under the potential diagnosis of acute appendicitis in a 4-year period. The day was divided into 2 time intervals, day to evening hours (08:00-23:59) and night hours (00:00-07:59). Relevant data regarding the admission and surgical procedures were categorized into these 2 time intervals. SETTING: Department of Surgery at a Danish university hospital in Copenhagen. PARTICIPANTS: A total of 2366 patients were included. There were no age limitations or selection in sex. RESULTS: There was no significant difference in the ability to diagnose appendicitis in day-evening hours vs night hours (p = 0.391), nor was any significant difference found on weekdays (Monday-Thursday) vs weekends (Friday-Sunday) (p = 0.278). There were no differences in duration of the procedures, rate of conversion, or severity of postoperative surgical complications between the 2 groups. More patients underwent diagnostic imaging during day to evening hours compared with night hours (308 vs 46; p = 0.014). The use of imaging had no effect on the ability to diagnose appendicitis. Male sex showed a higher probability of the diagnosis being appendicitis compared with other or no pathology (odds ratio: 3.094; p < 0.001). Age between 40 and 80 years was significantly associated with a higher probability of the diagnosis being appendicitis compared with other or no pathology. The negative appendectomy rate was 10.5%. CONCLUSION: We found no difference in the surgeons' ability to diagnose acute appendicitis during night hours compared with day to evening hours.

Test re-test reliability and construct validity of the star-track test of manual dexterity.

Objectives. We wished to determine test re-test reliability and construct validity of the star-track test of manual dexterity. Design. Test re-test reliability was examined in a controlled study. Construct validity was tested in a blinded randomized crossover study. Setting. The study was performed at a university hospital in Denmark. Participants. A total of 11 subjects for test re-test and 20 subjects for the construct validity study were included. All subjects were healthy volunteers. Intervention. The test re-test trial had two measurements with 2 days pause in between. The interventions in the construct validity study included baseline measurement, intervention 1: fatigue, intervention 2: stress, and intervention 3: fatigue and stress. There was a 2 day pause between each intervention. Main outcome measure. An integrated measure of completion time and number of errors was used. Results. All participants completed the study (test re-test n = 11; construct validity n = 20). The test re-testshowed a strong Pearson product-moment correlation (r = 0.90, n = 11, P < 0.01) with no sign of learning effect. The 20 subjects in the construct validity trial were randomized to the order of the four interventions, so that all subjects completed each intervention once. A repeated measures ANOVA determined that mean integrated measure differed between interventions (p = 0.002). Post hoc tests using Bonferroni correction revealed that compared with baseline all interventions had significantly higher integrated scores ranging from 47-59% difference in mean. Conclusion. The star track test of manual dexterity had a strong test re-test reliability, and was able to discriminate between a subject's normal manual dexterity and dexterity after exposure to fatigue and/or stress.

Working night shifts affects surgeons' biological rhythm.

BACKGROUND: Chronic sleep deprivation combined with work during the night is known to affect performance and compromise residents' own safety. The aim of this study was to examine markers of circadian rhythm and the sleep-wake cycle in surgeons working night shifts. METHODS: Surgeons were monitored prospectively for 4 days: pre call, on call, post call day 1 (PC1), and post call day 2 (PC2). The urinary metabolite of melatonin and cortisol in saliva were measured to assess the circadian rhythm. Sleep and activity were measured by actigraphy. Subjective measures were assessed by the Karolinska Sleepiness Scale and Visual Analog Scale of fatigue, general well-being, and sleep quality. RESULTS: For both metabolite of melatonin and cortisol, a significant difference (P < .05) was found in the measurement period between on call and pre call values. There was increased sleep time during the day on call and on PC1. For all subjective measures, a marked deterioration was seen on PC1. CONCLUSION: Surgeons' circadian rhythm was affected by working night shifts.

[Micropauses during surgery may benefit surgeons and patients].

Long working hours can lead to physical and mental fatigue. Surveys show that many surgeons suffer from musculoskeletal disorders. A method used to counter fatigue is frequent short pauses. Micropauses in prevention of musculoskeletal disorders appear to be effective, but more clinical research is needed. Studies show that micropauses may reduce muscular fatigue and improve concentration and precision of surgeons but the effect on patient outcome is still unknown.

The impact of sleep deprivation on surgeons' performance during night shifts.

The median incidence of adverse events that may result in patient injury is a total of 9% of all in-hospital admissions. In order to reduce this high incidence initiatives are continuously worked on that can reduce the risk of patient harm during admission by strengthening hospital systems. However, the influence of physicians' shift work on the risk on adverse events in patients remains controversial. In the studies included in this PhD thesis we wished to examine the impact of sleep deprivation and circadian rhythm disturbances on surgeons' during night shifts. Further we wished to examine the impact sleep deprivation had on surgeons' performance as a measure of how patient safety would be affected. We found that sleep deprivation subjectively had an impact on the surgeons and that they were aware of the effect fatigue had on their work performance. As a result they applied different mechanisms to cope with fatigue. Attending surgeons felt that they had a better overview now, due to more experience and better skills, than when they were residents, despite the fatigue on night shifts. We monitored surgeons' performance during night shifts by laparoscopic simulation and cognitive tests in order to assess their performance; no deterioration was found when pre call values were compared to on call values. The surgeons were monitored prospectively for 4 days across a night shift in order to assess the circadian rhythm and sleep. We found that surgeons' circadian rhythm was affected by working night shifts and their sleep pattern altered, resembling that of shift workers on the post call day. We assessed the quality of admission in medical records as a measure of surgeons' performance, during day, evening and night hours and found no deterioration in the quality of night time medical records. However, consistent high errors were found in several categories. These findings should be followed up in the future with respect of clarifying mechanism and consequences for patient safety. In conclusion the assessment of the impact of sleep deprivation on surgeons' performance during night shift is complex and multi-faceted. Surgeons do feel an impact of sleep deprivation during night shifts, and their circadian rhythm is affected. Despite this, it appears that the surgeons are able to compensate for the effects of sleep loss. We did not find any results to support that sleep loss results in psychomotor or cognitive deterioration during a 17-hour night shift or that sleep deprivation during a night shift results in reduced patient safety.

Decreased heart rate variability in surgeons during night shifts.

BACKGROUND: Heart rate variability (HRV) has been used as a measure of stress and mental strain in surgeons. Low HRV has been associated with death and increased risk of cardiac events in the general population. The aim of this study was to clarify the effect of a 17-hour night shift on surgeons' HRV. METHODS: Surgeons were monitored prospectively with an ambulatory electrocardiography device for 48 consecutive hours, beginning on a precall day and continuing through an on-call (17-h shift) day. We measured HRV by frequency domain parameters. RESULTS: We included 29 surgeons in our analysis. The median pulse rate was decreased precall (median 64, interquartile range [IQR] 56-70 beats per minute [bpm]) compared with on call (median 81, IQR 70-91 bpm, p < 0.001). Increased high-frequency (HF) activity was found precall (median 199, IQR 75-365 ms2) compared with on call (median 99, IQR 48-177 ms2, p < 0.001). The low-frequency:high-frequency (LF:HF) ratio was lower precall (median 2.7, IQR 1.9-3.9) than on call (median 4.9, IQR 3.7-6.5, p < 0.001). We found no correlation between the LF:HF ratio and performance in laparoscopic simulation. CONCLUSION: Surgeons working night shifts had a significant decrease in HRV and a significant increase in pulse rate, representing sympathetic dominance in the autonomic nervous system. TRIAL REGISTRATION: NCT01623674 (www.clinicaltrials.gov).

CONTEXTE: La variabilité de la fréquence cardiaque (VFC) a été utilisée comme mesure du stress et de l'effort mental chez les chirurgiens. On a établi un lien entre une faible VFC et la mort et le risque accru d'événement cardiaque dans la population générale. Cette étude visait à clarifier l'effet d'un quart de nuit de 17 heures sur la VFC des chirurgiens. MÉTHODES: On a surveillé prospectivement des chirurgiens au moyen d'un appareil d'électrocardiographie ambulatoire pendant 48 heures consécutives en commençant la veille de la période de garde et durant toute la journée de garde (quart de 17 heures). Nous avons mesuré la VFC au moyen de paramètres du domaine fréquentiel. RÉSULTATS: Notre analyse a porté sur 29 chirurgiens. Le pouls médian a diminué avant la période de garde (médiane de 64, plage interquartile [PIQ] de 56 à 70 battements/minute [b/m]) comparativement à la période de garde (médiane de 81, PIQ de 70 à 91 b/m, p < 0,001). On a constaté une activité de haute fréquence (HF) accrue avant la période de garde (médiane de 199, PIQ de 75 à 365 ms2) comparativement à la période de garde (médiane de 99, PIQ de 48 à 177 ms2, p < 0,001). Le ratio basses fréquences:hautes fréquences (BF:HF) était moins élevé avant (médiane de 2,7, PIQ de 1,9 à 3,9) que pendant la période de garde (médiane de 4,9, PIQ de 3,7 à 6,5, p < 0,001). Nous n'avons constaté aucun lien entre le ratio BF:HF et le rendement au cours d'une simulation de laparoscopie. CONCLUSION: Les chirurgiens qui faisaient des quarts de nuit présentaient une diminution importante de la VFC et une augmentation importante du pouls, ce qui représente une domination sympathique du système nerveux autonome. ENREGISTREMENT DE L'ESSAI: NCT01623674 (www.clinicaltrials.gov).

Admission medical records made at night time have the same quality as day and evening time records.

INTRODUCTION: A thorough and accurate admission medical record is an important tool in ensuring patient safety during the hospital stay. Surgeons' performance might be affected during night shifts due to sleep deprivation. The aim of the study was to assess the quality of admission medical records during day, evening and night time. MATERIAL AND METHODS: A total of 1,000 admission medical records were collected from 2009 to 2013 based equally on four diagnoses: mechanical bowel obstruction, appendicitis, gallstone disease and gastrointestinal bleeding. The records were reviewed for errors by a pre-defined checklist based on Danish standards for admission medical records. The time of dictation for the medical record was registered. RESULTS: A total of 1,183 errors were found in 778 admission medical records made during day- and evening time, and 322 errors in 222 admission medical records from night time shifts. No significant overall difference in error was found in the admission medical records when day and evening values were compared to night values. Subgroup analyses made for all four diagnoses showed no difference in day and evening values compared with night time values. CONCLUSION: Night time deterioration was not seen in the quality of the medical records.

Laparoscopic skills and cognitive function are not affected in surgeons during a night shift.

OBJECTIVE: To monitor surgeons' performance and cognition during night shifts. DESIGN: Surgeons were monitored before call and on call (17-hour shift). Psychomotor performance was assessed by laparoscopic simulation and cognition by the d2 test of attention. The surgeons performed the laparoscopic simulation and the d2 test of attention at 8 a.m. before call and at 4 a.m. on call. Sleep was measured by wrist actigraphy and sleepiness by the Karolinska sleepiness scale. SETTING: Department of Surgery at Herlev Hospital, Denmark. PARTICIPANTS: Overall, 30 interns, residents, and attending surgeons were included and completed the study. One participant was subsequently excluded owing to myxedema. RESULTS: The surgeons slept significantly less on call than before call. There was increasing sleepiness on call; however, no significant differences were found in the precall laparoscopic simulation values compared with on-call values. The d2 test of attention showed significantly improved values on call compared with before call. CONCLUSION: Sleep deprivation during a 17-hour night shift did not impair surgeons' psychomotor or cognitive performance.

[Uncertain if physicians' shift work causes patient harm]. / Usikkert om lægers vagtarbejde øger risikoen for patientfejl.

The role of physicians' shift work in adverse events causing patient harm is not clear. However, extended shifts reduce psychomotor performance and cognition in daytime after a 24-hour shift. The incidence and preventability of adverse events in Denmark are comparable to other Western countries, despite the fact that Danish physicians do not work extended hours. The role of physicians' shift work in adverse events causing patient harm remains controversial and further research is needed.

Analgesic effects of melatonin: a review of current evidence from experimental and clinical studies.

Melatonin is an endogenous indoleamine, produced mainly by the pineal gland. Melatonin has been proven to have chronobiotic, antioxidant, antihypertensive, anxiolytic and sedative properties. There are also experimental and clinical data supporting an analgesic role of melatonin. In experimental studies, melatonin shows potent analgesic effects in a dose-dependent manner. In clinical studies, melatonin has been shown to have analgesic benefits in patients with chronic pain (fibromyalgia, irritable bowel syndrome, migraine). The physiologic mechanism underlying the analgesic actions of melatonin has not been clarified. The effects may be linked to G(i) -coupled melatonin receptors, to G(i) -coupled opioid µ-receptors or GABA-B receptors with unknown downstream changes with a consequential reduction in anxiety and pain. Also, the repeated administration of melatonin improves sleep and thereby may reduce anxiety, which leads to lower levels of pain. In this paper, we review the current evidence regarding the analgesic properties of melatonin in animals and humans with chronic pain.

Conservatively treated perforation of the neovagina in a male to female transsexual patient.

An unknown number of patients have had male to female gender transformation. Various surgical techniques have been employed to construct the neovagina. The more traditional techniques include inverted penile grafts and vascular pedicle grafts, but also the small bowel and sigmoid colon have been used. In this case, the authors present a patient who previously had a gender transformation from male to female with use of bowel for the neovagina. The patient presented with severe abdominal pain, fever and leukocytosis. A CT scan revealed retroperitoneal free air, and an x-ray examination with contrast through the neovagina showed leakage from the neovaginal top. The patient was treated conservatively with antibiotics and discharged after 7 days.