Plastic physicians: The surgical salamanders of the COVID-19 pandemic.

At the time of writing, coronavirus disease-2019 (COVID-19) has affected 6.42 million people globally and over 380,000 deaths, with the United Kingdom now having the highest death rate in Europe. The plastic surgery department at Leeds Teaching Hospitals put necessary steps in place to maintain an excellent urgent elective and acute service whilst also managing COVID-positive medical patients in the ward. We describe the structures and pathways implemented together with complex decision-making, which has allowed us to respond early and effectively. We hope these lessons will prove a useful tool as we look to open conversations around the recovery of normal activity.

Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach.

Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery. Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41-84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.

Spontaneous resolution of a giant keratoacanthoma penetrating through the nose.

Although keratoacanthomas are common and spontaneous resolution well recognized, case reports with photographic documentation of resolution are few. The subtype of giant keratoacanthoma (GKA) can give rise to severe cosmetic destruction because of their size and their predilection for cosmetically sensitive areas (nose and eyelids). Spontaneous resolution of GKAs has not been widely reported. We present an impressive series of clinical photographs documenting the spontaneous resolution of a GKS on the nose of a 56-year-old patient.

[Concept analysis: sleep quality].

Poor sleep quality may impede recovery from illness and cause quality of life to decline. An increasing number of nurses today use sleep quality as a primary indicator to measure the nature of sleep in the nursing research field. Therefore, understanding the concept of sleep quality is necessary for nurses. This paper was designed to review the concept of sleep quality using Walker and Avant's (2005) concept analysis. Results indicate that: (1) defining attributes of sleep quality include subjective perception of sleep, actual sleep hours and evaluation of activity after awaking; (2) antecedents of sleep quality include subject ability to get naturally into the sleep cycle and status of conscious state; (3) consequences of sleep quality may affect physical, psychological, social, and global dimensions; (4) among the many instruments that may be used to assess sleep quality include self-reported questionnaires and physiological measurement tools. The purpose of this paper was to help nurses better comprehend the concept of sleep quality and propose an approach to evaluate in both clinical and research settings subjects suffering from sleep-related problems using concept analysis.

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

BACKGROUND: Disseminating new safe practices has proved challenging. In a statewide initiative we developed a framework for (1) selecting two safe practices, (2) developing operational details of implementation, (3) enlisting hospitals to participate, and (4) facilitating implementation. METHODS: Potential topics were selected by a multistep process to identify candidate practices, review the evidence for efficacy and feasibility, and then select them on the basis of importance, efficacy, feasibility, and impact. A multi-stakeholder advisory group representing all constituencies selected two practices: reconciling medications (RM) and communicating critical test results (CTR). Operational details and strategies for implementation were then developed for each practice using a consensus process of discipline stakeholders led by content experts. Hospital CEOs were solicited to participate by the Massachusetts Hospital Association which made the project a "flagship" initiative. A collaborative model was used to facilitate implementation, following the IHI Model for Improvement. In addition to providing exposure to content and method experts, we gave teams a "toolkit" containing recommendations, a change package, and implementation strategies. Each collaborative met four times over an 18 month period. Results were assessed using the IHI team assessment scale and surveys of teams and hospital leaders. RESULTS: Hospital participation rate was high with 88% of hospitals participating in one or both collaboratives. Partial implementation of the practices was achieved by 50% of RM teams and 65% of CTR teams. Full implementation was achieved by 20% of teams for each. CONCLUSIONS: Major factors leading to hospital participation included the intrinsic appeal of the practices, access to experts, and the availability of implementation strategies. Team success was correlated with active engagement of a senior administrator, engagement of physicians, increased use of PDSA cycles, and attendance at collaborative meetings. The prior development of subpractices, recommendations and implementation strategies was essential for the hospital teams. These should be well worked out before hospitals are required to implement any guideline.

A guide to using performance measurement systems for continuous improvement.

The Joint Commission on Accreditation of Healthcare Organizations requires accredited organizations to use a performance measurement system that meets its inclusion requirements to satisfy performance outcome and measurement expectations. The system, known as the ORYX initiative, is used for both internal performance control and external performance comparisons. This article outlines a three-step approach to using a performance measurement system based on the philosophy of continuous improvement and the methods of statistical process control (SPC). SPC, the methodology recommended by the Joint Commission, can be applied to the analysis of many quality measures and can be implemented with Microsoft Excel software.

Abdominoplasty wound-healing complications: assisted closure using foam suction dressing.

Abdominoplasty dehiscence, with or without skin necrosis, is a difficult reconstructive problem, which historically entailed protracted management with poor aesthetic outcome. The use of a foam suction dressing in combination with rapid serial wound closure achieves effective delayed primary closure of the abdominoplasty wound with an acceptable aesthetic result. This approach allows effective wound control and functioning, as a mechanical closure device enables rapid closure by serially reducing the foam dressing size with wound closure laterally. This technique has been used in four cases; successful closure was achieved within 8 days, resulting in a stable linear abdominoplasty scar in each case.

A study of the measurement errors associated with the analysis of velar movements assessed from lateral videofluoroscopic investigations.

OBJECTIVE: The analysis of lateral videofluoroscopic images of velar movements during speech is a commonly used tool in the management of the cleft palate patient. This study tests the general hypothesis that measurements of velar movements taken from lateral videofluoroscopic images are accurate and reliable. METHOD: A measurement system was used that allowed for the rapid assessment of velopharyngeal distance, soft palate velocity during the closure cycle, extension of the soft palate at maximum closure, and the angular lift of the soft palate above the plane of the hard palate. Ten recordings of soft palate movement during speech were randomly chosen from lateral X-rays of 27 normal adults. The video recordings were captured by digital frame grabber for subsequent analysis by three operators using a standard PC that was running image-analysis software. The uncertainties associated with the above measurements were analyzed in terms of the errors introduced by the inherent calibration and nonlinearity of the imaging system, the inaccuracy of the patient setup, and the operator-dependent measurement error. RESULTS: For both absolute dimensions and ratiometric measurements, the measurement uncertainties related to the inherent nonlinearity in the imaging system were shown to be less than 2%. Typical patient misalignments as a result of a 10 degree head rotation and a 10-mm translation out of the measurement plane introduced errors of between 2% and 3%. Results showed that the average standard deviation for measurement of gap size was 1.2 mm, extension ratio was 0.11, angular lift was 3.1 degrees, and soft palate velocity was 15.5 mm/second. The intra-class correlation coefficient generally showed a good agreement between operators, typically in the range 0.8 to 0.9. CONCLUSION: Measurements of velopharyngeal distance, extension of the soft palate at maximum closure, and the angular lift of the soft palate above the plane of the hard palate assessed from lateral videofluoroscopic images are reliable and accurate. The soft palate velocity during the closure cycle can also be determined, but clinical interpretations based on this parameter should be constrained by the measurement uncertainties.

Cognitive function and the costs of Alzheimer disease. An exploratory study.

OBJECTIVE: To estimate the dollar savings in costs attainable from drug or other treatments for Alzheimer disease (AD) that stabilize or reverse patients' cognitive decline. METHODS: Medical and other disease-related utilization data were collected from the caregivers of 64 patients diagnosed as having probable AD. The quantities of utilization were priced at national levels to generate measures of illness costs. Costs per patient were then estimated as regression functions of scores on the Mini-Mental State Examination (MMSE), which was used as an index of patient cognitive function. Potential savings in illness costs were estimated by comparing predicted costs at various baseline and intervention-level values of the patient's MMSE score. RESULTS: The potential savings in illness costs attainable from treatment are small for mildly and very severely demented patients with AD. However, for moderately to severely demented home-dwelling patients having, say, an MMSE score of 7 at baseline, prevention of a 2-point decline in the score would save about $3700 annually, and a 2-point increase in an MMSE score rather than a 2-point decline would save about $7100. CONCLUSION: Large savings in the costs of caring for moderately to severely demented home-dwelling patients with AD may be achievable from disease interventions that have minor effects on patients' cognitive status.

Melanoma of the foot in white South Africans.

There have been few studies that have compared the outcome of treatment of melanoma on the sole and dorsum of the foot or defined their prognostic factors. We describe 44 white patients (30 women and 14 men, mean age 53 years) with melanoma on the foot (sole, n = 25, dorsum, n = 19) seen over a 15 year period. Forty patients presented with stage I, two with stage II, one with stage III, and one with stage IV disease. The median Breslow depth of penetration was 2.8 mm (sole 3.3, dorsum 2.3). Of the 40 patients with stage I disease, 34 patients (17 dorsum, 17 sole) were treated by wide local excision (2 cm or more) and none developed local recurrence. Six patients (five sole, one dorsum) who had narrow excision margins (less than 1 cm, stage I disease) developed local recurrences. Ten patients underwent prophylactic hyperthermic limb perfusion. Sixteen patients with stage I disease (10 sole, six dorsum) developed metastases in the inguinal nodes. All 16 underwent block dissection of the nodes and five are alive. The overall survival for both dorsum (73%) and sole (66%) (stage I disease) was similar at 60 months. Both patients with stage II disease were alive at the time of writing, but the two patients with stage III and IV disease had died. The foot is an anatomical subsite associated with a poor prognosis for melanoma. There is little difference in prognostic factors and outcome between the sole and dorsum.

Effect of longterm misoprostol coadministration with non-steroidal anti-inflammatory drugs: a histological study.

Prostaglandins are widely used in the prevention and healing of non-steroidal anti-inflammatory drug (NSAID) induced gastric and duodenal ulcers, but their longterm effect on the human gastric mucosa is unknown. This study assessed the effect of coadministration of prostaglandins with NSAIDs on the histology of the gastroduodenal mucosa. Histological appearances (using the Sydney system) of gastric biopsy specimens from 180 patients receiving longterm NSAID treatment of whom 90 had been receiving misoprostol (400-800 micrograms/day) for one to two years were studied. Both groups of patients were comparable with regard to clinical and demographic details. There was no significant difference (p > 0.1) in the prevalence of chronic gastritis (total, corpus or antrum only) between patients receiving (36 of 90 (40%)) or not receiving misoprostol (35 of 90 (39%)). Chronic gastritis was equally associated with the presence of Helicobacter pylori, 86% and 73% (p > 0.1), respectively, in the two groups. Significantly fewer patients receiving misoprostol had reactive gastritis than those receiving only NSAIDs (8 (9%) versus 27 (30%), p < 0.01). Reactive gastritis was not associated with H pylori. Thirty nine (43%) of the misoprostol treated patients had normal histology compared with 16 (18%) receiving only NSAIDs (p < 0.01). These results show two different patterns of gastric damage in patients receiving NSAIDs, namely chronic and reactive gastritis. Misoprostol treatment was associated with a significantly reduced prevalence of reactive gastritis and it is suggested that this, along with its antisecretory action, may explain the reduced prevalence of gastroduodenal lesions when coadministered with NSAIDs.

Misoprostol reduces indomethacin-induced changes in human small intestinal permeability.

This study examined whether indomethacin-induced increases in small intestinal permeability in man are prevented by concomitant administration of a prostaglandin analog (misoprostol). Twelve male volunteers were tested as baseline, following misoprostol alone (200 micrograms, at -16, -12, -8.5, -4, -1.5, and +4 hr); following indomethacin alone (75 mg, at -8; 50 mg, -1 hr); and following coadministration of misoprostol and indomethacin as specified above. A 100-ml test solution containing 3-O-methyl glucose (0.2 g), D-xylose (0.5 g), L-rhamnose (1.0 g), and [51Cr]EDTA (100 microCi) was ingested at 8 AM, and a 5-hr collection made for marker analysis to assess active and passive carrier-mediated transport and trans- and intercellular permeation, respectively. Indomethacin increased the permeation of [51Cr]EDTA selectively, and this increase was significantly reduced by the coadministration of misoprostol. These changes were mirrored by changes in [51Cr]EDTA-L-rhamnose urine excretion ratios, which indicates that paracellular permeability was specifically altered. This study supports the suggestion that NSAIDs alter intestinal permeability by a mechanism involving reduced prostaglandin synthesis and indicates that coadministration of misoprostol with NSAIDs may reduce the frequency and severity of NSAID-induced small intestinal inflammation.

Effects of fluid, electrolyte and substrate ingestion on endurance capacity.

The availability of carbohydrate (CHO) as a substrate for the exercising muscles is known to be a limiting factor in the performance of prolonged cycle exercise, and provision of exogenous CHO in the form of glucose can increase endurance capacity. The present study examined the effects of ingestion of fluids and of CHO in different forms on exercise performance. Six male volunteers exercised to exhaustion on a cycle ergometer at a workload which required approximately 70% of Vo2max. After one preliminary trial, subjects performed this exercise test on six occasions, one week apart. Immediately before exercise, and at 10-min intervals throughout, subjects ingested 100 ml of one of the following: control (no drink), water, glucose syrup, fructose syrup, glucose-fructose syrup or a dilute glucose-electrolyte solution. Each of the syrup solutions contained approximately 36 g CHO per 100 ml; the isotonic glucose-electrolyte solution contained 4 g glucose per 100 ml. A randomised Latin square order of administration of trials was employed. Expired air samples for determination of Vo2, respiratory exchange ratio and rate of CHO oxidation were collected at 15-min intervals. Venous blood samples were obtained before and after exercise. Subjects drinking the isotonic glucose-electrolyte solution exercised longer (90.8 (12.4) min, mean (SEM] than on the control test (70.2 (8.3) min; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing life stressors and social resources: applications to alcoholic patients.

A growing body of evidence points to the importance of life stressors and social resources in the development and course of alcoholism and other substance abuse disorders. This article describes the Life Stressors and Social Resources Inventory (LISRES), which provides an integrated assessment of life stressors and social resources in eight domains: physical health, home/neighborhood, financial, work, spouse/partner, children, extended family, and friends. The indices were developed on data obtained at two points in time 18 months apart from four demographically comparable groups: alcoholic patients, depressed patients, arthritic patients, and non-problem-drinking adults. As expected, alcoholic patients reported more acute and chronic stressors and fewer social resources than did non-problem-drinking adults. More important, the indices were predictively related to changes in alcohol consumption, drinking problems, depression, and self-confidence. Procedures such as the LISRES have some potential clinical and research applications and may be helpful in examining the process of recovery and relapse in substance abuse disorders.

Life stressors and social resources: an integrated assessment approach.

The Life Stressors and Social Resources Inventory (LISRES) is described. The inventory provides an integrated assessment of an individual's life context. It taps both relatively stable and new aspects of life stressors and social resources in eight domains: physical health, home/neighborhood, financial, work, spouse/partner, children, extended family, and friends. The indices were developed on data obtained at two points in time from groups of depressed patients, alcoholic patients, arthritic patients, and healthy adults. The indices are internally consistent, moderately intercorrelated, and relatively stable over time. In addition, they are predictably related to changes in respondents' functioning. Although more developmental work is needed, the LISRES has some potential clinical and research applications and may be helpful in examining the process of stress and coping.

The effect of dietary carbohydrate intake on the metabolic response to prolonged walking on consecutive days.

Six healthy subjects walked 37 km per day for four consecutive days on two occasions one month apart; on one walk, subjects consumed a high carbohydrate (CHO) diet (85 +/- 1% CHO, Mean +/- SE) and on the other walk an isocaloric low CHO diet (2 +/- 0% CHO) was consumed. Subjects were fasted each day until after the completion of the walk. Blood samples were obtained at rest prior to exercise and after completion of each of three laps of 12.3 km. Exercise intensity corresponded to approximately 17% of VO2max. The first day of each walk demonstrated that the pattern of substrate mobilisation in response to this type of exercise is highly reproducible, there being no difference in any of the parameters measured between the two walks. Circulating glucose, lactate, insulin and triglyceride levels remained essentially unchanged; alanine fell progressively and glycerol, free fatty acid (FFA) and 3-hydroxybutyrate (BHB) rose progressively. After the first day there was a general tendency for the blood glucose concentration to decline as exercise progressed; by the end of the walk on Day 2, blood glucose was lower on the low CHO diet than on the high CHO diet. On Day 4 plasma insulin was higher (p less than 0.05) on the high CHO diet than on the low CHO diet and declined progressively on both diets. Blood lactate and alanine concentrations were generally higher at rest on the high CHO diet, but fell so that no differences existed by the end of exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic and circulatory responses to the ingestion of glucose polymer and glucose/electrolyte solutions during exercise in man.

Six men exercised on a cycle ergometer for 60 min on two occasions one week apart, at 68 +/- 3% of VO2max. On one occasion, a dilute glucose/electrolyte solution (E: osmolality 310 mosmol X kg-1, glucose content 200 mmol X l-1) was given orally at a rate of 100 ml every 10 min, beginning immediately prior to exercise. On the other occasion, a glucose polymer solution (P: osmolality 630 mosmol X kg-1, glucose content equivalent to 916 mmol X l-1) was given at the same rate. Blood samples were obtained from a superficial forearm vein immediately prior to exercise and at 15-min intervals during exercise; further samples were obtained at 15-min intervals for 60 min at rest following exercise. Heart rate and rectal temperature were measured at 5-min intervals during exercise. Blood glucose concentration was not different between the two tests during exercise, but rose to a peak of 8.7 +/- 1.2 mmol X l-1 (mean +/- SD) at 30-min post-exercise when P was drunk. Blood glucose remained unchanged during and after exercise when E was drunk. Plasma insulin levels were unchanged during exercise and were the same on both trials, but again a sharp rise in plasma insulin concentration was seen after exercise when P was drunk. The rate of carbohydrate oxidation during exercise, as calculated from VO2 and the respiratory exchange ratio, was not different between the two tests.(ABSTRACT TRUNCATED AT 250 WORDS)