'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist.

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Prehospital Protocols for Post-Return of Spontaneous Circulation Are Highly Variable.

BACKGROUND: Up to 44% of out-of-hospital cardiac arrest (OHCA) patients will rearrest in the immediate post-return of spontaneous circulation (post-ROSC) period, and rearrest is associated with decreased survival. Cardiac arrest guidelines are often equivocal regarding what post-ROSC care should be provided in the prehospital setting and when hospital transport should be initiated. Prehospital protocols must balance the benefit of time-dependent hospital-based care with the risk of early rearrest. We sought to describe current prehospital protocols for post-ROSC care in the treatment of OHCA. METHODS: A single trained abstractor systematically reviewed a purposeful sample of prehospital protocols for adult non-traumatic cardiac arrest from the United States using an a priori standardized data abstraction form. Protocols were either stand-alone or integrated into intra-arrest care. Exclusion criteria were non-911 ground transport agencies and protocols not revised since the 2015 American Heart Association guideline update. All protocols were publicly available via the Internet. Data abstraction was conducted in May 2019. Measures of interest were counted and summarized. Proportions and 95% confidence intervals were calculated. RESULTS: We identified and reviewed 82 prehospital protocols from 46 states and the District of Columbia. Seven protocols were excluded due to the revision date, leaving 75 protocols included in the study. Six protocols (8%; CI 3.7-16%) provide no guidance on prehospital post-ROSC care. 12-lead electrocardiogram (ECG) acquisition (63/75 [84%; CI 73-91%]) and transport to percutaneous coronary intervention-capable hospitals (55/75 [73%; CI 62-83%]) are common, although not ubiquitous. Of those that do require a 12-lead ECG, 40% [CI 27-54%] required the presence of an ST-elevation myocardial infarction to inform their transport decision. Only 9 (12%; CI 6.4-22%) provide any guidance on when to initiate transport post-ROSC, with 4 (5%; CI 2-13%) requiring a post-ROSC stabilization period prior to transport. CONCLUSION: Prehospital treatment and transport protocols for post-ROSC care are highly variable across the United States.

A comparison between flow-regulated and adjustable valves used in hydrocephalus during infancy.

INTRODUCTION: Ventriculoperitoneal shunt insertion during the neonatal period and early infancy is associated with a high rate of shunt failure when compared to the adult population. Furthermore, the function of flow-regulated valves and differential pressure valves may be different in neonatal hydrocephalus. METHODS: A retrospective case series of all primary shunt procedures carried out during or immediately following the neonatal period, from August 2011 to February 2018 at Sheffield Children's Hospital. The total sample size was 55. This included 34 patients with adjustable valves (Miethke ProGav) and 21 with flow-regulated valves (Orbis-Sigma); however, only 53 had adequate follow-up. RESULTS: The overall 1 year shunt survival was 34% (18/53), and there was no significant difference depending on which shunt valve was implanted. The primary shunt infection rate was 11% (6/53) with S. aureus being the most common causative organism. During the first year of life, clinical signs of shunt overdrainage were seen more frequently in patients with adjustable valves than in those with flow-regulated valves (59% [19/32] versus 24% [5/21], p = 0.02). Furthermore, 2 patients in the adjustable valve group developed sagittal craniosynostosis secondary to shunt overdrainage. CONCLUSION: Shunt failure is high when inserted during or immediately following the neonatal period. Overdrainage may be less common in patients with flow-regulated valves. However, if overdrainage is observed, adjusting the setting of a differential pressure valve can effectively treat the overdrainage without the need for invasive shunt revision surgery.

Visual Outcomes from Shunting for Idiopathic Intracranial Hypertension.

A retrospective notes review was conducted for 50 consecutive patients who underwent shunt surgery for idiopathic intracranial hypertension (IIH). The decimal visual acuity and the mean radial degrees (MRD) of the I4e isopter of the Goldmann visual field were measured pre-operatively and after a mean follow-up period of 1123 days (range: 13-3551 days). A ventriculo-peritoneal shunt was the first procedure in 38 patients and a lumbo-peritoneal shunt in 12. The mean decimal visual acuity of the worse affected eye improved from 0.75 to 0.84, p = 0.011. The MRD score of the worse affected eye improved on average from 25.6° to 35.5°, p < 0.0001. In those with significant pre-operative visual impairment in their worse affected eye (defined as an MRD score ≤30°), the MRD score improved on average from 10.3° to 26.5°, p = 0.0008. The mean number of surgical procedures for each patient was 2.8 (range: 1-15). Taking all surgical procedures into account, post-operative complications were experienced by 30 patients. At last follow-up, 28 patients still complained of headache, 8 of whom had the intervention performed primarily for headache. Shunting can improve visual function in patients with IIH. There is significant post-operative morbidity and often the need for repeated procedures. Headache also commonly remains in these patients. There is a need for a randomised controlled trial of operative interventions in IIH. Sample size calculations for such a trial to treat significant vision loss are presented.

The malignant transformation of endometriosis: Is there a left lateral predisposition of ovarian clear cell and endometrioid carcinomas?

INTRODUCTION: Endometriosis affects 10% of women of reproductive age. There is evidence for a left lateral predisposition of endometriotic lesions and a 1.9-fold greater risk of ovarian cancer in endometriosis. The aim of this study is to determine whether a left lateral predisposition of ovarian clear-cell carcinoma (CCC) and endometrioid carcinoma (EC) exists. MATERIALS AND METHODS: A retrospective cohort study of all EC and CCC patients in Northern Ireland between March-2011 and June-2018. ANOVA was used to analyse preoperative prediction of stage, chi-squared (χ2) was used to compare left- and right-sided masses. Survival was estimated using Kaplan-Meier and log-rank test. A p-value <0.05 was considered significant. RESULTS: 158 patients were identified (95 EC, 55 CCC, 8 mixed). Mean age was 57.65 years with 69% presenting at stage 1. The mean CA125 was 559 U/mL (p = 0.850) and mean abdominal mass size was 14.12 cm (p = 0.732). The most common presenting symptom was an abdominal mass (37%). Despite 67% of patients having endometriosis on final pathology, only 8.9% had a known history pre-operatively. 51% of tumours were located on the left (p = 0.036). For unilateral tumours this was significant for EC (P = 0.002) but not for CCC (P = 0.555). The 1-, 3- and 5-year overall survival for all types/stages was 85%, 78% and 71% respectively. CONCLUSION: While CCC and EC are associated with endometriosis, only EC exhibits a left lateral predisposition. There is no association between preoperative CA125 or abdominal mass size and stage of disease.

Vagus nerve stimulation in children with intractable epilepsy: indications, complications and outcome.

PURPOSE: To analyze the indication, complications and outcome of vagus nerve stimulation in intractable childhood epilepsy. MATERIALS AND METHODS: We retrospectively reviewed the data of 69 children who had insertion of vagal nerve stimulator (VNS) between June 1995 and August 2006 for medically intractable epilepsy. Outcome was based on the Engel's classification. Statistical analysis of the data was also done to see if any of the parameters significantly influenced the outcome. RESULT: Thirty-eight patients (55.08 %) had a satisfactory outcome (Engel class I, II or III), and in 31 patients (44.92 %), there was no worthwhile improvement of seizures (Engel class IV). There was no statistical significance between the type of seizure and outcome (Fisher's exact test, p = 0.351). Statistical analysis also showed that the following parameters did not significantly influence the outcome (p > 0.05): age at insertion of VNS, age of first fit, duration between first fit and insertion of VNS and the length of follow-up. Complications included infection, lead fracture, fluid collection around the stimulator, neck pain and difficulty swallowing. CONCLUSION: Vagus nerve stimulation is a relatively safe and potentially effective treatment for children with medically intractable epilepsy.

An initial assessment of spent mushroom compost as a potential energy feedstock.

The Irish mushroom industry has expanded rapidly in the last decade, particularly in the border counties. Its success has generated concern, however, as the production of spent mushroom compost (SMC) has increased. Until recently, SMC as an agricultural waste has been disposed of without due consideration to the environment. As County Councils increasingly address river pollution, restrictions will prevent expansion of the mushroom industry without an SMC waste management solution. This paper looks at the availability and composition of SMC and considers its potential as an energy feedstock. Variability in SMC composition was investigated by sampling from various locations over several months. Analyses showed that, on a dry ash free basis, SMC has a calorific value equivalent to sewage sludge which has been successfully fired for many years. Compositional analysis confirmed the dry fuel as consistent in make-up and showed the moisture content to vary within 60-77%, on an as-received basis.

A re-appraisal of wood-fired combustion.

Targets for a considerable increase in electricity generation from renewables have been set in order to reduce greenhouse gas emissions and fossil fuel dependence. Extensive planting of willow, poplar and alder as energy crops has been planned for power generation plants which use wood as the fuel. The current trend is to use gasification or pyrolysis technology, but alternatively a case may be made for wood combustion, if wood becomes readily available. A range of wood-fired circulating fluidised bed combustion (CFBC) plants, using from 10 to 10,000 dry tonne equivalent (DTE)/day, was examined using the ECLIPSE process simulation package. Various factors, such as wood moisture content, harvest yield, afforestation level (AL) and discounted cash flow rate (DCF) were investigated to test their influence on the efficiency and the economics of the systems. Steam cycle conditions and wood moisture content were found to have the biggest effects on the system efficiencies; DCF and AL had the largest influences on the economics. Plants which could handle more than 500 dry tonnes/day could be economically viable; those using more than 1000 dry tonnes wood/day could be competitive with large-scale, conventional coal-fired plants, if sufficient wood were available.

Defining the medical home: the Oregon experience.

OBJECTIVE: The patient-centered medical home (PCMH) is emerging as a key strategy to improve health outcomes, reduce total costs, and strengthen primary care, but a myriad of operational measures of the PCMH have emerged. In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. We report on the process of, outcomes of, and lessons learned by this committee. METHODS: The Oregon PCMH advisory committee was appointed by the director of the Oregon Department of Human Services and held 7 public meetings between October 2009 and February 2010. The committee engaged a diverse group of Oregon stakeholders, including a variety of practicing primary care physicians. RESULTS: The committee developed a PCMH measurement framework, including 6 core attributes, 15 standards, and 27 individual measures. Key successes of the committee's work were to describe PCMH core attributes and functions in patient-centered language and to achieve consensus among a diverse group of stakeholders. CONCLUSIONS: Oregon's PCMH advisory committee engaged local stakeholders in a process that resulted in a shared PCMH measurement framework and addressed stakeholders' concerns. The state of Oregon now has implemented a PCMH program using the framework developed by the PCMH advisory committee. The Oregon experience demonstrates that a brief public process can be successful in producing meaningful consensus on PCMH roles and functions and advancing PCMH policy.

What makes gambling news?

This paper examines print media coverage of casino and electronic gambling in one Canadian province from 1992 to 1997. It provides a theme analysis of content of 234 gambling stories printed in the top two daily newspapers in Nova Scotia. The findings of our content analysis indicate that pro-gambling corporate and political newspaper sources waged a successful media campaign and constructed a powerful public rhetoric in support of new gambling products, services, and institutions. The media, for their part, gave visibility and form to these structured messages. They helped create expectations about gambling and economics and gambling and government. Law and order, and moral and medical discourses about gambling, we discovered, were minor representations in the news coverage, although moral narratives were a pervasive secondary theme in much of the reporting. At bottom, the press produced a "politics of truth" about gambling that was both an external exercise of power and an internal organizational production.

Hospital discharge reports: content and design.

The information required by family doctors on initial and final discharge reports from hospitals was specified and 546 such reports from hospitals in Aylesbury, Amersham, Banbury, Oxford, and High Wycombe were reviewed for the availability and accessibility of important information. Several items could have been recorded better, including the name of the hospital, the specialty (or department) concerned, and the name of the consultant in charge of the case. Drug reactions seemed to be under-reported in the initial discharge reports and information about treatment on discharge was inadequate. The recording of the prognosis and information given to the patient was deficient and communication on follow-up needs to be improved. The use of obscure abbreviations was widespread. There is room for improvement in the ease of access to important information, especially the diagnostic assessment, and the time taken for final reports to reach the general practitioner.

The potential for adding plastic waste fuel at a coal gasification power plant.

Plastics wastes from a municipal solid waste plant have a high energy content which make it an interesting option for co-processing with coal. The potential for adding plastic waste to a coal fired Texaco IGCC (Integrated Gasification Combined Cycle) power station is examined. The resulting efficiency increases due to the improved gasification qualities of plastic over coal. For the overall economics to be the same as the coal only case, the maximum amount that the power station can afford to spend on preparing the plastic waste for use is similar to the assumed coal cost, plus the avoided landfill cost, minus the transport cost. The location of the power station plays a key role, since this has an effect on the transport costs as well as on the landfill charges. The sensitivity of the economics of co-processing plastic waste with coal for a variety of power station operational parameters is presented.