Perceptions of UK clinicians towards postoperative critical care.

Postoperative critical care is a finite resource that is recommended for high-risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk-stratified in practice; elucidate clinicians' opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri-operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real-world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk-averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure-specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri-operative critical care services, such as an overall lack of capacity, competition for beds with non-surgical cases and poor flow through the hospital leading to bed 'blockages'. Critical care is perceived to provide benefit to high-risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating 'enhanced care' units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals.

Cancelled operations: a 7-day cohort study of planned adult inpatient surgery in 245 UK National Health Service hospitals.

BACKGROUND: Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. METHODS: We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. RESULTS: We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12-4.02; P<0.001] and the presence of an emergency department in the treating hospital (OR=4.18; 95% CI, 2.22-7.89; P<0.001). Patients undergoing cancer surgery (OR=0.32; 95% CI, 0.22-0.46; P<0.001), obstetric procedures (OR=0.17; 95% CI, 0.08-0.32; P<0.001), and expedited surgery (OR=0.39; 95% CI, 0.27-0.56; P<0.001) were less likely to be cancelled. CONCLUSIONS: A significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

Gastrointestinal hemorrhage in patients in a respiratory intensive care unit.

Significant gastrointestinal hemorrhage occurred in 20% (20) of the patients in a respiratory intensive care unit. Risk factors significantly associated with the development of gastrointestinal hemorrhage included (1) the principal respiratory diagnosis of adult respiratory distress syndrome; (2) increasing numbers of days on a ventilator, days in the respiratory intensive care unit, and total days of hospitalization; and (3) the development of thrombocytopenia. Factors not associated with an increased risk of gastrointestinal hemorrhage were the age and sex of the patient, the respiratory diagnosis of chronic obstructive pulmonary disease, and the use of therapy with either heparin or corticosteroids. Routine prophylactic administration of antacids was associated with a decreased incidence of hemorrhage. The mortality of bleeders was significantly greater than that of nonbleeders.

Rapid identification of Mycobacterium bovis by a thin-layer chromatographic technique.

Lipid analyses were performed on 107 isolates of mycobacteria, using thin-layer chromatography. A distinctive blue-gray spot was observed after spraying and charring at an Rf of 0.75 for 35 of 38 Mycobacterium bovis isolates examined. The spot, designated M bovis identifying lipid, was observed only with M bovis and was not seen on any other of 9 mycobacterial species examined. This procedure has a high rate of agreement (97.2%) with standard biochemical tests and can rapidly detect M bovis from naturally occurring infections. Although chemical and antigenic characteristics are not fully elucidated, the apparent specificity of this spot for M bovis represents a simple timesaving method for differentiating this species from other mycobacteria when compared with conventional methods presently used.

Rapid identification of dominant Brucella antigens, using a microagglutination test.

A microagglutination test was used to identify Brucella dominant antigens from 400 Brucella and non-Brucella cultures. There was 100% agreement between microagglutination and tube agglutination tests in identifying dominant antigen.

Associations of depression, self-esteem, and substance use with sexual risk among adolescents.

BACKGROUND: Adolescents are the population at highest risk for acquiring sexually transmitted diseases (STDs). Previous research has suggested that mental health problems, including depression and low self-esteem, may play an important role in the development and maintenance of sexual risk behaviors. METHODS: National Longitudinal Study of Adolescent Health data from baseline interviews of 7th-12th graders reporting sexual intercourse in the preceding year were analyzed. Using logistic regression, associations of depressive symptoms, self-esteem, and substance use with condom nonuse at last sexual intercourse and with ever having had an STD were explored separately for each gender. RESULTS: Among boys (N = 3,192), depressive symptoms were associated with an increased risk of condom nonuse at last sexual intercourse. The association between depressive symptoms and STD appeared to be mediated by alcohol and marijuana use. For girls (N = 3,391), depressive symptoms were associated with a history of STD, but not with condom nonuse. Self-esteem was not significant in any model that included depressive symptoms. CONCLUSIONS: Adolescents with depressive symptoms are at risk for not using a condom and for having an STD. Further research is needed to elucidate the relationship among depression, substance use, and sexual risk to optimize STD prevention strategies for adolescents.

Behavior and injury in urban and rural adolescents.

OBJECTIVES: This study investigates the consistency of factors associated with adolescent injury in separate urban and rural samples. SAMPLES: Adolescents, 11-17 years old, in public schools in urban and rural Maryland (n = 2,712). METHODS: Separate bivariate and logistic regression analyses were conducted for each sample to determine individual and environmental factors associated with major and minor injuries experienced in the previous year. RESULTS: Multivariate analyses revealed that, for both samples, the probability of a major injury was highest for boys and, among both boys and girls, for those who played several team sports. Among rural youth, other significant covariates of both major and minor injuries were a tendency to engage in risky behavior and to use alcohol. For urban youth, being white, carrying a weapon for protection, attending an unsafe school, and working for pay were also significant covariates. Interactions were important and complex. CONCLUSIONS: The consistency of predictive factors, such as multiple sports team participation and risky and aggressive behaviors in completely different physical environments, underscores the need to address the contexts of heightened injury risk that some adolescents create wherever they live by playing sports and/or behaving in an antisocial, aggressive manner. Moreover, the perception of lack of safety in schools and neighborhoods is associated with increased injury rates, suggesting the need for policy interventions to target social environments as well as behavior.

The Island of Guam earthquake of august 8, 1993

A magnitude 8.0 earthquake occurred 30 kilometers off the southern coast of the pacific island of Guam, on Sunday, August 8, 1993. Moderate damage to structures and lifelines occurred throughout the island. Fortunately injuries were generally minor and there were no fatalities. Nearly all building structures on the island are constructed of reinforced concrete or masonry. High-rise hotels suffered the greatest effects from the earthquake. Os some two dozen high-rise structures, two or three suffered structural damage severe enough to justify demolition. Effects to lifelines on the island ranged from minor in communications systems, to moderate in electric power, water and transportation systems, and severe in the commercial port facility. The earthquake is expected to have a long term impact on the island's economy by diminished flow of material through the port, and reduced tourism.(AU)