The effect of the creation of a ring-fenced orthopaedic ward on length of stay for elective arthroplasty patients.

INTRODUCTION: More than 150,000 hip and knee joint replacements are carried out in the United Kingdom yearly, and variations in length of stay [LOS] affects the overall costs of the procedures. This audit assesses the effect of the introduction of specialist ward on LOS following arthroplasty. METHOD: A combination of prospective and retrospective data on length of stay, demographics, and surgical site infections [SSI] were collected for the six months before and six months after the specialist ward was opened. Primary lower limb arthroplasty data was evaluated. American Society of Anaesthesiologists Physical Status Scores [ASA] for all admissions for lower limb arthroplasty were compared. RESULTS: Mean LOS for 222 patients managed in general orthopaedic wards was 7.61 days compared to 5.67 days for 191 patients managed in a dedicated arthroplasty ward. Three surgical site infections [SSIs] were noted in the general ward compared to zero in the specialist ward. CONCLUSIONS: This audit demonstrates a two-day reduction in LOS for patients managed in a ring-fenced ward. The cause of the reduction is multifactorial and not solely due to a trend for reduced SSI but influenced by many other changes cascading from the original organisational revision. Overall reduced stay however can only increase efficiency if downstream resources are available. Other units may wish to explore the benefits from similar dedicated wards in response to a growing demand for arthroplasty within a system of fixed resources.

Heated lidocaine/tetracaine patch (Synera, Rapydan) compared with lidocaine/prilocaine cream (EMLA) for topical anaesthesia before vascular access.

BACKGROUND: We compared the lidocaine/tetracaine patch [Synera (USA), Rapydan (Europe)], a novel heat-aided patch using a eutectic mixture of lidocaine 70 mg and tetracaine 70 mg, with a eutectic mixture of lidocaine 25 mg ml(-1) and prilocaine 25 mg ml(-1) (EMLA Cream). The agents were administered at different time periods for local topical anaesthesia before a vascular access procedure. METHODS: In this double-blind, paired study, 82 adult volunteers were randomized to receive the lidocaine/tetracaine patch on one anticubital surface and lidocaine/prilocaine cream on the other concurrently for 10, 20, 30, or 60 min before a vascular access procedure. Subjects rated pain intensity using a 100 mm visual analogue scale (VAS). Skin reactions and adverse events were also evaluated. RESULTS: Median VAS scores were significantly lower for the lidocaine/tetracaine patch than for lidocaine/prilocaine cream in the 10 min (P=0.010), 20 min (P=0.042), and 30 min (P=0.001) application groups. The lidocaine/tetracaine patch was associated with significantly more erythema than lidocaine/prilocaine cream at 20, 30, and 60 min, whereas lidocaine/prilocaine cream produced more blanching than the lidocaine/tetracaine patch at 30 and 60 min. Two subjects reported nausea and faintness associated with the vascular access procedure; one was withdrawn from the study. CONCLUSIONS: The lidocaine/tetracaine patch provided effective anaesthesia with an application time as short as 10 min and was better than lidocaine/prilocaine cream at all application times shorter than 60 min, demonstrating a substantial improvement in time to onset of anaesthesia. The lidocaine/tetracaine patch provided an important alternative to lidocaine/prilocaine cream for topical local anaesthesia.

Venous thromboembolism in adult elective spinal surgery: a tertiary centre review of 2181 patients.

AIMS: To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis. PATIENTS AND METHODS: A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria. RESULTS: In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted for case-mix, LMWH remained a significant factor (p = 0.006) for VTE, but not for SSI. CONCLUSION: A peri-operative protocol involving mechanical anti-embolism stockings, adequate hydration, and early post-operative mobilisation is effective in significantly reducing the incidence of VTE. The addition of LMWH is safe in patients at higher risk of developing VTE. Cite this article: Bone Joint J 2017;99-B:1204-9.

Treatment of advanced differentiated thyroid carcinoma with high activity radioiodine therapy.

OBJECTIVES: This was a retrospective study to assess the efficacy and morbidity of high activity I therapy in patients with advanced differentiated thyroid carcinoma. METHODS: From 1975 to 2003, 38 patients with locally advanced or metastatic differentiated thyroid cancer (16 follicular, 20 papillary, one Hurthle cell, one insular) were treated with high activity radioiodine therapy (9 GBq) as the cancers had previously not responded to standard activities (5.5 GBq). RESULTS: Cumulative total activities received ranged from 11.8 to 84.5 GBq (mean 29.4 GBq per patient). Staging at presentation showed pT4 and/or M1 disease in 27/38 of patients (71.1%). Moderate (grade 2) and poorly differentiated (grade 3) tumours were present in a total of 9/38 patients (23.7%). Outcomes were evaluated according to the results of I whole-body scans, serum thyroglobulin, radiological assessments and physical examination. Neither [18F]flurodeoxyglucose positron emission tomography (F-FDG PET) nor 99mTc sestamibi were available during this study. The mean duration of follow-up was 83 months. A complete response was observed in 7/38 patients (18.4%), progressive disease in 27/38 (71.1%) and stable disease in 4/38 (10.5%). The mean survival from initiation of high activity treatment was 36.6 months. For patients with lung disease the mean survival was 45 months, neck disease 38.9 months, bone disease 35 months and multiple sites was 30.9 months. Twelve patients died during follow-up (10 due to thyroid carcinoma). After high activity treatment, 9.7% of patients suffered grade 3 and 3.2% suffered grade 4 WHO haematological toxicity. Significant salivary gland morbidity was observed (30% dry mouth, 27% salivary swelling). CONCLUSIONS: Repeated treatment with high activity (9 GBq) I in patients with advanced differentiated thyroid carcinoma appears to be of no apparent benefit and may lead to late morbidity.

Acute coronary syndrome.

Acute coronary syndromes encompass a heterogenous group of patients with different clinical presentations, who have differences in both the extent and severity of underlying coronary atherosclerosis and who have different degrees of risk of progression to myocardial infarction. For each patient, the pre-hospital practitioner should make individual treatment decisions based on the history and examination, the ECG findings, the facilities and diagnostic equipment available and the transfer time to the nearest appropriate hospital. Patients with acute ischaemic chest pain should have oxygen, aspirin, nitrates and opioid analgesia. A 12 lead ECG should be performed within 5 minutes of initial assessment. If the ECG reveals ST-segment elevation or presumed new LBBB, this signifies acute myocardial infarction and in most cases immediate reperfusion therapy should be considered. The evidence of benefit in terms of mortality and morbidity following prompt anti-platelet and fibrinolytic therapy in such cases is unequivable. Pre-hospital fibrinolysis is now well established and should be undertaken in patients with acute infarction on clinical and ECG grounds if the transfer to hospital is likely to exceed 30 minutes and it is less than 12 hours since the onset of pain. Patients with no ECG evidence of infarction may still be at considerable risk and should still be conveyed to the nearest appropriate medical facility. Whilst en-route, they should receive aspirin, nitrates, low molecular weight heparin (LMWH) and beta blockers provided there are no contra-indications.

Visioning in the brain: an fMRI study of inspirational coaching and mentoring.

Effective coaching and mentoring is crucial to the success of individuals and organizations, yet relatively little is known about its neural underpinnings. Coaching and mentoring to the Positive Emotional Attractor (PEA) emphasizes compassion for the individual's hopes and dreams and has been shown to enhance a behavioral change. In contrast, coaching to the Negative Emotional Attractor (NEA), by focusing on externally defined criteria for success and the individual's weaknesses in relation to them, does not show sustained change. We used fMRI to measure BOLD responses associated with these two coaching styles. We hypothesized that PEA coaching would be associated with increased global visual processing and with engagement of the parasympathetic nervous system (PNS), while the NEA coaching would involve greater engagement of the sympathetic nervous system (SNS). Regions showing more activity in PEA conditions included the lateral occipital cortex, superior temporal cortex, medial parietal, subgenual cingulate, nucleus accumbens, and left lateral prefrontal cortex. We relate these activations to visioning, PNS activity, and positive affect. Regions showing more activity in NEA conditions included medial prefrontal regions and right lateral prefrontal cortex. We relate these activations to SNS activity, self-trait attribution and negative affect.

The yield and safety of string capsule endoscopy in patients with dysphagia.

BACKGROUND: Dysphagia is a contraindication for the use of conventional capsule endoscopy (CE). Because string CE (SCE) allows for the immediate retrieval of the device, it eliminates the risk of capsule retention. OBJECTIVE: To assess the yield and safety of SCE in patients with dysphagia. DESIGN: Comparative study of SCE and EGD. SETTING: Phoenix Veteran Affairs Medical Center. PATIENTS AND INTERVENTIONS: Patients with dysphagia underwent SCE and EGD. RESULTS: In 40 patients with dysphagia, the EGD findings were normal in 13 (32.5%); Schatzki's ring in 10 (25%); esophageal tumors in 9 (22.5%), with 1 of these having 2 separate and distinct malignancies; erosive esophagitis in 4 (10%); strictures in 2 (5%); and a web and large esophageal varices in 1 patient each (2.5%). The sensitivity of SCE for diagnosing anatomic pathology as the likely cause of dysphagia was 92.9%, with a specificity of 92.3%, a positive predictive value of 96.3%, and negative predictive value of 85.7%. The overall agreement between SCE and EGD was 92.7% and the kappa index was 0.83. There were no complications with either procedure. There was no case of capsule retention. The SCE recording time was 385.8 seconds; 77.5% patients preferred SCE to EGD. CONCLUSIONS: (1) SCE was safe, well tolerated, and accurate for the diagnosis of pathology responsible for dysphagia; (2) SCE was preferred to EGD by more than three fourths of patients; (3) SCE can be safely performed in patients with dysphagia.

Feasibility and safety of string, wireless capsule endoscopy in the diagnosis of Barrett's esophagus.

BACKGROUND: Capsule endoscopy is a major technological advancement in the visualization of the small bowell. Its utility in the evaluation of the esophagus is mainly limited by its rapid and unpredictable transmission, thus limiting the number of pictures of the esophagus, in particular, the distal esophagus. METHODS: Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Microbiologic cultures of the capsule's surface after high-level disinfection were carried out after the procedure. At the time of recording, discomfort associated with the procedure was documented. Patient preference compared with conventional EGD was recorded. An independent endoscopist blinded to the EGD diagnoses assessed the diagnostic accuracy of pictures obtained. OBSERVATIONS: Fifty patients with Barrett's esophagus were enrolled: 28 with short-segment Barrett's and 22 with long-segment Barrett's. The procedure was safe (no strings were disrupted, and no capsule was lost), and it rendered negative microbiologic cultures after high-level disinfection. The mean recording time was 7.9 minutes; all patients with both short- and long-segment Barrett's esophagus were successfully identified. The difficulty/discomfort associated with swallowing the device, throat discomfort, gagging, moving the capsule (up and down and upon retrieval of the capsule) was none or minimal in 74%, 98%, 96%, 94%, and 76%, respectively. A single capsule was used in 24 studies, and the majority of patients (92%) preferred string-capsule endoscopy to EGD. CONCLUSIONS: String-capsule endoscopy was feasible, safe, and highly acceptable, and was preferred by patients and may prove to be more cost effective than screening EGD.

Feasibility and safety of string wireless capsule endoscopy in the diagnosis of esophageal varices.

OBJECTIVE: To assess the feasibility, safety, accuracy, and acceptability of "string-capsule endoscopy" in the evaluation of esophageal varices. MATERIAL AND METHODS: Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Time of recording and discomfort associated with the procedure was documented. Patient's preference compared to conventional esophago-gastro-duodenoscopy (EGD) was recorded. An independent endoscopist blinded to EGD diagnoses assessed the diagnostic accuracy of pictures obtained. RESULTS: Thirty patients with clinical liver cirrhosis (mean age: 54.4 yr; mean MELD score: 12.5, and mean Child-Pugh score: 6.3) were enrolled; 19 for surveillance and 11 for screening purposes. The procedure was safe (no strings were disrupted and no capsule was lost). The mean recording time was 5.8 min (2.9-8.7), the accuracy 96.7%, and discomfort was minimal. The majority (83.3%) of patients preferred string-capsule endoscopy to EGD. CONCLUSIONS: String-capsule endoscopy was feasible, safe, accurate, highly acceptable, and preferred by cirrhotic patients undergoing screening/surveillance of esophageal varices. The technique may prove to be more cost effective than conventional EGD.

Gas chromatographic determination of volatile anaesthetic agents in blood. Part 2. Clinical studies.

A method is described for the direct determination of the volatile anaesthetics halothane and isoflurane in blood by gas chromatography with flame-ionisation detection. The method is accurate and precise and allows rapid measurements of blood levels of anaesthetic agents. Headspace concentrations of anaesthetic agents in the concentration range 0-3% V/V are determined with an accuracy of +/- 0.01% V/V. The relative standard deviation of these results is less than 4.0%. A relatively small volume of blood is required for each determination, a factor of great significance in the treatment of children. The need for separate blood calibration graphs for each patient is discussed, further emphasising the need for a rapid calibration procedure. The results from the clinical application of this method show conclusively its suitability for the management of anaesthetised subjects.

Gamma-globulin modulates growth of EBV-derived B-cell tumors in SCID mice reconstituted with human lymphocytes.

The effect of weekly gamma-globulin injection on the development of human B-cell tumors was studied in 120 mice with severe combined immunodeficiency (SCID). The mice were injected intraperitoneally (i.p.) with human peripheral mononuclear cells (PBMC) from 6 different Epstein-Barr virus (EBV)-seropositive donors. Animals repopulated with cells from 5 donors received gamma-globulin or saline for 20 weeks and were followed up to 24 weeks after reconstitution. A delay in the appearance of fata EBV-derived human B-cell tumors was noticed in the gamma-globulin-treated groups as compared to the controls. In a separate experiment, the effect of gamma-globulin treatment during the initial 4 weeks after reconstitution was compared to treatment from week 5 to week 8 as well as to a continuous 20-week treatment. The results from this experiment showed that B-cell tumor growth could be prevented just as efficiently when the animals were treated only during the first 4 weeks. In contrast, no preventive effect was seen when the first gamma-globulin dose was given at the beginning of week 5 after reconstitution. Our results indicate that gamma-globulin reduces the frequency of EBV-derived B-cell tumor development and suggest that SCID mice repopulated with human cells represent a useful in vivo model for evaluation of the prophylactic and/or therapeutic effects of immunomodulatory treatments in lympho-proliferative disorders associated with immunosuppression.