The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Randomized clinical trial investigating the stress response from two different methods of analgesia after laparoscopic colorectal surgery.

BACKGROUND: One of the key elements of managed recovery is thought to be suppression of the neuroendocrine response using regional analgesics. This may be superfluous in laparoscopic colorectal surgery with small wounds. This trial assessed the effects of spinal analgesia versus intravenous patient-controlled analgesia (PCA) on neuroendocrine responses in that setting. METHODS: A randomized clinical trial was conducted with participation of patients undergoing laparoscopic colorectal surgery within a managed recovery programme. Consenting patients were allocated randomly to spinal analgesia or morphine PCA as primary postoperative analgesia. The primary outcome was interleukin (IL) 6 levels; secondary outcomes were levels of cortisol, glucose, insulin and other cytokines, pain scores, morphine use and length of hospital stay. Stress response analysis was conducted before operation, and 3, 6, 12, 24 and 48 h after surgery. RESULTS: Of 143 eligible patients, 133 were randomized and 120 completed the study. Baseline patient characteristics were similar in the two groups. There were no significant differences in median levels of insulin, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, interferon γ, tumour necrosis factor α or vascular endothelial growth factor between the spinal analgesia and PCA groups at any time point. Three hours after surgery (but at no other time point) median (i.q.r.) levels of cortisol (468 (329-678) versus 701 (429-820) nmol/l; P = 0.004) and glucose (6.1 (5.4-7.5) versus 7.0 (6.0-7.7) mmol/l; P = 0.012) were lower in the spinal analgesia group than in the PCA group. Median (i.q.r.) levels of total intravenous morphine were lower in the spinal analgesia group (10.0 (3.3-15.8) versus 45.5 (34.0-60.5) mg; P < 0.001). CONCLUSION: Spinal analgesia reduced early neuroendocrine responses and overall parenteral morphine use. REGISTRATION NUMBER: NCT01128088 (http://www.clinicaltrials.gov).

Time to adjuvant chemotherapy following colorectal cancer resection is associated with an improved survival.

AIM: Multicentre randomized trials have demonstrated equivalent long-term outcomes for open and laparoscopic resection of colon cancer. Some studies have indicated a possible survival advantage in certain patients undergoing laparoscopic resection. Patients who receive adjuvant chemotherapy in < 8 weeks following surgery can have an improved survival. METHOD: Data were collated for patients having an elective laparoscopic or open resection for non-metastatic colorectal cancer between October 2003 and December 2010 and subsequently having adjuvant chemotherapy. Survival analysis was conducted. RESULTS: In all, 209 patients received adjuvant chemotherapy following open (n = 76) or laparoscopic (n = 133) surgery. Median length of stay was 3 days with laparoscopic resection and 6 days with open resection (P < 0.0005). Median number of days to initiation of adjuvant chemotherapy was 52 with laparoscopic resection and 58 with open resection (P = 0.008). The 5-year overall survival was 89.6% in patients receiving chemotherapy in < 8 weeks after surgery, compared with 73.5% who started the treatment over 8 weeks (P = 0.016). The 5-year overall survival for those patients with a laparoscopic resection was 82.3% compared with 80.3% with an open resection (P = 0.049). CONCLUSION: There is an overall survival advantage when patients receive adjuvant chemotherapy < 8 weeks after surgery. Laparoscopic resection allows earlier discharge and, subsequently, earlier initiation of adjuvant chemotherapy.

Increase in phosphorus losses from grassland in response to Olsen-P accumulation.

The Olsen-P status of grazed grassland (Lolium perenne L.) swards in Northern Ireland was increased over a 5-yr period (March 2000 to February 2005) by applying different rates of P fertilizer (0, 10, 20, 40, or 80 kg P ha(-1) yr(-1)) to assess the relationship between soil P status and P losses in land drainage water and overland flow. Plots (0.2 ha) were hydrologically isolated and artificially drained to v-notch weirs, with flow proportional monitoring of drainage water and overland flow. Annually, the collectors for overland flow intercepted between 11 and 35% of the surplus rainfall. Single flow events accounted for up to 52% of the annual dissolved reactive phosphorus (DRP) load. The Olsen-P status of the soil influenced DRP and total phosphorus (TP) concentrations in land drainage water and overland flow. Annual TP loss was highly variable and ranged from 0.19 to 1.55 kg P ha(-1) yr(-1) for the plot receiving no P fertilizer and from 0.35 to 2.94 kg P ha(-1) yr(-1) for the plot receiving 80 kg P ha(-1) yr(-1). Despite the Olsen-P status in the soils ranging from 22 to 99 mg P kg(-1), after 5 yr of fertilizer P applications it was difficult to identify a clear Olsen-P concentration at which P losses increased. Any relationship was confounded by annual variability of hydrologic events and flows and by hydrologic differences between plots. Withholding P fertilizer for over 5 yr was not long enough to lower P losses or to have an adverse effect on herbage P concentrations.

Classification of DNA methylation patterns in tumor cell genomes using a CpG island microarray.

Our group has initiated experiments to epigenetically profile CpG island hypermethylation in genomic DNA from tissue specimens of head and neck squamous cell carcinoma (HNSCC) using a microarray of 12,288 CpG island clones. Our technique, known as a methylation-specific restriction enzyme (MSRE) analysis, is a variation of the differential methylation hybridization (DMH) technique, in that it is not an array comparison of two DNA samples using methylation-specific restriction enzymes. Instead, it is a comparison of a single DNA sample's response to a methylation-sensitive restriction enzyme (HpaII) and its corresponding methylation-insensitive isoschizomer (MspI). Estimation of the reproducibility of this microarray assay by intraclass correlation (ICC) demonstrated that in four replicate experiments for three tumor specimens, the ICC observed for a given tumor specimen ranged from 0.68 to 0.85 without filtering of data. Repeated assays achieved 87% concordance or greater for all tumors after filtering of array data by fluorescence intensity. We utilized hierarchical clustering on a population of 37 HNSCC samples to cluster tumor samples with similar DNA methylation profiles. Supervised learning techniques are now being utilized to allow us to identify associations between specific epigenetic signatures and clinical parameters. Such techniques will allow us to identify select groups of CpG island loci that could be used as epigenetic markers for both diagnosis and prognosis in HNSCC.

[3H]dexamethasone binding to plasma membrane-enriched fractions from liver of nonadrenalectomized rats.

Using liver from nonadrenalectomized adult male rats, binding sites for [3H]dexamethasone in particulate fractions are demonstrated. The binding is thermolabile, saturable, and specific for glucocorticoid. The apparent dissociation constant (Kdapp) for [3H]dexamethasone (0.48 +/- 0.084 microM) is 60-fold greater than that for cytosolic receptor (7.9 +/- 1.5 nM). The Kdapp for [3H]cortisol in particulate fractions is 2.5-fold lower than for [3H]dexamethasone (Kdapp = 0.18 microM). The binding capacities for particulate and cytosolic glucocorticoid-binding sites also differ significantly, with particulate sites at least 9.1-fold more concentrated than cytosolic sites in liver tissue. Particulate sites are determined in Percoll density gradients to have a density of 1.039 g/cc. Saturable [3H]dexamethasone radioactivity coelutes from these gradients with the plasma membrane marker enzyme 5'-nucleotidase. Adrenalectomy causes the complete loss of particulate binding sites by 6 days postadrenalectomy; however, these sites can be regenerated to two thirds of the nonadrenalectomy level by 20-30 days postadrenalectomy.

Benign parotid hypertrophy on +HIV patients: limited late failures after external radiation.

PURPOSE: Although 8-10 Gy of external radiation therapy for +HIV associated parotid hypertrophy has achieved high response rates, the responses were transient with only 1/12 of patients retaining cosmetic control at median follow-up procedures of 9.5 months. Retreatment for failures after 8-10 Gy has also been unsatisfactory. Having shown that 24 Gy of external radiation therapy for benign parotid hypertrophy produced more durable cosmetic control than 8-10 Gy, we now report on longer follow-up periods on a group of patients receiving 24 Gy. MATERIALS AND METHODS: Twenty +HIV patients with clinical and radiographic evidence of lymphoepithelial lesions of the parotid were treated with 24 Gy of external radiation therapy using daily 1.5 Gy fractions; parallel opposed technique and 6 MV photons were used in 19 patients, and unilateral electron treatment was performed for one patient. RESULTS: With a mean follow-up period of 24 months, the cosmetic control appears durable. We have had no late failures past 24 months. Two patients have complained of modest xerostomia. There was no correlation with size of the cyst and eventual cosmetic result. CONCLUSIONS: Twenty-four Gy produces durable parotid control for HIV associated lymphoepithelial lesions of the parotid glands in +HIV patients. Failures after 2 years are uncommon and the side effects have been tolerable.

Close or positive margins after surgical resection for the head and neck cancer patient: the addition of brachytherapy improves local control.

PURPOSE: Microscopically positive or close margins after surgical resection results in an approximately 21-26% local failure rate despite excellent postoperative external radiation therapy. We sought to demonstrate improved local control in head and neck cancer patients who had a resection with curative intent, and had unexpected, microscopically positive or close surgical margins. METHODS AND MATERIALS: Twenty-nine patients with microscopically close or positive margins after curative surgery were given definitive, adjuvant external radiation therapy and 125I brachytherapy. All 29 patients had squamous cell cancer and tonsil was the most common subsite within the head and neck region. After external radiation therapy and thorough discussions with the attending surgeon and pathologists, the slides, gross specimens, and appropriate radiographs were reviewed and a target volume was determined. The target volume was the region of the margin in question and varied in size based on the surgery and pathologic results. Once the target volume was identified the patient was taken back to the operating room for insertion of 125I seeds. Activity implanted (range 2.9-21.5 millicuries) was designed to administer a cumulative lifetime dose of 120-160 Gy. RESULTS: Twenty-nine patients were followed for a median of 26 months (range 5-86 months). Two-year actuarial local control was 92%. CONCLUSION: 125I, after external radiation therapy, is an excellent method to improve local control in the subset of patients with unexpectedly unsatisfactory margins.

Interactions of apomorphine with serum and tissue proteins.

Physical and covalent interactions of apomorphine with serum and tissue proteins could influence the drug's disposition and pharmacological activities in mammals. Ultrafiltration, equilibrium dialysis, and ultraviolet spectrophotometric methods have been used to study the reversible binding of apomorphine to bovine, human, rat, and swine plasma proteins. The degree of binding was generally greater than 90%, but variations were noted in some instances on the basis of drug concentrations and pH over the range of 6.8-7.8. Incubation of [8,9-3H2]apomorphine with bovine serum albumin led to retention of radioactivity and a stoichiometrically controlled released of tritium which arose from the reaction of an electrophilic drug oxidation product and protein, producing drug-protein conjugates. In vitro experiments with mouse striatal brain preparations indicated parallel covalent binding reactions. In vivo experiments in mice indicated accumulation of radioactivity in brain regions and other tissues following daily injections of [8,9-3H2]apomorphine for 14 days. The physical and covalent interactions of apomorphine with mammalian tissue proteins could be the cause of longer disposition half-lives in mammals than those previously reported. The covalent interactions, in particular, may be important in elucidating the mechanism of apomorphine-induced behavioral effects in mice.

Microbial models of mammalian metabolism. O-Dealkylation of 10,11-dimethoxyaporphine.

Microbial transformations of 10,11-dimethoxyaporphine were studied to determine the potential of microorganisms to produce monomethoxyaporphines. Ten microorganisms were identified as being capable of yielding apocodeine and/or isoapocodeine as the major metabolite in 24 and 20% yield, respectively. Cunninghamella blakesleeana (ATCC 9245) converted 10,11-dimethoxyaporphine quantitatively into isapocodeine. O-Dealkylation of this aporphine system is a facile microbial transformation, and the 10-methoxyl group is more susceptible to metabolic cleavage than the sterically hindered 11-methoxyl group. Selectivity in O-dealkylation may be accomplished with different microorganisms. This is the first report dealing with the microbial transformation of an aporphine system.

Hypothermic effects of N-n-propylnorapomorphine in mice: antagonism by neurotransmitter receptor blockers.

Six receptor blockers were compared in mice for their ability to alter hypothermia induced by the dopamine agonist N-n-propylnorapomorphine (NPA). The dopamine antagonist haloperidol inhibited NPA-induced hypothermia whereas phentolamine, propranolol, sotalol, atropine, cyproheptadine, or naloxone (alpha-adrenergic, beta-adrenergic, muscarinic cholinergic, serotonergic, and opiate antagonists, respectively) failed to inhibit it. The degree of antagonism of the hypothermic effect of NPA induced by haloperidol pretreatment suggests that the hypothermic response may serve as a useful model of specific dopaminergic activity of aporphines. Hypothermia induced by NPA and other aporphines may supplement the measure of aporphine-induced stereotypic cage-climbing previously reported to be specifically dopaminergic.

Dopamine receptor sensitivity after chronic dopamine agonists. Striatal 3H-spiroperidol binding in mice after chronic administration of high doses of apomorphine, N-n-propylnorapomorphine and dextroamphetamine.

Several previous reports have demonstrated that chronic administration of both directly and indirectly acting dopamine agonists produces a supersensitive behavioral response to challenge doses of dopamine agonists when compared to the responses induced by acute administration of these drugs. That is, a given dose of a dopamine agonist will produce a greater response after chronic dopamine agonist treatment than is observed upon acute administration of that dose. A similar behavioral phenomenon resulting from chronic administration of dopamine antagonists has been suggested to be due to an increase in the number of dopamine receptors present in relevant brain areas. The same hypothesis has been put forward for the hypersensitivity induced by chronic dopamine agonist administration. The present study was designed to investigate the effect of chronic administration of high doses of both direct and indirect dopamine agonists on the dopamine receptors labeled by 3H-spiroperidol. Groups of animals (CD-1 mice) were sacrificed 1, 3 and 5 days following the last chronic injection. Striatal tissue from these mice was incubated with 3H-spiroperidol and dopamine receptor binding evaluated. Affinity of the receptors for the ligand was unaltered by treatments. The receptors labeled by 3H-spiroperidol showed no significant differences in number following the chronic administration of high doses of apomorphine (30 mg/kg). The Bmax was significantly decreased at only one time period following chronic administration of dextroamphetamine (4 mg/kg); however, there was a dramatic 30% reduction in the Bmax in striatal tissue from those mice treated with N-n-propylnorapomorphine. These results suggest that the hypersensitive behavioral response in mice following chronic administration of direct and indirect acting dopamine agonists is not due to an increase in the number of dopamine receptors in the striatum which are labeled by 3H-spiroperidol.

Behavioral facilitation following chronic administration of N-n-propylnorapomorphine.

Chronic administration of drugs which interfere with normal neurotransmission within animal nervous tissue (e.g. neurotransmitter receptor antagonists) is known to result in the development of behavioral supersensitivity. During recent years, evidence has been presented which indicates that neurotransmitter receptor agonists also produce behavioral supersensitivity. This study shows that, using stereotypic cage-climbing behavior in mice, chronic administration of apomorphine, and N-n-propylnorapomorphine (two direct-acting dopamine agonists) and d-amphetamine (an indirect dopamine agonist) produced an enhanced behavioral response to a test dose of apomorphine 4, 8 and 12 days after cessation of chronic drug injections.

Effects of apomorphine and piribedil on pentylenetetrazol-induced seizures in mice.

Based on previous work examining the effects of dextroamphetamine on pentylenetetrazol (PTZ)-induced clonic seizure threshold, the objective of the present study was to determine the effects of two other dopamine agonists, apomorphine (AP) and piribedil, on PTZ seizures. TD50 and LD50 values for CD-1 mice were determined initially for the two drugs. Subsequently, dose- and time-response analyses established that AP decreased PTZ seizure threshold 15 min after administraton, but increased the threshold at 60 min. Piribedil elevated the seizure threshold, but like AP, did not exhibit a clear dose-response relationship. Subsequent blocker studies with phentolamine, (-)sotalol, pimozide, and atropine suggested the possible neurotransmitter systems involved in the modulation of the PTZ-induced seizures by AP and piribedil. Pimozide blocked the changes in seizure threshold induced by both drugs. Atropine also decreased the AP-induced increase in threshold at 60 min. The pattern of inhibition of seizure threshold changes induced by the neurotransmitter blockers suggested that piribedil blocked seizures by means of indirect actions on several neurotransmitters.

Stereoisomers of apomorphine differ in affinity and intrinsic activity at presynaptic dopamine receptors modulating [3H]dopamine and [3H]acetylcholine release in slices of cat caudate.

We investigated the effects of R(-)-apomorphine and S(+)-apomorphine on dopamine receptors modulating electrically evoked [3H]dopamine and [3H]acetylcholine release from slices of cat caudate nucleus. R(-)-Apomorphine inhibited the release of both [3H]dopamine and [3H]acetylcholine with an IC50 of 20 nM, while S(+)-apomorphine was without inhibitory action on the electrically evoked release of either neurotransmitter at concentrations up to 1 microM. At a concentration of 1 microM, however, S(+)-apomorphine antagonized the inhibition by R(-)-apomorphine, producing a parallel five-fold shift to the right in the concentration-response curve to R(-)-apomorphine. These results indicate that S(+)-apomorphine is devoid of intrinsic activity to stimulate presynaptic dopamine receptors modulating the electrically evoked release of dopamine and acetylcholine. In addition, S(+)-apomorphine has an approximately ten-fold lower affinity for presynaptic dopamine receptors compared to R(-)-apomorphine.

Stereotypic and hypothermic effects of apomorphine and N-n-propylnorapomorphine in mice.

Two dopaminergic agonists, apomorphine (APO) and N-n-propylnorapomorphine (NPA) were compared in mice for their ability to induce stereotypic cage-climbing and hypothermia. Stereotypic cage-climbing responses were recorded on videotape and subsequently rated "blind" in comparison to the animal's predrug behavior and to the behavior of animals administered control solutions. Hypothermia was measured as changes from predug body temperature. Both APO and NPA produced statistically significant cage-climbing and hypothermia vs. controls. Dose-response analyses (0.5-10 mg/kg, i.p.) indicated that on a milligram basis the two drugs induced similar magnitudes of stereotypic activity. In contrast, dose-response analyses (0.008-40 mg/kg, i.p.) of APO and NPA induced hypothermia suggested an approximate 90-fold greater effect for NPA. These results suggest that there may be two different types of dopaminergic systems responsible for the hypothermic and stereotypic responses measured.

Intradural disc rupture. Report of two cases.

Two cases of intradural disc rupture are presented, and 43 cases found in the literature are reviewed. Dandy's original observations concerning this lesion correlate well with contemporary experience. Characteristics of the history and physical findings are uniform enough to suggest a clinically identifiable syndrome. Microscopic examination of the Cytospin cerebrospinal fluid specimen and the use of computerized tomography with metrizamide may suggest the diagnosis preoperatively. Despite significant neurological deficit associated with lumbar lesions, the prognosis following surgery is good.

Microbial transformations of pergolide to pergolide sulfoxide and pergolide sulfone.

Fifty-eight microorganisms were investigated for their ability to effect the biotransformation of the ergoline alkaloid pergolide. A majority of these organisms formed pergolide sulfoxide, and a Helminthosporium species was investigated in greater detail since it yielded significant amounts of pergolide sulfoxide. A preparative-scale transformation afforded material which was identified as the sulfoxide based on melting point, spectral, and chromatographic comparison with authentic material as well as its conversion to pergolide by reduction with triphenylphosphine. An analytical high-performance liquid chromatographic determination of the enzymatic versus spontaneous air-oxidation of pergolide in growing cultures and controls showed negligible air-oxidation and an approximately 40% enzymatic conversion of pergolide to the sulfoxide. Several organisms, including Aspergillus alliaceus formed a second metabolite, pergolide sulfone, which was identified on the basis of co-chromatographic data.

Mechanism studies of coomassie blue and silver staining of proteins.

A relatively high complexation affinity has been found for coomassie blue G-250 and the following amino acids: arginine; tyrosine; lysine; and histidine. A linear relationship was observed between log molar absorptivity and log molecular weight of 52 of 69 proteins, polypeptides, and di- and tripeptides that were allowed to react with coomassie blue G-250 in solution. The solution complexation results were used in a study of the detection of the following model proteins: bovine serum albumin, lysozyme, recombinant DNA derived human insulin, and calmodulin. Interactions between coomassie blue stained gels and silver detection reagents were determined and used as the basis for studies of enhanced sensitivity of detection of electrophoretically developed proteins. Sensitivity enhancements of up to eight-fold were observed when various sulfonic acid dye complexed proteins were detected with silver reagents versus the use of silver reagents alone. A site-directed nucleation of silver caused by the protein complexed sulfonic acid dyes is proposed as a mechanism for the observed enhancements.

Spectrofluorometric determination of hydroflumethiazide in plasma and urine.

A rapid, accurate, sensitive, and reproducible assay for hydroflumethiazide in plasma and urine was developed after studies of its UV and fluorescence spectral properties and partitioning behavior. The assay is based on initial extraction from acidified plasma or urine into ether, back-extraction into basic solution followed by acidification to about pH 1, and measurement of the fluorescence derived from the unionized molecule. Analysis of variance indicated no significant differences in assays performed on the same day. The mean recovery was 98.8 +/- 7.4% for plasma over a concentration range of 0.2-2.0 mug/ml. The method is convenient for routine clinical use and has sufficient sensitivity to quantify hydroflumethiazide levels after administration of therapeutic doses.