Effectiveness of enhanced pulse oximetry sonifications for conveying oxygen saturation ranges: a laboratory comparison of five auditory displays.

Background: Anaesthetists monitor auditory information about a patient's vital signs in an environment that can be noisy and while performing other cognitively demanding tasks. It can be difficult to identify oxygen saturation (SpO2) values using existing pulse oximeter auditory displays (sonifications). Methods: In a laboratory setting, we compared the ability of non-clinician participants to detect transitions into and out of an SpO2 target range using five different sonifications while they performed a secondary distractor arithmetic task in the presence of background noise. The control sonification was based on the auditory display of current pulse oximeters and comprised a variable pitch with an alarm. The four experimental conditions included an Alarm Only condition, a Variable pitch only condition, and two conditions using sonifications enhanced with additional sound dimensions. Accuracy to detect SpO2 target transitions was the primary outcome. Results: We found that participants using the two sonifications enhanced with the additional sound dimensions of tremolo and brightness were significantly more accurate (83 and 96%, respectively) at detecting transitions to and from a target SpO2 range than participants using a pitch only sonification plus alarms (57%) as implemented in current pulse oximeters. Conclusions: Enhanced sonifications are more informative than conventional sonification. The implication is that they might allow anaesthetists to judge better when desaturation decreases below, or returns to, a target range.

The effect of two cognitive aid designs on team functioning during intra-operative anaphylaxis emergencies: a multi-centre simulation study.

This multi-centre repeated measures study was undertaken to determine how contrasting designs of cognitive aids affect team performance during simulated intra-operative anaphylaxis crises. A total of 24 teams consisting of a consultant anaesthetist, an anaesthetic trainee and anaesthetic assistant managed three simulated intra-operative anaphylaxis emergencies. Each team was assigned at random to a counterbalanced order of: no cognitive aid; a linear cognitive aid; and a branched cognitive aid, and scored for team functioning. Scores were significantly higher with a linear compared with either a branched version of the cognitive aid or no cognitive aid for 'Team Overall Behavioural Performance', difference between study groups (F-value) 5.8, p = 0.01. Aggregate scores were higher with the linear compared with the branched aid design (p = 0.03). Cognitive aids improve co-ordination of the team's activities and support team members to verbalise their actions. A linear design of cognitive aid improves team functioning more than a branched design.

The effectiveness of pulse oximetry sonification enhanced with tremolo and brightness for distinguishing clinically important oxygen saturation ranges: a laboratory study.

UNLABELLED: Our study examined the effectiveness of pulse oximetry sonification enhanced with acoustic tremolo and brightness to help listeners differentiate clinically relevant oxygen saturation ranges. In a series of trials lasting 30 s each, 76 undergraduate participants identified final oxygen saturation range ( TARGET: 100% to 97%; Low: 96% to 90%; Critical: 89% and below), and detected threshold transitions into and out of the target range using conventional sonification (n = 38) or enhanced sonification (n = 38). Median (IQR [range]) accuracy for range identification with the conventional sonification was 80 (70-85 [45-95])%, whereas with the enhanced sonification it was 100 (99-100 [80-100])%; p < 0.001. Accuracy for detecting threshold transitions with the conventional sonification was 60 (50-75 [30-95])%, but with the enhanced sonification it was 100 (95-100 [75-100]%; p < 0.001. Participants can identify clinically meaningful oxygen saturation ranges and detect threshold transitions more accurately with enhanced sonification than with conventional sonification.

Comparison of the identification and ease of use of two alarm sound sets by critical and acute care nurses with little or no music training: a laboratory study.

The melodic alarm sound set for medical electrical equipment that was recommended in the International Electrotechnical Commission's IEC 60601-1-8 standard has proven difficult for clinicians to learn and remember, especially clinicians with little prior formal music training. An alarm sound set proposed by Patterson and Edworthy in 1986 might improve performance for such participants. In this study, 31 critical and acute care nurses with less than one year of formal music training identified alarm sounds while they calculated drug dosages. Sixteen nurses used the IEC and 15 used the Patterson-Edworthy alarm sound set. The mean (SD) percentage of alarms correctly identified by nurses was 51.3 (25.6)% for the IEC alarm set and 72.1 (18.8)% for the Patterson-Edworthy alarms (p = 0.016). Nurses using the Patterson-Edworthy alarm sound set reported that it was easier to distinguish between alarm sounds than did nurses using the IEC alarm sound set (p = 0.015). Principles used to construct the Patterson-Edworthy alarm sounds should be adopted for future alarm sound sets.

Do we understand the pathophysiology of endometrial cancer?

Endometrial carcinoma is the fourth most common cancer in U.K. women. Previous literature describes local, haematological or lymphatic dissemination to common sites including vaginal vault, lungs, liver, bones and brain. The authors present two unusual cases of endometrial cancer metastases to the psoas major muscle and laparoscopic port sites. Case 1 involves a 71-year-old female who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and peritoneal washings (TAH, BSO, PW) for Grade 1 endometrial cancer, Stage lB. Three years later she represented with lower back and right hip pain, with MRI imaging revealing psoas muscle metastases. Case 2 describes a 60-year-old female who underwent laparoscopic-assisted vaginal hysterectomy (LAVH), BSO+ PW for Grade 1 endometrial cancer, Stage 1B. Three years postoperatively she presented with a lateral abdominal mass overlying the laparoscopic port site scar, which was Grade 1 endometrial cancer on biopsy. These rare metastatic locations question our traditional understanding of the pathophysiology of endometrial carcinoma.

The role of needle tip position on the accuracy of diagnostic selective nerve root blocks in spinal deformity.

PURPOSE: The specificity of a selective nerve root block (SNRB) is dependant on isolating only the required nerve root whilst avoiding injectate flow to traversing nerves. Needle tip position is therefore crucial. Nerve root blocks (SNRBs) in the presence of deformity can be particularly technically challenging to perform. The aims of this study were to document the relationship of needle tip position and SNRB accuracy in patients with and without spinal deformity. METHODS: Over an 8-month period, all SNRBs performed by one spinal surgeon were included. Patients with radiographic evidence of spinal deformity were analysed separately and their lumbar deformity graded using the Schwab grading system. Needle tip position in relation to the superior pedicle and flow of contrast was documented. RESULTS: 76 patients received 85 injections without deformity, 26 patients with deformity underwent 30 SNRBs. In the normal spinal alignment group, there was on overall accuracy of 70.1% regardless of needle tip position, which improved to 91.8% for a lateral needle tip position (P < 0.001). In patients with deformity, the overall accuracy was significantly lower irrespective of needle tip position 36 versus 70%, respectively (P < 0.0019). CONCLUSIONS: Selective nerve root blocks are accurate in patients without deformity where a needle tip placement lateral to the middle third of the pedicle is achieved. The presence of spinal deformity significantly reduces the accuracy of SNRBs with a higher chance of epidural infiltration.

Imiquimod therapy for extramammary Paget's disease of the vulva: a viable non-surgical alternative.

Extramammary Paget's disease (EMPD) is a rare intraepidermal adenocarcinoma that can affect the vulval skin. Surgical excision is the gold-standard treatment, however, recurrence rates are high and extensive excisions can produce long-lasting cosmetic and functional defects. We describe one of the largest case series to-date (n = 6) on the use of topical 5% imiquimod cream as a novel treatment option and discuss our experiences. With the addition of our six cases to the literature, there are now 29 documented cases of vulval EMPD treated with 5% imiquimod cream. Of these, 50% of primary disease cases and 73% of recurrent primary disease cases have achieved clinical resolution with 5% imiquimod therapy alone. These findings suggest that imiquimod provides a viable alternative to surgical excision for vulval EMPD. However, we acknowledge that this is a simple retrospective analysis and that treatment scheduling and follow-up needs investigation in a trial setting.

Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.

Despite the potential dangers of clinical tasks being forgotten, few researchers have investigated prospective memory (PM) - the ability to remember to execute future tasks - in health-care contexts. Visual cues help people remember to execute intentions at the appropriate moment. Using an intensive care unit simulator, we investigated whether nurses' memory for future tasks improves when visual cues are present, and how nurses manage PM demands. Twenty-four nurses participated in a 40-minute scenario simulating the start of a morning shift. The scenario included eight PM tasks. The presence or absence of a visually conspicuous cue for each task was manipulated. The presence of a visual cue improved recall compared to no cue (64% vs. 50%, p = 0.03 one-tailed, η(p)(2) = 0.15). Nurses used deliberate reminders to manage their PM demands. PM in critical care might be supported by increasing the visibility of cues related to tasks. PRACTITIONER SUMMARY: Nurses must remember to execute multiple future tasks to ensure patient safety. We investigated the effect of visual cues on nurses' ability to remember future tasks. Experimental manipulation of cues in a representative intensive care unit simulation indicated that visual cues increase the likelihood that future tasks are executed.

The cognitive aids in medicine assessment tool (CMAT) applied to five neonatal resuscitation algorithms.

OBJECTIVE: The International Liaison Committee on Resuscitation (ILCOR) provides recommendations on neonatal resuscitation training and practice, which includes a template for a decision-making algorithm. We evaluated the design properties of the ILCOR algorithm and four adaptations by member resuscitation organizations using the validated Cognitive Aids in Medicine Assessment Tool (CMAT). STUDY DESIGN: Two experts rated five neonatal resuscitation algorithms against the CMAT and against medical device design criteria. RESULTS: The ILCOR algorithm scored 32 of a possible 60 CMAT points, showing an adherence rate to CMAT of 53%. The ILCOR algorithm scored higher than the design variations by member organizations. Nonetheless, there are design limitations in the ILCOR algorithm. CONCLUSION: In principle, cognitive aids can improve neonatal resuscitation team performance; however, a considered design process that incorporates the full complexity of the 'procedure as performed' is needed to improve future versions of the algorithm for incorporation in international guidelines.