Patient experience and overall satisfaction after emergency abdominal surgery.

BACKGROUND: There is a growing recognition of the importance of patient experience in healthcare, however little is known in the context of emergency abdominal surgery. This study sought to quantify the association between patient experience and overall satisfaction. METHODS: Patient demographics, operation details and 30-day clinical outcome data of consecutive patients undergoing emergency abdominal surgery were collected. Data was collected using validated Patient Reported Experience Measures (PREMs) questionnaires. Categorical data were tested using Mann Whitney U test. Multivariable regression was used to determine independent factors associated with satisfaction. RESULTS: In a well-fitting multivariable analysis (R2 = 0.71), variables significantly associated with a higher global satisfaction score were "sufficient information given about treatment" (ß = 0.86, 95% CI 0.01-1.70, p = 0.047), "sufficient explanation of risks and benefits of surgery" (ß = 1.26, 95% CI 0.18-2.34, p = 0.020), "absence of night-time noise" (ß = 1.35, 95% CI 0.56-2.14, p = 0.001) and "confidence and trust in nurses" (ß = 1.51, 95% CI 0.54-2.49, p = 0.003). CONCLUSIONS: Overall patient satisfaction was strongly associated with perceptions of good communication and transfer of information. Confidence and trust in the clinical team is an important determinant of patient experience. Improving the ward environment by reducing noise at night may also improve the overall experience and satisfaction in emergency surgery.

Assessment of CAOS as a training model in spinal surgery: a randomised study.

The objectives of this study were (1) to quantify the benefit of computer assisted orthopaedic surgery (CAOS) pedicle screw insertion in a porcine cadaver model evaluated by dissection and computed tomography (CT); (2) to compare the effect on performance of four surgeons with no experience of CAOS, and varying experience of pedicle screw insertion; (3) to see if CT with extended windows was an acceptable method to evaluate the position of the pedicle screws in the porcine cadaver model, compared to dissection. This was a prospective, randomised, controlled and blinded porcine cadaver study. Twelve 6-month-old porcine (white skinned Landrace) lumbar spines were scanned pre-operatively by spiral CT, as required for the CAOS computer data set. Computer randomisation allocated the specimens to one of four surgeons, all new to CAOS but with different levels of experience in spinal surgery. The usual anatomical landmarks for the freehand technique were known to all four surgeons. Two pedicles at each vertebral level were randomly allocated between conventional free hand insertion and an electromagnetic image guided surgery (NAVITRAK) and 6.5 mm cancellous AO screws inserted. Post-operatively, spiral CT was blindly evaluated by an independent radiologist and the spine fellow to assess the accuracy of pedicle screw placement, by each method. The inter- and intra-observer reliability of CT was evaluated compared to dissection. The pedicle screw placement was assessed as perfect if within the pedicle along its central axis, or acceptable (within < 2 mm from perfect), and measured in millimetres from perfect thereafter. One hundred and sixty-six of 168 pedicles in 12 porcine spines were operated on. Complete data were present for 163 pedicles (81 CAOS, 82 freehand). In the CAOS group 84% of screws were deemed acceptable or perfect, compared to 75.6% with the freehand technique. Screw misplacement was significantly reduced using CAOS (P = 0.049). Seventy-nine percent of CAOS screws were ideally placed compared with 64% with a conventional freehand technique (P = 0.05). A logistic linear regression model showed that the miss placed pedicle screw rate was significantly reduced using CAOS (P = 0.047). CAOS benefited the least experienced surgeons most (the research registrars acceptable rate increased from 70 to 90% and the spine fellow from 76 to 86%). CAOS did not have a statistically significant effect on the experienced consultant spine surgeon increasing from 70 to 79% (P = 0.39). The experienced general orthopaedic surgeon did not benefit from CAOS (P = 0.5). CT compared to dissection showed an intra-observer reliability of 99.4% and inter-observer reliability of 92.6%. The conclusions of this study were as follows: (1) an increased number of pedicle screws were ideally placed using the CAOS electromagnetic guidance system compared to the conventional freehand technique; (2) junior surgeons benefited most from CAOS; (3) we believe CAOS (Navitrak) with porcine lumbar spines evaluated by post operative CT, represents a useful model for training junior surgeons in pedicle screw placement; (4) experienced spine surgeons, who have never used CAOS, may find CAOS less helpful than previously reported.

Ten-year survivorship of rough-surfaced femoral stem with geometry similar to Charnley femoral stem.

The aim of this study is to review the 10-year results of 269 cemented total hip arthroplasties performed using the Harvard femoral stem with matte surface finish and Charnley stem-like geometry. This is a retrospective cross-sectional survivorship study. We retrospectively reviewed the results of 269 cemented total hip arthroplasties performed using the Harvard femoral stem in 257 patients (men/women 93:164, mean age 71.2 years) between 1990 and 1994. The median duration of follow-up for the surviving implants was 118 (range 60-129) months. Radiographs were reviewed to evaluate the type of osteoarthritis, cement mantle thickness, alignment of the components, presence of aseptic loosening, and radiolucent lines. Kaplan-Meier survival analysis and Cox proportional hazards analysis were performed to evaluate 10-year survival and the impact of various radiological parameters on the prosthesis survival respectively. Of the 248 eligible patients (260 hips), 6 patients (7 hips) were lost to follow-up, and 67 patients had died at the time of the study; 36 hips (35 patients) underwent revision surgery for aseptic failure (median duration 60 months, range 12-125 months), and 11 hips were revised for septic failure (median duration 24 months, range 10-53 months from the index procedure). The femoral component was revised in all patients, whereas the acetabular component was revised in 27 patients. Ten-year survival for the femoral and acetabular components using aseptic loosening (with and without revision surgery) as an end point was 77.5% (71.5%-83.5%) and 91.1% (87.2%-95%), respectively. Cox regression analysis did not reveal a statistically significant (P > 0.05) effect of various radiological parameters on survival rate. Our results demonstrate that the matte surface finish femoral component (with geometry similar to Charnley femoral component) has less satisfactory long-term survival rate.

Fatal haemorrhage following a low-energy fracture of the pubic ramus.

We report a case of fatal haemorrhage following a low-energy fracture of the pubic ramus in an 85-year-old woman.

Inactivation of the srtA gene in Streptococcus gordonii inhibits cell wall anchoring of surface proteins and decreases in vitro and in vivo adhesion.

The srtA gene product, SrtA, has been shown to be required for cell wall anchoring of protein A as well as virulence in the pathogenic bacterium Staphylococcus aureus. There are five major mechanisms for displaying proteins at the surface of gram-positive bacteria (P. Cossart and R. Jonquieres, Proc. Natl. Acad. Sci. USA 97:5013-5015, 2000). However, since many of the known surface proteins of gram-positive bacteria are believed to be exported and anchored via the sortase pathway, it was of interest to determine if srtA plays a similar role in other gram-positive bacteria. To that end, the srtA gene in the human oral commensal organism Streptococcus gordonii was insertionally inactivated. The srtA mutant S. gordonii exhibited a marked reduction in quantity of a specific anchored surface protein. Furthermore, the srtA mutant had reduced binding to immobilized human fibronectin and had a decreased ability to colonize the oral mucosa of mice. Taken together, these results suggest that the activity of SrtA plays an important role in the biology of nonpathogenic as well as pathogenic gram-positive cocci.

Percentage hypochromic red cells and the response to intravenous iron therapy in anaemic haemodialysis patients.

INTRODUCTION: Iron deficiency is commonly encountered in haemodialysis (HD) patients and may be overcome by i.v. iron therapy. We have examined the percentage hypochromic red cells (%HRC) for predicting response to i.v. iron in subjects with a low serum ferritin. METHODS: Prospective study of i.v. iron saccharate (trivalent iron 200 mg/week for 8 weeks) in anaemic (Hb < 10 g/dl) HD patients with serum ferritin < 100 microg/l despite oral iron therapy. Response to i.v. iron was assessed by comparing Hb at 0 and 8 weeks according to %HRC at baseline (0-3%, 4-9%, > or = 10%). Results are mean+/-1 SD. RESULTS: For all subjects (n=82), Hb and ferritin increased between 0 and 8 weeks (8.9+/-1.0 to 10.1+/-1.4, P<0.0001; 55+/-24 to 288+/-126, P<0.0001). Patients were stratified into three groups according to %HRC at baseline (0-3%, 4-9%, > or = 10%). Hb increased significantly in all three groups. The mean increase in Hb was greater (0-3%, 0.6+/-1.2; 4-9%, 1.2+/-1.0; > or = 10%, 1.6+/-1.4; P=0.02) and the proportion of patients showing a > or = 1 g/dl increase in Hb was greater (0-3%, 27%; 4-9%, 57%; > or = 10%, 67%; P=0.02) in those with the largest %HRC pre-treatment. CONCLUSION: Intravenous iron therapy is effective in improving Hb in anaemic HD patients with a low ferritin. However, the magnitude of this response and the proportion of patients responding is related to the percentage hypochromic red cells prior to treatment.

Prevention of mucosal Escherichia coli infection by FimH-adhesin-based systemic vaccination.

Virtually all uropathogenic strains of Escherichia coli, the primary cause of cystitis, assemble adhesive surface organelles called type 1 pili that contain the FimH adhesin. Sera from animals vaccinated with candidate FimH vaccines inhibited uropathogenic E. coli from binding to human bladder cells in vitro. Immunization with FimH reduced in vivo colonization of the bladder mucosa by more than 99 percent in a murine cystitis model, and immunoglobulin G to FimH was detected in urinary samples from protected mice. Furthermore, passive systemic administration of immune sera to FimH also resulted in reduced bladder colonization by uropathogenic E. coli. This approach may represent a means of preventing recurrent and acute infections of the urogenital mucosa.

Development of pilus organelle subassemblies in vitro depends on chaperone uncapping of a beta zipper.

The major subassemblies of virulence-associated P pili, the pilus rod (comprised of PapA) and tip fibrillum (comprised of PapE), were reconstituted from purified chaperone-subunit complexes in vitro. Subunits are held in assembly-competent conformations in chaperone-subunit complexes prior to their assembly into mature pili. The PapD chaperone binds, in part, to a conserved motif present at the C terminus of the subunits via a beta zippering interaction. Amino acid residues in this conserved motif were also found to be essential for subunit-subunit interactions necessary for the formation of pili, thus revealing a molecular mechanism whereby the PapD chaperone may prevent premature subunit-subunit interactions in the periplasm. Uncapping of the chaperone-protected C terminus of PapA and PapE was mimicked in vitro by freeze-thaw techniques and resulted in the formation of pilus rods and tip fibrillae, respectively. A mutation in the leading edge of the beta zipper of PapA produces pilus rods with an altered helical symmetry and azimuthal disorder. This change in the number of subunits per turn of the helix most likely reflects involvement of the leading edge of the beta zipper in forming a right-handed helical cylinder. Organelle development is a fundamental process in all living cells, and these studies shed new light on how immunoglobulin-like chaperones govern the formation of virulence-associated organelles in pathogenic bacteria.

HDR microSelectron quality-assurance studies using a well-type ion chamber.

A modified Standard Imaging HDR 1000 re-entrant ion chamber has been used with an NE 2570/1 electrometer as part of a quality-assurance programme for checking 192Ir source strengths and for source localization studies. The chamber measurements correlate well with in-air calibration measurements made over a three-month source-decay period; the maximum discrepancy between the in-air measurement and the re-entrant chamber measurement was 0.9%. The source position may be determined with an uncertainty of lower than 0.5 mm. The reproducibility of measurements made with each of four electrometers used with the reentrant ion chamber was typically 0.1% (1 sigma).

Measurement of small-angle photon scattering for some breast tissues and tissue substitute materials.

For photon energies encountered in diagnostic radiology the shape of the scattering distributions for low-atomic-number media exhibits peaks in intensity close to the forward direction that are not predicted by conventional theoretical models. The positions and shapes of the peaks depend upon the interatomic and intermolecular configurations of the scatterers. The phenomenon is of particular interest because of its relevance to the understanding and modelling of x-ray imaging processes and the possibility that the peaking may be characteristic of tissue type. In the present study, peaks in the forward scattering distributions have been demonstrated for 19 samples of breast tissue and three tissue substitute materials using a position-sensitive photon detector and a 60 kVp x-ray source. Prominent features were observed for all samples investigated. Large differences were found in the shapes of the distributions between adipose and fibroglandular tissues and only small differences were found between carcinomas and fibroglandular tissues.

Carbon fibre composite bone plates. Development, evaluation and early clinical experience.

We compared the mechanical properties of carbon fibre composite bone plates with those of stainless steel and titanium. The composite plates have less stiffness with good fatigue properties. Tissue culture and small animal implantation confirmed the biocompatibility of the material. We also present a preliminary report on the use of the carbon fibre composite plates in 40 forearm fractures. All fractures united, 67% of them showing radiological remodelling within six months. There were no refractures or mechanical failures, but five fractures showed an unexpected reaction; this is discussed.

Pes planus after tibial osteotomy.

When 100 patients who had had a high tibial osteotomy for monocompartmental arthritis were reviewed, 15 were found to have evidence of neurological impairment. A severe symptomatic pes planus deformity of the ipsilateral limb had developed in 4 patients within months of surgery. Electromyographic results showed evidence of dysfunction in the territory of the posterior tibial nerve in all 4 patients, and, in 3 there was evidence of deep peroneal nerve damage. All had surgery for varus malalignment.

Interaction of the lymphocyte-derived Epstein-Barr virus nuclear antigen EBNA-1 with its DNA-binding sites.

The Epstein-Barr virus (EBV) nuclear antigen EBNA-1 plays an integral role in the maintenance of latency in EBV-infected B lymphocytes. EBNA-1 binds to sequences within the plasmid origin of replication (oriP). It is essential for the replication of the latent episomal form of EBV DNA and may also regulate the expression of the EBNA group of latency gene products. We have used sequence-specific DNA-binding assays to purify EBNA-1 away from nonspecific DNA-binding proteins in a B-lymphocyte cell extract. The availability of this eucaryotic protein has allowed an examination of the interaction of EBNA-1 with its specific DNA-binding sites and an evaluation of possible roles for the different binding loci within the EBV genome. DNA filter binding assays and DNase I footprinting experiments showed that the intact Raji EBNA-1 protein recognized the two binding site loci in oriP and the BamHI-Q locus and no other sites in the EBV genome. Competition filter binding experiments with monomer and multimer region I consensus binding sites indicated that cooperative interactions between binding sites have relatively little impact on EBNA-1 binding to region I. An analysis of the binding parameters of the Raji EBNA-1 to the three naturally occurring binding loci revealed that the affinity of EBNA-1 for the three loci differed. The affinity for the sites in region I of oriP was greater than the affinity for the dyad symmetry sites (region II) of oriP, while the physically distant region III locus showed the lowest affinity. This arrangement may provide a mechanism whereby EBNA-1 can lowest affinity. This arrangement may provide a mechanism whereby EBNA-1 can mediate differing regulatory functions through differential binding to its recognition sequence.