The Royal Free Hospital 'hub-and-spoke network model' delivers effective care and increased access to liver transplantation.

OBJECTIVES: 'Hub-and-spoke' networks may be one solution to reduce the geographical inequality in access to liver transplantation (LT) and the growing demands on, and saturation of, LT centres. It is not clear if such networks improve equity of access, deliver comparable patient outcomes or effect patient satisfaction. STUDY DESIGN: Retrospective evaluation of outcomes and patient satisfaction within the Royal Free liver transplant 'hub-and-spoke' network. METHODS: Patient outcomes in those assessed for LT between September 2011 and 2014 at spoke centres (n = 4) were compared retrospectively with those assessed at the LT hub centre. Patient satisfaction questionnaires were completed and changes in LT referral patterns were explored with data obtained directly from NHS Blood and Transplant (NHSBT). RESULTS: A total of 655 patients (180 spoke; 475 hub) were assessed for LT. Patients referred from spoke centres were more likely to have viral hepatitis as an underlying aetiology (72/180 vs 110/475; P < 0.001), or hepatocellular carcinoma (48/180 vs 60/475; P < 0.001) as an indication for LT and were more likely to be listed for LT when compared with hub patients (139/180 vs 312/475, P = 0.005). Mortality on the waiting list (9/123 vs 25/269, P = 0.57), waiting time to LT (64-days vs 78-days, P = 0.91) and Model for End-Stage liver disease (MELD)/United Kingdom End-Stage Liver Disease (UKELD) score (P = 0.24/0.26) in listed patients were equivalent as were 1- and 3-year patient and graft survival rates. Patient satisfaction rates were high at both types of centre, with significantly more patients preferring 'locally delivered care' at spoke vs hub (11/50 vs 70/73, P≤0.0001). Since the development of formal hub-and-spoke networks data from NHSBT based on postcode confirmed a significant increase in patients undergoing LT (153%) from spoke centres, whereas numbers assessed and transplanted from the hub centre have remained static. CONCLUSION: Hub-and-spoke LT networks are effective in offering equivalent clinical outcomes, high patient satisfaction and alleviate clinical pressure on the hub centre. They have to potential to help eliminate the geographical disparity in mortality rates from chronic liver disease.

OSCE as a Summative Assessment Tool for Undergraduate Students of Surgery-Our Experience.

Traditional examination has inherent deficiencies. Objective Structured Clinical Examination (OSCE) is considered as a method of assessment that may overcome many such deficits. OSCE is being increasingly used worldwide in various medical specialities for formative and summative assessment. Although it is being used in various disciplines in our country as well, its use in the stream of general surgery is scarce. We report our experience of assessment of undergraduate students appearing in their pre-professional examination in the subject of general surgery by conducting OSCE. In our experience, OSCE was considered a better assessment tool as compared to the traditional method of examination by both faculty and students and is acceptable to students and faculty alike. Conducting OSCE is feasible for assessment of students of general surgery.

Luminescence and advanced mass spectroscopic characterization of sodium zinc orthophosphate phosphor for low-cost light-emitting diodes.

A new rare-earth-free NaZnPO4:Mn(2+) (NZP:Mn) phosphor powder has been developed by our group and investigated meticulously for the first time using secondary ion mass spectroscopy and chemical imaging techniques. The studies confirmed the effective incorporation of Mn(2+) into the host lattice, resulting in an enhancement of photoluminescence intensity. Phase purity has been verified and structure parameters have been determined successfully by Rietveld refinement studies. The NZP:Mn phosphor powder exhibits strong absorption bands in the ultraviolet and visible (300-470 nm) regions with a significant broad yellow-green (~543 nm) emission due to the characteristic spin forbidden d-d transition ((4)T1→(6)A1) of Mn(2+) ions, indicating weak crystal field strength at the zinc-replaced manganese site. The decay constants are a few milliseconds, which is a pre-requisite for applications in many display devices. The results obtained suggest that this new phosphor powder will find many interesting applications in semiconductor physics, as cost-effective light-emitting diodes (LEDs), as solar cells and in photo-physics.

Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: a prospective cohort study.

BACKGROUND: The aim of this study was to assess the cosmetic outcome of patients undergoing oncoplastic breast conserving surgery in Indian population. MATERIALS AND METHODS: A prospective cohort of 35 patients who were eligible for breast conservation surgery was included in the study from year 2007 to 2009. Patients with central quadrant tumors were excluded from the study. A double - blind cosmetic assessment was done by a plastic surgeon and a senior nurse not involved in the management of patients. Moreover, self-assessment was carried out by the patient regarding the satisfaction of surgery, comfort with brasserie, social and sexual life after oncoplastic surgery. RESULTS: In this study, 35 patients underwent oncoplastic breast conservation surgery by various techniques. The cosmetic outcome scores of the surgeon and nurse were analyzed for inter rater agreement using inter-class Correlation Coefficients. There was a good association between them. The risk factors for poor cosmetic outcome was studied by univariate analysis and significant correlation was obtained with age, volume of breast tissue excised and estimated percentage of breast volume excised (P < 0.05). Moreover, 96% of patients were moderately to extremely satisfied with the surgery. Patients were offered an option for cosmetic correction of contralateral breast by mastopexy or reduction mammoplasty however, none of them agreed for another procedure. CONCLUSIONS: Oncoplastic breast surgery helps to resect larger volume of tissue with wider margins around the tumor. It helps to achieve better cosmesis and extends the indications for breast conservation. Most of the patients were satisfied with mere preservation of the breast mound rather than a symmetrical contralateral breast.

A high-dose preparation of lactobacilli and bifidobacteria in the prevention of antibiotic-associated and Clostridium difficile diarrhoea in older people admitted to hospital: a multicentre, randomised, double-blind, placebo-controlled, parallel arm trial (PLACIDE).

BACKGROUND: Antibiotic-associated diarrhoea (AAD) occurs most commonly in older people admitted to hospital and within 12 weeks of exposure to broad-spectrum antibiotics. Although usually a mild and self-limiting illness, the 15-39% of cases caused by Clostridium difficile infection [C. difficile diarrhoea (CDD)] may result in severe diarrhoea and death. Previous research has shown that probiotics, live microbial organisms that, when administered in adequate numbers, are beneficial to health, may be effective in preventing AAD and CDD. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of a high-dose, multistrain probiotic in the prevention of AAD and CDD in older people admitted to hospital. DESIGN: A multicentre, randomised, double-blind, placebo-controlled, parallel-arm trial. SETTING: Medical, surgical and elderly care inpatient wards in five NHS hospitals in the UK. PARTICIPANTS: Eligible patients were aged ≥ 65 years, were exposed to one or more oral or parenteral antibiotics and were without pre-existing diarrhoeal disorders, recent CDD or at risk of probiotic adverse effects. Out of 17,420 patients screened, 2981 (17.1%) were recruited. Participants were allocated sequentially according to a computer-generated random allocation sequence; 1493 (50.1%) were allocated to the probiotic and 1488 (49.9%) to the placebo arm. INTERVENTIONS: Vegetarian capsules containing two strains of lactobacilli and two strains of bifidobacteria (a total of 6 × 10(10) organisms per day) were taken daily for 21 days. The placebo was inert maltodextrin powder in identical capsules. MAIN OUTCOME MEASURES: The occurrence of AAD within 8 weeks and CDD within 12 weeks of recruitment was determined by participant follow-up and checking hospital laboratory records by research nurses who were blind to arm allocation. RESULTS: Analysis based on the treatment allocated included 2941 (98.7%) participants. Potential risk factors for AAD at baseline were similar in the two study arms. Frequency of AAD (including CDD) was similar in the probiotic (159/1470, 10.8%) and placebo arms [153/1471, 10.4%; relative risk (RR) 1.04; 95% confidence interval (CI) 0.84 to 1.28; p = 0.71]. CDD was an uncommon cause of AAD and occurred in 12/1470 (0.8%) participants in the probiotic and 17/1471 (1.2%) in the placebo arm (RR 0.71; 95% CI 0.34 to 1.47; p = 0.35). Duration and severity of diarrhoea, common gastrointestinal symptoms, serious adverse events and quality of life measures were also similar in the two arms. Total health-care costs per patient did not differ significantly between the probiotic (£8020; 95% CI £7620 to £8420) and placebo (£8010; 95% CI £7600 to £8420) arms. CONCLUSION: We found no evidence that probiotic administration was effective in preventing AAD. Although there was a trend towards reduced CDD in the probiotic arm, on balance, the administration of this probiotic seems unlikely to benefit older patients exposed to antibiotics. A better understanding of the pathogenesis of AAD and CDD and the strain-specific effects of probiotics is needed before further clinical trials of specific microbial preparations are undertaken. Evaluation of the effectiveness of other probiotics will be difficult where other measures, such as antibiotic stewardship, have reduced CDD rates. TRIAL REGISTRATION: This trial is registered as ISRCTN70017204. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 57. See the NIHR Journals Library website for further project information.

Ultrasonographic assessment of gall bladder kinetics in the elderly.

BACKGROUND: The incidence of gallstones increases with age but the factors that influence gallstone formation in the elderly are poorly understood. Proposed factors include changes in bile composition and hypomotility of the gall bladder. Studies on gall bladder motility in the elderly have provided conflicting results, and none has been reported from India. AIM: To determine gall bladder contractility in healthy elderly subjects and compare it with that in young healthy volunteers. METHODS: Thirty healthy elderly (above the age of 60 years) and 30 young volunteers with no abdominal complaints were studied. Using real-time ultrasonography and the ellipsoid method, gall bladder volume was measured after overnight fast and at 10, 20, 30, 40, 50 and 60 minutes after a standard fatty meal. Residual volume, delta volume and ejection fraction were calculated. RESULTS: Mean fasting gall bladder volume in elderly subjects was higher than that in young subjects (13.5 [5.8] mL vs 10.9 [3.6] mL; p < 0.05). However, there was no difference in the 60-min postprandial residual gall bladder volumes in the two groups. Change in gall bladder volume and ejection fraction were also similar in the two groups. CONCLUSION: There was no difference in gall bladder emptying between elderly and young subjects though the fasting gall bladder volume was higher in the elderly.

Residence time distribution for a class of Gaussian Markov processes.

We study the distribution of residence time or equivalently that of "mean magnetization" for a family of Gaussian Markov processes indexed by a positive parameter alpha. The persistence exponent for these processes is simply given by theta=alpha but the residence time distribution is nontrivial. The shape of this distribution undergoes a qualitative change as theta increases, indicating a sharp change in the ergodic properties of the process. We develop two alternate methods to calculate exactly but recursively the moments of the distribution for arbitrary alpha. For some special values of alpha, we obtain closed form expressions of the distribution function.

Intensive care unit admission following successful cardiopulmonary resuscitation: resource utilization, functional status and long-term survival.

A retrospective review of consecutive admissions (n = 285) to a university hospital intensive care unit (ICU) following cardiopulmonary resuscitation was conducted to determine long-term outcome, length of stay (LOS), and ICU resource consumption. Ninety-four patients (33%) survived to hospital discharge. Hospital survivors had longer ICU LOS than non-survivors (5.1 +/- 0.8 vs. 2.8 +/- 0.4 days, P < 0.001) and longer hospital stays (22.5 +/- 3.7 vs. 2.9 +/- 1.2 days, P < 0.001). Average laboratory and pharmacy costs per admission were greater in hospital survivors than non-survivors. Most patients returned to their pre-arrest homes functionally independent and 58% of hospital survivors were alive 2 years after discharge. It is possible that attempts to appropriately limit therapy in patients with poor prognosis may help direct resources towards patients who will benefit.