The effect of metrics-based feedback on acquisition of sonographic skills relevant to performance of ultrasound-guided axillary brachial plexus block.

The objective of this study was to examine the effect of metrics-based vs. non-metrics-based feedback on novices learning predefined competencies for acquisition and interpretation of sonographic images relevant to performance of ultrasound-guided axillary brachial plexus block. Twelve anaesthetic trainees were randomly assigned to either metrics-based-feedback or non-metrics-based feedback groups. After a common learning phase, all participants attempted to perform a predefined task that involved scanning the left axilla of a single volunteer. Following completion of the task, all participants in each group received feedback from a different expert in regional blocks (consultant anaesthetist) and were allowed to practise the predefined task for up to 1 h. Those in the metrics-based feedback group received feedback based on previously validated metrics, and they practised each metric item until it was performed satisfactorily, as assessed by the supervising consultant. Subsequently, each participant attempted to perform ultrasonography of the left axilla on the same volunteer. Two trained consultant anaesthetists independently scored the video recording pre- and post-feedback scans using the validated metrics list. Both groups showed improvement from pre-feedback to post-feedback scores. Compared with participants in the non-metrics-based feedback group, those in the metrics-based feedback group completed more steps: median (IQR [range]) 18.8 (1.5 [17-20]) vs. 14.3 (4.5 [11-18.5]), p = 0.009, and made fewer errors 0.5 (1 [0-1.5]) vs. 1.5 (2 [1-6]), p = 0.041 postfeedback. In this study, novices' sonographic skills showed greater improvement when feedback was combined with validated metrics.

Construct validity of a novel assessment tool for ultrasound-guided axillary brachial plexus block.

The purpose of this study was to examine the construct validity and reliability of a novel metrics-based assessment tool, previously developed for ultrasound-guided axillary brachial plexus block. Five expert and eight novice anaesthetists performed a total of 18 ultrasound-guided axillary brachial plexus blocks on the same number of patients. A trained investigator video-taped procedures according to a pre-defined protocol. Two trained consultant anaesthetists independently scored the videos using the assessment tool. Compared with novices, experts completed more steps (mean 41.0 vs. 33.1, p = 0.001), had fewer procedural errors (2.8 vs. 7.9, p < 0.0001), had fewer critical errors (0.8 vs. 1.3, p = 0.030), and fewer total errors (3.5 vs. 9.1, p < 0.0001). The mean inter-rater reliability for scoring of experts' performance was 0.91, for novices' performance was 0.84, and for all performance combined (n = 18) was 0.88. This assessment tool is valid, and discriminates reliably between expert and novice performance for placement of ultrasound-guided axillary brachial plexus blocks.

Nerve localization techniques for peripheral nerve block and possible future directions.

BACKGROUND: Ultrasound guidance is now a standard nerve localization technique for peripheral nerve block (PNB). Ultrasonography allows simultaneous visualization of the target nerve, needle, local anesthetic injectate, and surrounding anatomical structures. Accurate deposition of local anesthetic next to the nerve is essential to the success of the nerve block procedure. Due to limitations in the visibility of both needle tip and nerve surface, the precise relationship between needle tip and target nerve is unknown at the moment of injection. Importantly, nerve injury may result both from an inappropriately placed needle tip and inappropriately placed local anesthetic. The relationship between the block needle tip and target nerve is of paramount importance to the safe conduct of peripheral nerve block. METHODS: This review summarizes the evolution of nerve localization in regional anesthesia, characterizes a problem faced by clinicians in performing ultrasound-guided nerve block, and explores the potential technological solutions to this problem. RESULTS: To date, technology newly applied to PNB includes real-time 3D imaging, multi-planar magnetic needle guidance, and in-line injection pressure monitoring. This review postulates that optical reflectance spectroscopy and bioimpedance may allow for accurate identification of the relationship between needle tip and target nerve, currently a high priority deficit in PNB techniques. CONCLUSIONS: Until it is known how best to define the relationship between needle and nerve at the moment of injection, some common sense principles are suggested.

Propranolol for the treatment of infantile haemangiomas: our experience with 44 patients.

Propranolol is an effective, safe treatment for complicated infantile haemangiomas (IH). We evaluated all patients (n = 44) with IH treated with propranolol in our department. Of the 44 patients who were begun on propranolol therapy, 26 patients have completed the treatment to date and all had a good response. The mean duration of treatment was 45.7 weeks. Four patients developed rebound growth of their IH, which responded to the reintroduction of propranolol. Two patients with PHACES (posterior fossa malformations, haemangiomas, arterial anomalies, coarctation of the aorta/cardiac abnormalities, eye anomalies and sternal defects/supraumbilical raphe) syndrome were treated with lower than standard doses, because of concern about possible cerebrovascular compromise. Adverse effects were minor in most patients. Three patients discontinued propranolol because of vomiting, wheeze, and hypoglycaemia, respectively. Our duration of treatment was longer than that of other series, and may be due to our group having higher rates of hypotension, recorded in 27.3% of patients, precluding an increase in propranolol dose. Our experience supports that propranolol is an effective first-line agent for complicated IH.

Effects of lasalocid and intermittent feeding of chlortetracycline on the growth of prepubertal dairy heifers.

Forty Holstein heifers entered the 12-wk study at approximately 12 wk of age. At enrollment, heifers were blocked by birth date and assigned to 1 of 4 treatments: (1) carrier (30 g; control); (2) lasalocid + carrier (1 mg/kg of body weight; L); (3) chlortetracycline + carrier (22 mg/kg of body weight; CTC); (4) L + CTC + carrier (CTCL). Heifers on CTC and CTCL were provided treatment Monday through Friday and carrier only on Saturday and Sunday. These heifers were provided their respective treatment during wk 1 to 4, 6, and 10; wk 5, 7 to 9, and 11 to 12 heifers were provided the nonmedicated carrier. Heifers were individually fed a total mixed ration with treatments top-dressed at 1200 h daily. Dry matter intake was monitored for each heifer and feed provided was adjusted according to individual intakes. Skeletal measurements were taken weekly and blood samples were obtained every Monday, Wednesday, and Friday. Blood samples were analyzed for thyroxine concentration via radial immunoassay. Heifers supplemented with L had lower average daily gain , overall body weight gain, and trends for lower daily body length gain and overall girth gain compared with CTC heifers, but similar to control and CTCL heifers. Heifers fed L had lower hip height gain and overall hip height gain compared with CTCL heifers, but similar to control and CTC heifers. Heifers fed L had lower overall withers height gain compared with control heifers, but similar to CTC and CTCL heifers. No treatment effect on thyroxine concentrations was observed. These data indicate that L did not increase growth. Results from this experiment indicate that supplementing heifers with L was not beneficial and no benefits to supplementing heifers with CTC or the combination of CTC and L were evident compared with control heifers. Heifers in this study experienced minimal health problems and were regarded to be under low stress levels. Supplementing CTC and L may be beneficial to growing heifers under conditions where disease exposure and stressors are greater.

"In somno securitas" anaesthetists' noise exposure in Orthopaedic operating theatres.

Excessive noise exposure can have adverse effects on the health and performance of healthcare providers. Irish statutory regulations limit daily workplace noise exposure to 87 A-weighted decibels [dB(A)]. The World Health Organisation recommends noise levels remain under 35 dB(A) in patient treatment rooms. We measured anaesthetists' noise exposure during elective orthopaedic surgery. The mean and maximum sound levels were 63.0 (SD 4.26) and 92.8 dB(A) respectively. Noise was louder than 65 dB(A) 22.2% of the time and louder than 80 dB(A) less than 1% of the time. Staff conversation and metal instruments were responsible for 29.5% and 19.9% of peaks louder than 65 dB(A) respectively. Sound levels recorded were lower than recognised levels associated with hearing loss. Sound regularly exceeded World Health Organisation (WHO) recommended levels for patient comfort and safety. Anaesthetists need to be aware of the influence of environmental noise on clinical practice.

Rings in the neonate.

Neonatal lupus erythematosus (NLE) is an uncommon disease of the neonate. It is believed to be caused by the transplacental passage of maternal autoantibodies to the ribonucleoproteins (Ro/SSA, La/SSB or rarely U RNP) as these are almost invariably present in NLE sera. The most common clinical manifestations include cutaneous lupus lesions and congenital complete heart block. Hepatobiliary and haematologic abnormalities are reported less frequently. We describe a patient with cutaneous NLE to illustrate and raise awareness of the characteristic annular eruption of this condition. We also emphasize the need for thorough investigation for concomitant organ involvement and for maternal education regarding risk in future pregnancies.

Steady state and induced auditory gamma deficits in schizophrenia.

Steady state auditory evoked potentials (SSAEPs) in the electroencephalogram (EEG) and magnetoencephalogram (MEG) have been reported to be reduced in schizophrenia, most consistently to frequencies in the gamma range (40 Hz and greater). The current study evaluated the specificity of this deficit over a broad range of stimulus frequencies and harmonics, the relationship between phase locking and signal power, and whether induced 40 Hz activity was also affected. SSAEPs to amplitude modulated tones from 5 to 50 Hz were obtained from subjects with schizophrenia (SZ) and healthy control subjects in 5 Hz steps. Time-frequency spectral analysis was used to differentiate EEG activity synchronized in phase across trials using Phase Locking Factor (PLF) and Mean Power (MP) change from baseline activity. In the SSAEP frequency response condition, patients with SZ showed broad band reductions in both PLF and MP. In addition, the control subjects showed a more pronounced increase in PLF with increases in power compared to SZ subjects. A noise pulse embedded in 40 Hz stimuli resulted in a transient reduction of PLF and MP at 40 Hz in control subjects, while SZ showed diminished overall PLF. Finally, induced gamma (around 40 Hz) response to unmodulated tone stimuli was also reduced in SZ, indicating that disturbances in this oscillatory activity are not confined to SSAEPs. In summary, SZ subjects show impaired oscillatory responses in the gamma range across a wide variety of experimental conditions. Reduction of PLF along with reduced MP may reflect abnormalities in the auditory cortical circuits, such as a reduction in pyramidal cell volume, spine density and alterations in GABAergic neurons.

Calciphylaxis in a patient with normal renal function: response to treatment with sodium thiosulfate.

Calciphylaxis is a rare, life-threatening cause of skin necrosis. The condition is primarily reported in patients with end-stage renal disease, and is associated with significant morbidity and mortality. Treatment has mainly been empirical. We report a case of calciphylaxis in a patient with normal renal function and hypoparathyroidism, who responded to treatment with sodium thiosulfate. To our knowledge, this is the first reported case of the use of sodium thiosulfate to treat calciphylaxis in a patient with normal renal function.

Double deletion of Panx1 and Panx3 affects skin and bone but not hearing.

Pannexins (Panxs), large-pore channel forming glycoproteins, are expressed in a wide variety of tissues including the skin, bone, and cochlea. To date, the use of single knock-out mouse models of both Panx1 and Panx3 have demonstrated their roles in skin development, bone formation, and auditory phenotypes. Due to sequence homology between Panx1 and Panx3, when one Panx is ablated from germline, the other may be upregulated in a compensatory mechanism to maintain tissue homeostasis and function. To evaluate the roles of Panx1 and Panx3 in the skin, bone, and cochlea, we created the first Panx1/Panx3 double knock-out mouse model (dKO). These mice had smaller litters and reduced body weight compared to wildtype controls. The dKO dorsal skin had decreased epidermal and dermal area as well as decreased hypodermal area in neonatal but not in older mice. In addition, mouse skull shape and size were altered, and long bone length was decreased in neonatal dKO mice. Finally, auditory tests revealed that dKO mice did not exhibit hearing loss and were even slightly protected against noise-induced hearing damage at mid-frequency regions. Taken together, our findings suggest that Panx1 and Panx3 are important at early stages of development in the skin and bone but may be redundant in the auditory system. KEY MESSAGES: Panx double KO mice had smaller litters and reduced body weight. dKO skin had decreased epidermal and dermal area in neonatal mice. Skull shape and size changed plus long bone length decreased in neonatal dKO mice. dKO had no hearing loss and were slightly protected against noise-induced damage.

Tinea capitis in a paediatric population.

Tinea capitis is an increasing problem in Europe. The pattern of infection is changing with an increase in pathogenic anthropophilic dermatophytes particularly Trichophyton tonsurans. We aimed to determine the frequency of tinea capitis in a paediatric population attending dermatology outpatients and examine the clinical spectrum of disease. A retrospective analysis was performed of all laboratory proven tinea capitis cases presenting to the dermatology outpatient department at The Children's University Hospital, Temple Street over an 18-month period (1st January 2004 to 30th of June 2005 inclusive). Sixty-two children had tinea capitis of whom 53 (85.5%) were of African descent. Thirty-five (56%) were male and 27 female (44%). The average age at presentation was 4.02 years (age range 1-163 months) with five cases occurring in children less than one year of age. The most common pathogen was the anthropophilic dermatophyte Trichophyton tonsurans, accounting for 47 (75.8%) of all cases of tinea capitis. Eight (12.9%) were secondary to Microsporum ferrigineum, 2 (3.2%) secondary to Trichophyton violaceum, both Trichophyton soudanese and Trichophyton verruosum accounted for 1.6% each. The zoophilic organism Microsporum canis was diagnosed in 3 cases (4.8%). Presenting signs included scaling of the scalp (35.47%), scaling of the scalp and alopecia (53.24%), and alopecia and kerion (11.29%/o). The duration of symptoms was recorded in 52 patients with the average duration 8.38 months (range 0.5-72 months). In 20 cases an associated skin involvement on other areas of the body was recorded. All patients at diagnosis were either on no, suboptimal or inappropriate treatment. The prevalence of tinea capitis is increasing in this hospital based cohort. The main pathogen is now Trichophyton tonsurans. Children of African descent are at increased risk of infection. The diagnosis is poorly recognized and needs to be highlighted as a public health issue. There is a need for community based prevalence studies.

Older patient hospital admissions following primary care referral: the truth is in the referring.

BACKGROUND: Health information has a major role in the planning of future healthcare provision. With current reconfiguration and cost saving measures, further demands are being placed on acute hospitals. AIM: To examine the elderly admissions and the referral documentation of older patients admitted to a tertiary level hospital. METHODS: A retrospective analysis of primary care referral documentation for all acute admissions of patients over 75 years to University Hospital Limerick (UHL) over a 2-month period. Documentation was analysed on the basis of patient demographics, presenting complaint and referral source. Primary care referral documentation was then analysed on the basis of presenting complaint, patient demographics, referrer details, and the clinical information provided. RESULTS: Over the 2-month period there were a total of 381 elderly admissions through the Emergency department. The most common presenting complaint was with shortness of breath (21.5 %). 42.5 % of admissions were from a primary care setting. 31.1 % of referrals were typed and 47.0 % handwritten. Over 90 % of referrals contained the patient's name, date of birth and address. 98.7 % of referrals included a presenting complaint and 54 % included a past medical history. 20 % of referrals listed known drug allergies, while 9.3 % documented social history or baseline functional status. Referral letters from general practice and after-hour services were largely similar. CONCLUSIONS: Almost all primary care referrals included the required details as per recent HIQA guidelines. The further inclusion of optional information relating to patient social or functional status, which are of particular relevance to the older population may help patient management.