Peri-operative management and analgesic strategy for a patient undergoing quadruple limb amputation.

Inadequately managed amputation pain can contribute to postoperative morbidity and mortality. However, amputation pain can be challenging to manage due to its complex nature, with both central and peripheral nociceptive and neuropathic elements. Here, we present the case of a 47-year old man who developed irreversible ischaemic injuries to all four limbs following admission to intensive care with sepsis. He required quadruple amputation and we describe our approach to his peri-operative management including anaesthesia, invasive monitoring and the multi-modal approach to his peri-operative management using a combination of intravenous analgesics, bilateral brachial plexus nerve catheters and a combined spinal and epidural. The patient made a good recovery and was able to return home from a rehabilitation facility 12 months after the operation, able to undertake many tasks himself with the aid of prosthetics.

Point-of-care diagnostics - is this driven by supply or demand?

The diagnostic point-of-care testing (POCT) market is about one-third of the in vitro diagnostic (IVD) testing market but, although there are many different POCT products, most are for pregnancy and monitoring of diabetes (∼ 70% of all POCT). Despite the small contribution outside these areas there is huge investment from both suppliers and users of POCT to establish new products and increase the infrastructure for their use. The review is focused on determining the balance between the different drivers of supply and demand and how they have impacted the conflicts seen in POCT evolution. The conflicts have been based on a mix of analytical, regulatory, political and commercial aspects and here the supply and demand drivers are examined separately to determine whether the conflicts are real or whether there are hidden synergies. The focus is on recent publications, with reference to some key historical articles, so that the full environment can be assessed. It is concluded that the synergies between supply and demand now overcome the conflicts where clinical and economic benefit can be demonstrated.