Preoperative priming results in improved operative performance with surgical trainees.

BACKGROUND: Preoperative warm-up regimens are increasingly utilised in the surgical field, however no consensus on benefits of priming across surgical experience has been realised. The aim of this study was to evaluate the impact of simulation preoperative priming on operative performance across levels of resident experience. METHODS: A single-blinded randomised control trial was carried out in a regional surgical training centre. Volunteers were randomised to undergo simulated surgical warm-up procedure prior to their first case as primary operator or proceed directly to surgery. RESULTS: Performances of 147 operative procedures were collected over an 18 month period, experience ranging from PGY2-PGY 7. Senior participants consistently outperformed junior residents in unprimed operative cases (p = 0.005). In primed operative performances no significant difference in aggregate performance scores was found (p = 0.07). CONCLUSION: Priming confers a greater advantage to junior residents with particular regard to generic surgical skills. Senior residents demonstrate improved self-efficacy scores measured following priming.

Virtualised care and COVID-19.

Following the declaration by the World Health Organization (WHO) of the Covid-19 pandemic on March 11, 2020, health organisations and staff have had to adapt and restructure services in order to respond to this global health emergency. Numerous containment strategies have been, and continue to be, introduced in this rapidly evolving and fluid situation with a significant shift towards virtual or remote patient assessment. The concept of virtual patient evaluation has previously been adopted across a range of medical and surgical specialities yielding safe and efficient pathways associated with good Patient Reported Outcome Measures (PROMs) and patient satisfaction rates. Whilst the idea of virtual patient review may be perceived as counterintuitive to the basic foundations and principles of face-to-face clinical practice, the current global pandemic, now more than ever, highlights the importance, need and benefits of this care model.

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland.

INTRODUCTION: The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot. METHODS AND PATIENTS: Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment. RESULTS: To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment. CONCLUSION: Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.

An Unusual Case of a Facial Guard Causing Penetrating Soft Tissue Injury in the Game of Hurling

Aim To highlight the dangers of hurling helmet modification. Methods A case report highlighting the consequences of modifying a hurling helmet from factory settings. Results Photographic evidence of a penetrating injury from helmet modification. Conclusion Rule changes to allow referees to inspect helmets before games take place.

Home blood-pressure monitoring in a hypertensive pregnant population: cost-minimization study.

OBJECTIVE: Traditional blood-pressure monitoring in hypertensive pregnant women requires frequent visits to the maternity outpatient services. Home blood-pressure monitoring (HBPM) could offer a cost-saving alternative that is acceptable to patients. The aim of this study was to undertake a health economic analysis of HBPM compared with traditional monitoring in hypertensive pregnant women. METHODS: This was a cost-minimization study of hypertensive pregnant women who had HBPM with or without the adjunct of a smartphone application (App), via a specially designed pathway, and a control group managed according to the local protocol of regular hospital visits for blood-pressure monitoring. Outcome measures were the number of outpatient visits, inpatient bed stays and investigations performed. Maternal, fetal and neonatal adverse outcomes were also recorded. Health economic analysis was performed using direct cost comparison of the study dataset and process scenario modeling. RESULTS: The HBPM group included 108 women, of whom 29 recorded their results on the smartphone App and 79 in their notes. The control group comprised 58 patients. There were significantly more women with chronic hypertension in the HBPM group than in the control group (49.1% vs 25.9%, P = 0.004). The HBPM group had significantly longer duration of monitoring (9 weeks vs 5 weeks, P = 0.004) and started monitoring at an earlier gestational age (30.0 weeks vs 33.6 weeks, P = 0.001) compared with the control group. Despite these differences, the mean saving per week for each patient using HBPM compared with traditional monitoring was £200.69, while for each HBPM patient using the smartphone App, the weekly saving was £286.53 compared with the control group. The process modeling method predicted weekly savings of between £98.32 and £245.80 per patient using HBPM compared with traditional monitoring. CONCLUSION: HBPM in hypertensive pregnancy appears to be cost saving compared with traditional monitoring, without compromising maternal, fetal or neonatal safety. Larger studies are required to confirm these findings. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Home blood-pressure monitoring in a hypertensive pregnant population.

OBJECTIVE: The majority of patients with chronic or gestational hypertension do not develop pre-eclampsia. Home blood-pressure monitoring (HBPM) has the potential to offer a more accurate and acceptable means of monitoring hypertensive patients during pregnancy compared with traditional pathways of frequent outpatient monitoring. The aim of this study was to determine whether HBPM reduces visits to antenatal services and is safe in pregnancy. METHODS: This was a case-control study of 166 hypertensive pregnant women, which took place at St George's Hospital, University of London. Inclusion criteria were: chronic hypertension, gestational hypertension or high risk of developing pre-eclampsia, no significant proteinuria (≤ 1+ proteinuria on dipstick testing) and normal biochemical and hematological markers. Exclusion criteria were maternal age < 16 years, systolic blood pressure > 155 mmHg or diastolic blood pressure > 100 mmHg, significant proteinuria (≥ 2+ proteinuria on dipstick testing or protein/creatinine ratio > 30 mg/mmol), evidence of small-for-gestational age (estimated fetal weight < 10th centile), signs of severe pre-eclampsia, significant mental health concerns or insufficient understanding of the English language. Pregnant women in the HBPM group were taught how to measure and record their blood pressure using a validated machine at home and attended every 1-2 weeks for assessment depending on clinical need. The control group was managed as per the local protocol prior to the implementation of HBPM. The two groups were compared with respect to number of visits to antenatal services and outcome. RESULTS: There were 108 women in the HBPM group and 58 in the control group. There was no difference in maternal age, parity, body mass index, ethnicity or smoking status between the groups, but there were more women with chronic hypertension in the HBPM group compared with the control group (49.1% vs 25.9%, P = 0.004). The HBPM group had significantly fewer outpatient attendances per patient (6.5 vs 8.0, P = 0.003) and this difference persisted when taking into account differences in duration of monitoring (0.8 vs 1.6 attendances per week, P < 0.001). There was no difference in the incidence of adverse maternal, fetal or neonatal outcome between the two groups. CONCLUSION: HBPM in hypertensive pregnancies has the potential to reduce the number of hospital visits required by patients without compromising maternal and pregnancy outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Research amongst Irish surgical trainees: what's the trend?

INTRODUCTION: A high publication rate for surgical trainees is considered a prerequisite for progression to Higher Specialist Training (HST). This rate has arguably been decreased by the formation of a new 'run-through' training pathway. We aim to quantify the number of publications that the 'new' pathway trainees have attained compared to the 'old' pathway trainees. We further aim to compare the H-index and average citations between General Surgery (GS) and Trauma and Orthopaedic (T&O) trainees. METHODS: Publications from old pathway trainee years 2007-2014 (T&O n = 59, GS n = 64) were compared with new pathway trainees from 2015 to 2016 (T&O n = 11, GS n = 12). H-index and average citations were also compared for trainees commencing HST years 2007-2009. Statistical analysis involved D'Agostino normality testing. An unpaired Student's t test ± Welch's correction was utilised for parametric data and a Mann-Whitney U test for non-parametric data. RESULTS: The average number of publications attained by the old pathway T&O trainee was 4.2 ± 3.1 and was 3.1 ± 2.4 for the new trainee. Old GS trainees had an average of 6.5 ± 3.3 publications prior to HST with new GS trainees having an average of 3.7 ± 2.8 publications. The average H-index attained for GS trainees on completion of the HST pathway was 5.1 ± 3.2 and 4.6 ± 2.4 for T&O trainees. CONCLUSION: There has been a significant decrease in publication rates between new and old GS pathways. No significant changes were identified between new and old T&O pathways. There was no difference between H-index and average citations between specialties.

A retrospective review of farm injuries presenting to an Irish hospital emergency department in 2013.

BACKGROUND: The agricultural and equestrian businesses are an important source of employment in the Midlands. This is a retrospective study examining the demographics, characteristics, and outcomes of agricultural and equestrian related injuries presenting to the Midland Regional Hospital, Tullamore, Co. Offaly. There were a total of 30,700 attendances to the Emergency Department for 2013. AIMS: This study is an epidemiological review of agricultural injuries, their mechanisms, and consequences presenting to a rural regional hospital over a 1 year period. METHODS: Every presentation to the Accident and Emergency Department at the Midlands Regional Hospital in 2013 was assessed retrospectively to determine if an injury had been sustained in an agricultural environment. Patient demographics, month of occurrence, mechanism of injury, radiology results, management, and follow-up data were collected and analysed using Microsoft Excel. RESULTS: There were 144 agricultural-related presentations to the Accident and Emergency Department. 23% of the agricultural injuries were identified as having a radiological abnormality. There were significantly more males involved in agricultural injuries than females (97 vs 3%). 16% of presentations required admission or transfer to tertiary specialist care and 8% required surgical intervention. Farming machinery accidents contributed to more admissions than any other cause in the agricultural category and resulted in more surgical interventions. CONCLUSION: Our study has identified high-risk mechanisms of injury, which should alert clinicians to the potential for significant injury. In addition, our findings could be used to help policy makers promote safety and awareness through public health policies that target high-risk practices with appropriate training and legislation.

Resting-state connectivity deficits associated with impaired inhibitory control in non-treatment-seeking adolescents with psychotic symptoms.

OBJECTIVE: Psychotic symptoms are common in the population and index risk for a range of severe psychopathological outcomes. We wished to investigate functional connectivity in a community sample of adolescents who reported psychotic symptoms (the extended psychosis phenotype). METHOD: This study investigated intrinsic functional connectivity (iFC) during resting-state functional magnetic resonance imaging (fMRI; rs-fMRI). Following screening in schools, 11 non-treatment seeking, youth with psychotic symptoms (aged 11-13) and 14 community controls participated in the study. Seed regions of interest comprised brain regions previously shown to exhibit aberrant activation during inhibitory control in adolescents with psychotic symptoms. RESULTS: Relative to controls, adolescents with psychotic symptoms exhibited reduced iFC between regions supporting inhibitory control. Specifically, they showed weaker iFC between the right inferior frontal gyrus (IFG) and the cingulate, IFG and the striatum, anterior cingulate and claustrum, and precuneus and supramarginal gyrus. Conversely, the psychotic symptoms group exhibited stronger iFC between the superior frontal gyrus and claustrum and IFG and lingual gyrus. CONCLUSION: The present findings are the first to reveal aberrant functional connectivity in resting-state networks in a community sample of adolescents with psychotic symptoms and suggest that disruption in integration between distributed neural networks (particularly between prefrontal, cingulate and striatal brain regions) may be a key neurobiological feature of the extended psychosis phenotype.

Drawing lines at the sand: evidence for functional vs. visual reef boundaries in temperate Marine Protected Areas.

Marine Protected Areas (MPAs) can either protect all seabed habitats within them or discrete features. If discrete features within the MPA are to be protected humans have to know where the boundaries are. In Lyme Bay, SW England a MPA excluded towed demersal fishing gear from 206 km(2) to protect rocky reef habitats and the associated species. The site comprised a mosaic of sedimentary and reef habitats and so 'non reef' habitat also benefited from the MPA. Following 3 years protection, video data showed that sessile Reef Associated Species (RAS) had colonised sedimentary habitat indicating that 'reef' was present. This suggested that the functional extent of the reef was potentially greater than its visual boundary. Feature based MPA management may not adequately protect targeted features, whereas site based management allows for shifting baselines and will be more effective at delivering ecosystem goods and services.

Through the looking glass; bioactive glass S53P4 (BonAlive®) in the treatment of chronic osteomyelitis.

BACKGROUND: In terms of eradication, osteomyelitis represents one of the most challenging infective conditions in medicine and surgery. In recent years, the use of bioactive glass in conjunction with antimicrobial therapy has emerged as a viable new treatment. AIM: We present a short study, from a regional orthopaedic unit, demonstrating its successful use in three patients with chronic osteomyelitis. METHODS: Between September 2010 and May 2011, bioactive glass S53P4 was used in conjunction with intravenous and oral antibiotics to treat chronic osteomyelitis in three patients (two male, one female). All patients underwent debridement and sequestrectomy procedures with the insertion of bioactive glass followed by antimicrobial regimens tailored to isolated pathogen sensitivities. Patient age ranged from 28 to 68 years, with a mean age of 44.7 years. The presentation period, from time of initial diagnosis to treatment, varied from 16 months to 16 years and all three patients had underwent multiple previous debridements and antimicrobial regimens to no avail. RESULTS: A follow-up of 14-21 months has been achieved with a mean follow-up of 17.3 months. We have seen excellent results in all three patients. All haematological and biochemical parameters have returned to normal, pain has ceased and function has returned in the affected limbs. All antibiotics have stopped and there is no radiological evidence of osteomyelitis. The bioactive glass has integrated with the surrounding bone. CONCLUSIONS: Though a relatively recent development, bioactive glass used in concurrence with antibiotic therapy has significant potential in the treatment of chronic osteomyelitis.

Assessing wave energy effects on biodiversity: the wave hub experience.

Marine renewable energy installations harnessing energy from wind, wave and tidal resources are likely to become a large part of the future energy mix worldwide. The potential to gather energy from waves has recently seen increasing interest, with pilot developments in several nations. Although technology to harness wave energy lags behind that of wind and tidal generation, it has the potential to contribute significantly to energy production. As wave energy technology matures and becomes more widespread, it is likely to result in further transformation of our coastal seas. Such changes are accompanied by uncertainty regarding their impacts on biodiversity. To date, impacts have not been assessed, as wave energy converters have yet to be fully developed. Therefore, there is a pressing need to build a framework of understanding regarding the potential impacts of these technologies, underpinned by methodologies that are transferable and scalable across sites to facilitate formal meta-analysis. We first review the potential positive and negative effects of wave energy generation, and then, with specific reference to our work at the Wave Hub (a wave energy test site in southwest England, UK), we set out the methodological approaches needed to assess possible effects of wave energy on biodiversity. We highlight the need for national and international research clusters to accelerate the implementation of wave energy, within a coherent understanding of potential effects-both positive and negative.

LacI(Ts)-regulated expression as an in situ intracellular biomolecular thermometer.

In response to needs for in situ thermometry, a temperature-sensitive vector was adapted to report changes in the intracellular heat content of Escherichia coli in near-real time. This model system utilized vectors expressing increasing quantities of ß-galactosidase in response to stepwise temperature increases through a biologically relevant range (22 to 45°C). As judged by calibrated fluorometric and colorimetric reporters, both whole E. coli cells and lysates expressed significant repeatable changes in ß-galactosidase activity that were sensitive to temperature changes of less than 1°C (35 to 45°C). This model system suggests that changes in cellular heat content can be detected independently of the medium in which cells are maintained, a feature of particular importance where the medium is heterogeneous or nonaqueous, or otherwise has a low heat transfer capacity. We report here that the intracellular temperature can be reliably obtained in near-real time using reliable fluorescent reporting systems from cellular scales, with a 20°C range of detection and at least 0.7°C sensitivity between 35 and 45°C.

Self-reported complication rates following primary total hip arthroplasty in Ireland: fact or fiction.

BACKGROUND: There are little data available on complication rates following primary total hip arthroplasty (THA) surgery in Ireland. AIMS: To determine self-reported complication rates and national data for primary THA. METHODS: A postal questionnaire surveyed Irish orthopaedic association consultant members. Additional data were obtained from the economic and social research institute (ESRI). RESULTS: We achieved an 83% response rate. 5,424 THAs were self-reported. Mean dislocation rates were 1%, but higher using a posterior surgical approach (p < 0.05). Mean deep infection rates were 0.4%. 29% were MRSA. No reduction was reported from additional barrier prophylaxes. Mean venous thrombo-embolism (VTE) rates were 3.5%. No reduction was reported from commencing prophylaxis preoperatively or extending treatment duration. National rates for dislocation, deep infection and VTE were 25.7, 0.87, and <0.1%, respectively. CONCLUSIONS: The creation of a National Hip Register is strongly recommended. A register would improve surgical practices and patient outcomes, and provide significant healthcare savings.

Application of mid-infrared spectroscopy to the prediction of maturity and sensory texture attributes of cheddar cheese.

The objective of this study was to determine the potential of mid-infrared spectroscopy in conjunction with partial least squares (PLS) regression to predict various quality parameters in cheddar cheese. Cheddar cheeses (n= 24) were manufactured and stored at 8 degrees C for 12 mo. Mid-infrared spectra (640 to 4000/cm) were recorded after 4, 6, 9, and 12 mo storage. At 4, 6, and 9 mo, the water-soluble nitrogen (WSN) content of the samples was determined and the samples were also evaluated for 11 sensory texture attributes using descriptive sensory analysis. The mid-infrared spectra were subjected to a number of pretreatments, and predictive models were developed for all parameters. Age was predicted using scatter-corrected, 1st derivative spectra with a root mean square error of cross-validation (RMSECV) of 1 mo, while WSN was predicted using 1st derivative spectra (RMSECV = 2.6%). The sensory texture attributes most successfully predicted were rubbery, crumbly, chewy, and massforming. These attributes were modeled using 2nd derivative spectra and had corresponding RMSECV values in the range of 2.5 to 4.2 on a scale of 0 to 100. It was concluded that mid-infrared spectroscopy has the potential to predict age, WSN, and several sensory texture attributes of cheddar cheese.

Evaluating mid-infrared spectroscopy as a new technique for predicting sensory texture attributes of processed cheese.

The objective of this study was to investigate the potential application of mid-infrared spectroscopy for determination of selected sensory attributes in a range of experimentally manufactured processed cheese samples. This study also evaluates mid-infrared spectroscopy against other recently proposed techniques for predicting sensory texture attributes. Processed cheeses (n = 32) of varying compositions were manufactured on a pilot scale. After 2 and 4 wk of storage at 4 degrees C, mid-infrared spectra (640 to 4,000 cm(-1)) were recorded and samples were scored on a scale of 0 to 100 for 9 attributes using descriptive sensory analysis. Models were developed by partial least squares regression using raw and pretreated spectra. The mouth-coating and mass-forming models were improved by using a reduced spectral range (930 to 1,767 cm(-1)). The remaining attributes were most successfully modeled using a combined range (930 to 1,767 cm(-1) and 2,839 to 4,000 cm(-1)). The root mean square errors of cross-validation for the models were 7.4 (firmness; range 65.3), 4.6 (rubbery; range 41.7), 7.1 (creamy; range 60.9), 5.1 (chewy; range 43.3), 5.2 (mouth-coating; range 37.4), 5.3 (fragmentable; range 51.0), 7.4 (melting; range 69.3), and 3.1 (mass-forming; range 23.6). These models had a good practical utility. Model accuracy ranged from approximate quantitative predictions to excellent predictions (range error ratio = 9.6). In general, the models compared favorably with previously reported instrumental texture models and near-infrared models, although the creamy, chewy, and melting models were slightly weaker than the previously reported near-infrared models. We concluded that mid-infrared spectroscopy could be successfully used for the nondestructive and objective assessment of processed cheese sensory quality.

Composition, sensory and shelf life stability analyses of Longissimus dorsi muscle from steers reared under organic and conventional production systems.

In recent years the demand for organically grown food has increased. In this study, organic (O, n=6) and conventionally (C, n=6) reared steers aged between 18 and 24 months were slaughtered during the month of September 2002. Four days post-slaughter, the Longissimus dorsi (LD) muscle was excised from the left side of each carcass. All muscles were vacuum packed and aged in a chill for a further seven days. Steaks were cut from each sample, and from these, lean meat was removed, blended and compositional analysis was carried out. O samples were significantly higher (P>0.05) in fat content and therefore were significantly (P>0.05) lower in moisture content than C samples. No significant differences were observed between C and O samples for protein, ash, ß-carotene, α-tocopherol or retinol. There was also no significant difference in fatty acid content between C and O samples. Colour stability and fat oxidative stability of samples were also measured, while stored under retail conditions. Samples were packed using both modified atmosphere packaging (MAP) and by overwrapping with cling film. MAP C samples had the best colour stability while overwrapped C samples had the best lipid stability. Therefore, colour and lipid stability of beef samples were influenced by sample composition and packaging format used, which resulted in C samples outperforming O samples with respect to shelf life stability.