Impact of clinicians' behavior, an educational intervention with mandated blood pressure and the hypotension prediction index software on intraoperative hypotension: a mixed methods study.

PURPOSE: Intraoperative hypotension (IOH) is associated with adverse outcomes. We therefore explored beliefs regarding IOH and barriers to its treatment. Secondarily, we assessed if an educational intervention and mandated mean arterial pressure (MAP), or the implementation of the Hypotension Prediction Index-software (HPI) were associated with a reduction in IOH. METHODS: Structured interviews (n = 27) and questionnaires (n = 84) were conducted to explore clinicians' beliefs and barriers to IOH treatment, in addition to usefulness of HPI questionnaires (n = 14). 150 elective major surgical patients who required invasive blood pressure monitoring were included in three cohorts to assess incidence and time-weighted average (TWA) of hypotension (MAP < 65 mmHg). Cohort one received standard care (baseline), the clinicians of cohort two had a training on hypotension and a mandated MAP > 65 mmHg, and patients of the third cohort received protocolized care using the HPI. RESULTS: Clinicians felt challenged to manage IOH in some patients, yet they reported sufficient knowledge and skills. HPI-software was considered useful and beneficial. No difference was found in incidence of IOH between cohorts. TWA was comparable between baseline and education cohort (0.15 mmHg [0.05-0.41] vs. 0.11 mmHg [0.02-0.37]), but was significantly lower in the HPI cohort (0.04 mmHg [0.00 to 0.11], p < 0.05 compared to both). CONCLUSIONS: Clinicians believed they had sufficient knowledge and skills, which could explain why no difference was found after the educational intervention. In the HPI cohort, IOH was significantly reduced compared to baseline, therefore HPI-software may help prevent IOH. TRIAL REGISTRATION: ISRCTN 17,085,700 on May 9th, 2019.

Robenacoxib versus meloxicam following ovariohysterectomy in cats: A randomised, prospective clinical trial involving owner-based assessment of pain.

BACKGROUND: Injectable non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to queens undergoing ovariohysterectomy (OVH), but the requirement for postoperative administration is unclear and practices vary. Existing studies assessing efficacy rely on pain scoring by experienced clinicians. However, following OVH, most cats are discharged within hours of recovery. METHODS: Cats undergoing OVH were randomly assigned to two treatment groups: MEL and ROB. Cats in the MEL group (n = 76) received meloxicam (0.2 mg/kg) and those in the ROB group (n = 65) received robenacoxib (2 mg/kg). Owners were contacted by a blinded assessor 3 days postoperatively and asked to identify physical or behavioural changes and to assign pain scores using a numerical rating scale. RESULTS: More cats in the ROB group displayed abnormal behaviours than cats in the MEL group (p = 0.03). Most owners assigned a pain score of 0 (72%) (n = 101), but pain scores were significantly higher in the ROB group than in the MEL group (p = 0.005). LIMITATION: Methods of owner assessment of pain in cats have not been validated. CONCLUSIONS: Both meloxicam and robenacoxib are effective in controlling postoperative pain. Meloxicam may have improved efficacy in certain patient populations. Applying a blanket approach to prescribing NSAIDs to cats undergoing OVH postoperatively may not be necessary. This has safety, environmental and cost implications.

A Rare Case of Sagittal Sinus Obstruction Following Posterior Cranial Vault Distraction Osteogenesis.

Posterior cranial vault distraction osteogenesis (PCVDO) is a relatively new paradigm in the treatment of syndromic craniosynostosis, having first been introduced in 2009. PCVDO directly addresses the underdeveloped cranial vault and appears to allow for a larger increase in intracranial volume when compared to traditional techniques. Although reported as safe in the literature, critical appraisal is still required as PCVDO is a relatively uncommon procedure that may require greater numbers to detect true complication rates. The overall reported incidence of serious complications in PCVDO to date is low. This presentation highlights a rare case of sagittal sinus obstruction following posterior cranial vault distraction and raises questions as to the safest technical considerations when planning the operation.

Glycaemic control in critical care: Can flash glucose monitoring help?

Good glycaemic control confers an outcome benefit in both diabetic and non-diabetic critically unwell patients. Critically unwell patients receiving intravenous insulin in the intensive care unit (ICU) require hourly glucose monitoring. This brief communication highlights the impact of the introduction of the FreeStyle Libre glucose monitor, a form of continuous glucose monitoring, on the frequency of glucose recordings in patients receiving intravenous insulin in the ICU at York Teaching Hospital NHS Foundation Trust.

Clinical accuracy of infrared temperature measurement devices: a comparison against non-invasive core-body temperature.

During the coronavirus 2019 (COVID-19) pandemic, the implementation of non-contact infrared thermometry (NCIT) became an increasingly popular method of screening body temperature. However, data on the accuracy of these devices and the standardisation of their use are limited. In the current study, the body temperature of non-febrile volunteers was measured using infrared (IR) thermography, IR tympanic thermometry and IR gun thermometry at different facial feature locations and distances and compared with SpotOn core-body temperature. Poor agreement was found between all IR devices and SpotOn measurements (intra-class correlation coefficient <0.8). Bland-Alman analysis showed the narrowest limits of agreement with the IR gun at 3 cm from the forehead (bias = 0.19°C, limits of agreement (LOA): -0.58°C to 0.97°C) and widest with the IR gun at the nose (bias = 1.40°C, LOA: -1.15°C to 3.94°C). Thus, our findings challenge the established use of IR thermometry devices within hospital settings without adequate standard operating procedures to reduce operator error.

Management of Unicoronal and Metopic Synostoses: Minimally Invasive Approaches.

Early endoscopic-assisted correction of unicoronal and metopic synostosis is an excellent, safe, cost-effective, and highly effective option for affected patients. Although open calvarial remodeling has a place in the armamentarium of the craniofacial team, the skull base changes seen in endoscopic-assisted techniques are unparalleled. The procedures are associated with low morbidity and no mortality. There is minimal blood loss, decreased operating time, significantly reduced blood transfusion rates, decreased hospitalization length, decreased cost, and less pain and swelling. Early diagnosis and referral for surgical evaluation are critical to obtaining these results.

GLOBathy, the global lakes bathymetry dataset.

Waterbodies (natural lakes and reservoirs) are a critical part of a watershed's ecological and hydrological balance, and in many cases dictate the downstream river flows either through natural attenuation or through managed controls. Investigating waterbody dynamics relies primarily on understanding their morphology and geophysical characteristics that are primarily defined by bathymetry. Bathymetric conditions define stage-storage relationships and circulation/transport processes in waterbodies. Yet many studies oversimplify these mechanisms due to unavailability of the bathymetric data. We developed a novel GLObal Bathymetric (GLOBathy) dataset of 1.4+ million waterbodies to align with the well-established global dataset, HydroLAKES. GLOBathy uses a GIS-based framework to generate bathymetric maps based on the waterbody maximum depth estimates and HydroLAKES geometric/geophysical attributes of the waterbodies. The maximum depth estimates are validated at 1,503 waterbodies, making use of several observed data sources. We also provide estimations for head-Area-Volume (h-A-V) relationships of the HydroLAKES waterbodies, driven from the bathymetric maps of the GLOBathy dataset. The h-A-V relationships provide essential information for water balance and hydrological studies of global waterbody systems.

Utility and reliability of the Clinical Frailty Scale in patients scheduled for major vascular surgery: a prospective, observational, multicentre observer-blinded study.

BACKGROUND: Frailty is a distinctive health state associated with a loss of physiological reserve that results in higher rates of perioperative complications and impaired return to pre-morbid functional status. It is prevalent in the vascular population; however routine assessment is not common despite national guidance to the contrary. We aimed to evaluate the reliability of the Clinical Frailty Scale in assessing frailty in the surgical vascular population. METHODS: In this prospective, observational, observer-blinded study, we compared assessment of frailty in patients scheduled for major vascular surgery attending the pre-operative assessment clinic using the Clinical Frailty Scale against the Edmonton Frailty Scale. The study investigator completed the Edmonton Frailty Scale assessment; this was compared to the Clinical Frailty Scale assessments performed by the pre-assessment consultant and pre-assessment nurse, who were blinded to the Edmonton Frailty Scale score. The inter-rater reliability of the Clinical Frailty Scale between the pre-assessment consultant and pre-assessment nurse was determined by comparing their frailty scores for each patient. RESULTS: Ninety-seven patients were included in the analysis (median age 72 years, 84% male and 16% female). There was a moderate level of agreement between the Edmonton and Clinical Frailty Scale score for both consultants (87.6% agreement) and pre-assessment nurses (87.6% agreement). There was a substantial level of agreement between consultants and pre-assessment nurses for the Clinical Frailty Scale (89.7% agreement) CONCLUSIONS: The Clinical Frailty Scale is a useful tool to assess frailty in the vascular surgical population. It is more practical than the Edmonton Frailty Scale: quick to complete, requires minimal training and can be used when physical disability is present. TRIAL REGISTRATION: The study was approved by the Wales Health and Care Research Ethics Service (REC reference 17/WA/0160, IRAS 201173). TRIAL REGISTRATION: NCT03403673. Registered 19 January 2018, https://clinicaltrials.gov/ct2/show/NCT03403673.

Integrated miRNA/cytokine/chemokine profiling reveals severity-associated step changes and principal correlates of fatality in COVID-19.

Inflammatory cytokines and chemokines (CC) drive COVID-19 pathology. Yet, patients with similar circulating CC levels present with different disease severity. Here, we determined 171 microRNAomes from 58 hospitalized COVID-19 patients (Cohort 1) and levels of 25 cytokines and chemokines (CC) in the same samples. Combining microRNA (miRNA) and CC measurements allowed for discrimination of severe cases with greater accuracy than using miRNA or CC levels alone. Severity group-specific associations between miRNAs and COVID-19-associated CC (e.g., IL6, CCL20) or clinical hallmarks of COVID-19 (e.g., neutrophilia, hypoalbuminemia) separated patients with similar CC levels but different disease severity. Analysis of an independent cohort of 108 patients from a different center (Cohort 2) demonstrated feasibility of CC/miRNA profiling in leftover hospital blood samples with similar severe disease CC and miRNA profiles, and revealed CCL20, IL6, IL10, and miR-451a as key correlates of fatal COVID-19. These findings highlight that systemic miRNA/CC networks underpin severe COVID-19.

Yoga for older adults with multimorbidity (the Gentle Years Yoga Trial): study protocol for a randomised controlled trial.

BACKGROUND: Multimorbidity is common in older adults and associated with high levels of illness burden and healthcare expenditure. The evidence base for how to manage older adults with multimorbidity is weak. Yoga might be a useful intervention because it has the potential to improve health-related quality of life, physical functioning, and several medical conditions. The British Wheel of Yoga's Gentle Years Yoga© (GYY) programme was developed specifically for older adults, including those with chronic medical conditions. Data from a pilot trial suggested feasibility of using GYY in this population, but its effectiveness and cost-effectiveness remain uncertain. METHODS: This is a multi-site, individually randomised, superiority trial with an embedded process evaluation and an economic analysis of cost-effectiveness. The trial will compare an experimental strategy of offering a 12-week GYY programme against a control strategy of no offer in community-dwelling adults aged 65 or over who have multimorbidity, defined as having two or more chronic conditions from a predefined list. The primary outcome is health-related quality of life measured using the EQ-5D-5L, the primary endpoint being the overall difference over 12 months. Both groups will continue to be able to access their usual care from primary, secondary, community, and social services. Participants, care providers, and yoga teachers will not be blinded to the allocated intervention. Outcome measures are primarily self-reported. The analysis will follow intention-to-treat principles. DISCUSSION: This pragmatic randomised controlled trial will demonstrate if the GYY programme is an effective, cost-effective, and viable addition to the management of older adults with multimorbidity. TRIAL REGISTRATION: ISRCTN ISRCTN13567538 . Registered on 18 March 2019.

Community-based prehabilitation before elective major surgery: the PREP-WELL quality improvement project.

Optimising health and well-being before elective major surgery via prehabilitation initiatives is important for good postoperative outcomes. In a busy tertiary centre in North East England, the lack of a formal prehabilitation service meant that opportunities were being missed to optimise patients for surgery. This quality improvement project aimed to implement and evaluate a community-based prehabilitation service for people awaiting elective major surgery: PREP-WELL. A multidisciplinary, cross-sector team introduced PREP-WELL in January 2018. PREP-WELL provided comprehensive assessment and management of perioperative risk factors in the weeks before surgery. During a 12-month pilot, patients were referred from five surgical specialties at James Cook University Hospital. Data were collected on participant characteristics, behavioural and health outcomes, intervention acceptability and costs, and process-related factors. By December 2018, 159 referrals had been received, with 75 patients (47%) agreeing to participate. Most participants opted for a supervised programme (72%) and were awaiting vascular (43%) or orthopaedic (35%) surgery. Median programme duration was 8 weeks. The service was delivered as intended with participants providing positive feedback. Health-related quality of life (HRQoL; EuroQol 5D (EQ-5D) utility) and functional capacity (6 min walk distance) increased on average from service entry to exit, with mean (95% CI) changes of 0.108 (-0.023 to 0.240) and 35 m (-5 to 76 m), respectively. Further increases in EQ5D utility were observed at 3 months post surgery. Substantially more participants were achieving recommended physical activity levels at exit and 3 months post surgery compared with at entry. The mean cost of the intervention was £405 per patient; £52 per week. The service was successfully implemented within existing preoperative pathways. Most participants were very satisfied and improved their risk profile preoperatively. Funding has been obtained to support service development and expansion for at least 2 more years. During this period, alternative pathways will be developed to facilitate wider access and greater uptake.

An Overview of Timeline of Interventions in the Continuum of Cleft Lip and Palate Care.

This article provides an overview of timeline of interventions and the critical role different providers have in the continuum of cleft lip and palate care. The earliest intervention is the presurgical infant orthopedic treatment, which is initiated in the first few weeks of life. This is followed by several interventions done in a phased manner. These include: lip repair, palate repair, velopharyngeal surgery, maxillary expansion, maxillary bone grafting, limited phase of orthodontic treatment, comprehensive phase of orthodontic treatment (with/without orthognathic surgery), and restorative dentistry.

Exercise-induced myocardial dysfunction detected by cardiopulmonary exercise testing is associated with increased risk of mortality in major oncological colorectal surgery.

BACKGROUND: Cardiopulmonary exercise testing (CPET) identifies high-risk patients before major surgery. In addition to using oxygen uptake and ventilatory efficiency to assess functional capacity, CPET can be used to identify underlying myocardial dysfunction through the assessment of the oxygen uptake to heart rate response (oxygen pulse response). We examined the relationship of oxygen pulse response, in combination with other CPET variables and known cardiac risk factors, with mortality after colorectal cancer surgery. METHODS: This work focused on a retrospective cohort study of patients who had CPET and underwent colorectal cancer surgery. The primary outcome was a composite of in-hospital and 30-day mortality. Ventilatory inefficiency (Ve/Vco2>34) and exercise-induced myocardial dysfunction (abnormal oxygen pulse response) were investigated for an association with mortality using bivariable analysis and multivariable Cox regression. RESULTS: A total of 1214 patients who underwent colorectal cancer surgery were included, and the primary outcome occurred in 26 patients (2.1%). Multivariable Cox regression showed abnormal oxygen pulse response was independently associated with the primary outcome (odds ratio [OR]=2.75; 95% confidence interval [CI], 1.17-6.47). Bivariable analysis showed that Ve/Vco2 >34 was associated with the primary outcome (OR=3.43; 95% CI, 1.47-8.01). Combining Ve/Vco2 >34 and abnormal oxygen pulse response conferred an increased risk for the primary outcome (OR=4.47; 95% CI, 1.62-12.34), compared with Ve/Vco2 >34 and normal oxygen pulse response. CONCLUSION: Ventilatory inefficiency and an abnormal oxygen pulse response were independently associated with short- (30-day) and long-term (2-yr) mortality. Oxygen pulse response may provide additional information when considering perioperative risk stratification.

Comparison of the effects of buprenorphine and methadone in combination with medetomidine followed by intramuscular alfaxalone for anaesthesia of cats undergoing ovariohysterectomy.

OBJECTIVES: The aim of this study was to compare the quality of anaesthesia and analgesia between methadone and buprenorphine in combination with medetomidine after induction with intramuscular (IM) alfaxalone in cats undergoing ovariohysterectomy. METHODS: Fifty-one female cats (American Society of Anesthesiologists status I-II), with a median age of 12 months (range 2-60 months), weighing a mean ± SD of 2.5 ± 0.5 kg, were recruited to the study. Cats were randomly allocated to receive medetomidine (600 µg/m2) and buprenorphine (180 µg/m2) (group MB) or medetomidine (500 µg/m2) and methadone (5 mg/m2) (group MM) IM. Anaesthesia was induced 15 mins later using alfaxalone (3 mg/kg) IM. Anaesthesia was maintained with isoflurane in oxygen. All cats received meloxicam preoperatively. Quality of premedication and induction and intraoperative physiological parameters were recorded. Atipamezole (50% of medetomidine dose) was administered at the end of surgery. Cats were assessed postoperatively by the same blinded observer using a simple descriptive scale, numeric rating scale, dynamic interactive visual analogue scale (DIVAS) and UNESP-Botucatu multidimensional composite pain scales, at 10, 20 and 30 mins post-extubation. Parametric and non-parametric data were compared using Student's t-test or Mann-Whitney U-tests, respectively. RESULTS: Forty-one cats completed the study. No significant differences were detected between groups before or during anaesthesia. No cats required rescue analgesia. DIVAS scores at 10 mins were significantly less in the MM group compared with the MB. No differences between groups at any other time points were detected using the four metrology instruments. CONCLUSIONS AND RELEVANCE: Both protocols provided good anaesthesia conditions for ovariohysterectomy in the cat.

Effects of atipamezole dosage and timing of administration on recovery time and quality in cats following injectable anaesthesia incorporating ketamine.

OBJECTIVES: The aim of this study was to establish the optimum dosage and timing of administration of atipamezole in cats undergoing general anaesthesia incorporating ketamine to provide the shortest recovery possible without unacceptably compromising recovery quality. METHODS: In total, 128 healthy male cats (age range 2-108 months, weight range 0.56-5.22 kg) admitted for castration were randomly allocated to groups of 32. Anaesthesia was induced with 60 mg/m2 ketamine, 180 µg/m2 buprenorphine, 3 mg/m2 midazolam and 600 µg/m2 medetomidine intramuscularly (IM). Cats received 600 µg/m2 (groups 1ATI20 and 1ATI40) or 1.5 mg/m2 (groups 2.5ATI20 and 2.5ATI40) atipamezole IM either 20 (groups 1ATI20 and 2.5ATI20) or 40 mins (groups 1ATI40 and 2.5ATI40) after the 'quad'. Preparation time, surgical time, auricular temperature, times to sternal recumbency and first standing, and recovery quality score were recorded. Data were analysed using ANOVA, Kruskal-Wallis, Mann-Whitney U-tests and χ2 tests. Statistical significance was deemed to be P ⩽0.05. RESULTS: Groups did not differ significantly in preparation or surgical time. Auricular temperature decreased significantly over time (P <0.01) but did not differ between atipamezole treatment groups. Time to sternal recumbency in group 2.5ATI20 (52.9 ± 22.3 mins) was faster than group 1ATI20 (65.7 ± 24.7 mins) (P ⩽0.05), but there were no significant differences between other groups. Time to first standing and recovery quality scores did not differ significantly between groups. Minimal adverse effects were seen. CONCLUSIONS AND RELEVANCE: Atipamezole administration after 20 mins did not reduce recovery time but neither was recovery quality adversely affected compared with when it was administered after 40 mins, following datasheet recommendations with concurrent ketamine administration. The results of this study also suggest that an atipamezole:medetomidine dose ratio of 2.5:1 is more effective than 1:1 in reducing recovery time, regardless of timing of administration, although this only reached statistical significance for time to sternal recumbency when atipamezole was administered after 20 mins.

A novel approach to welfare interventions in problem multi-cat households.

BACKGROUND: Thousands of injured, stray and relinquished cats are received at the RSPCA Greater Manchester Animal Hospital each year. A significant and challenging proportion of these cats are confiscated from multicat households by RSPCA Inspectors, due to the owners' inability to care for them. These households share many characteristics of animal hoarding, including poor owner compliance with suggested welfare improvements and recidivism. The relatively poor adoption potential of animals from such households are a perennial problem for the charity. The aim of this study was to determine if offering female cat neutering assistance to multi-cat owners significantly improved colony welfare. RESULTS: Ten multicat households with a history of public complaint to the RSPCA were recruited. An RSPCA veterinary surgeon (VS) initially assessed the overall welfare of each household's cat population, individual cat welfare and the living environment. All entire female cats aged over 8 weeks were neutered and basic animal care education provided. Follow up visits were completed two and 12 months later to reassess welfare parameters and population numbers. The total number of cats was 176 across ten households (range 7-33, median 16). All owners consented to having all entire female cats spayed. At the first visit, mean individual cat welfare scores ranged from 5.4-8.7/ 16 across the 10 households, where 16 represented best possible welfare. Overall household mean welfare scores were significantly improved at both the 2 month and 12 month revisits (p = 0.011 and p = 0.01 respectively) when compared to the initial visits. By the end of the study period, three out of the ten households had voluntarily relinquished all of their cats, and overall there was a 40% reduction in the number of cats. CONCLUSIONS: Animal hoarding has previously been an intractable welfare concern with little evidence informing intervention techniques. These results show that positive veterinary engagement on site, focused on preventative care and population control, can yield significant improvement in welfare scoring systems in relatively short timescales. Promptly collecting and neutering all female cats at a site, combined with advice and support, show promise in improving welfare.

Sciadopitys verticillata Resin: Volatile Components and Impact on Plant Pathogenic and Foodborne Bacteria.

Sciadopitys verticillata (Sv) produces a white, sticky, latex-like resin with antimicrobial properties. The aims of this research were to evaluate the effects of this resin (Sv resin) on bacterial populations and to determine the impact of its primary volatile components on bioactivity. The impact of sample treatment on chemical composition of Sv resin was analyzed using Fourier transform infrared spectroscopy (FTIR) coupled with principal component analysis. The presence and concentration of volatiles in lyophilized resin were determined using gas chromatography/mass spectrometry (GC/MS). Changes in bacterial population counts due to treatment with resin or its primary volatile components were monitored. Autoclaving of the samples did not affect the FTIR spectra of Sv resin; however, lyophilization altered spectra, mainly in the CH and C=O regions. Three primary bioactive compounds that constituted >90% of volatiles (1R-α-pinene, tricyclene, and ß-pinene) were identified in Sv resin. Autoclaved resin impacted bacterial growth. The resin was stimulatory for some plant and foodborne pathogens (Pseudomonas fluorescens, P. syringae, and Xanthomonas perforans) and antimicrobial for others (Escherichia coli, Bacillus cereus, Agrobacterium tumefaciens, and Erwinia amylovora). Treatment with either 1R-α-pinene or ß-pinene reduced B. cereus population growth less than did autoclaved resin. The complex resin likely contains additional antimicrobial compounds that act synergistically to inhibit bacterial growth.