Use of the Obstetric Quality-of-Recovery score (ObsQoR-11) to measure the impact of an enhanced recovery programme for elective caesarean section.

BACKGROUND: Enhanced recovery after caesarean (ERAC) has been shown to postoperatively reduce opioid consumption, reduce pain scores, and shorten hospital stay. Arguably, none of these measures provide for a patient-centred approach. We believe that patient-reported outcome measures (PROMs) represent a more holistic approach to the reporting of outcomes. One such PROM is the Obstetric Quality-of-Recovery Score (ObsQoR-11). This has been shown to be a valid and reliable assessment of recovery after elective caesarean section. METHODS: This before-and-after quality improvement programme studied consecutive patients undergoing elective caesarean section. We implemented an ERAC pathway with the aim of improving quality of recovery and patient satisfaction. Our primary outcome was the change in the ObsQoR-11 score. RESULTS: A total of 318 medical records were reviewed (n = 93 before ERAC, n = 225 after ERAC). There was a significant improvement in ObsQoR-11 score in ERAC patients compared with pre-ERAC patients (85.0 vs 82.3, P < 0.001). Morphine consumption (MMEQ) was reduced by 10% overall in the ERAC group, with no increase in pain scores at day 1 postoperatively and a decrease in pain scores on day 2 in the ERAC group (P = 0.02). The length of hospital stay was significantly shorter in ERAC patients (63.1 h vs 79.9 h, P < 0.001). CONCLUSIONS: Our study demonstrated an improved ObsQoR-11 score after ERAC implementation. This is the first example in the literature of using ObsQoR-11 in ERAC. We believe this is a more comprehensive way to assess patient recovery and the impact of an ERAC programme.

Infrared thermographic assessment of spinal anaesthesia-related cutaneous temperature changes during caesarean section.

INTRODUCTION: Assessment of adequacy of spinal anaesthesia, prior to obstetric surgery is extremely important but can be problematic because currently available clinical assessment methods are indirect and subjective. As the sympathectomy associated with spinal anaesthesia is known to cause vasodilation and heat redistribution, we sought to assess whether spinal anaesthesia led to significant and consistent cutaneous temperature changes as measured by infrared thermography. METHODS: Following ethics committee approval, this observational study was conducted in a tertiary level obstetric centre. Participants included women undergoing elective caesarean section under spinal anaesthesia. Following consent, a Flir T540 infrared camera captured thermographic images over the feet, patella, buttock, iliac crests, xiphisternum and axilla. Temperature was measured prior to spinal needle insertion (T0) and following clinical assessment when the block was deemed adequate. RESULTS: Thirty patients were included. Baseline temperature varied considerable by site. Spinal anaesthesia altered skin temperature in all areas of interest: right and left hallux (mean of differences (MD) +4.0°C and 5.2°C respectively, P <0.0001), right and left plantar (MD +6.1°C and 6.8°C respectively, P <0.0001), patella (MD -0.33°C, P=0.0445), buttock (MD -0.5°C, P=0.009), iliac crest (MD -0.7°C, P=0.0004), xiphisternum (MD -0.95°C, P <0.0001) and axilla (MD -0.71°C, P=0.0002). CONCLUSIONS: Following spinal anaesthesia thermographic imaging identified different patterns of skin temperature changes, with pronounced temperature increases measured in the feet and cooling of a lesser amplitude in the thoracic and lumbar dermatomes. Infrared thermography has the potential to provide objective measurement of sympathectomy.

Site-specific covalent capture of human O6-alkylguanine-DNA-alkyltransferase using single-stranded intrastrand cross-linked DNA.

A methodology is reported to conjugate human O6-alkylguanine-DNA-alkyltransferase (hAGT) to the 3'-end of DNA in excellent yields with short reaction times by using intrastrand cross-linked (IaCL) DNA probes. This strategy exploited the substrate specificity of hAGT to generate the desired DNA-protein covalent complex. IaCL DNA linking two thymidine residues, or linking a thymidine residue to a 2'-deoxyguanosine residue (either in a 5'→3' or 3'→5' fashion), lacking a phosphodiester linkage at the cross-linked site, were prepared using a phosphoramidite strategy followed by solid-phase synthesis. All duplexes containing the model IaCL displayed a reduction in thermal stability relative to unmodified control duplexes. The O4-thymidine-alkylene-O4-thymidine and the (5'→3') O6-2'-deoxyguanosine-alkylene-O4-thymidine IaCL DNA adducts were not repaired by any of the AGTs evaluated (human AGT and Escherichia coli homologues, OGT and Ada-C). The (5'→3') O4-thymidine-alkylene-O6-2'-deoxyguanosine IaCL DNA containing a butylene or heptylene tethers were efficiently repaired by the human variant, whereas Ada-C was capable of modestly repairing the heptylene IaCL adduct. The IaCL strategy has expanded the toolbox for hAGT conjugation to DNA strands, without requiring the presence of a complementary DNA sequence. Finally, hAGT was functionalized with a fluorescently-labelled DNA sequence to demonstrate the applicability of this conjugation method.

Lesion Orientation of O4-Alkylthymidine Influences Replication by Human DNA Polymerase η.

DNA lesions that elude repair may undergo translesion synthesis catalyzed by Y-family DNA polymerases. O4-Alkylthymidines, persistent adducts that can result from carcinogenic agents, may be encountered by DNA polymerases. The influence of lesion orientation around the C4-O4 bond on processing by human DNA polymerase η (hPol η) was studied for oligonucleotides containing O4-methylthymidine, O4-ethylthymidine, and analogs restricting the O4-methylene group in an anti-orientation. Primer extension assays revealed that the O4-alkyl orientation influences hPol η bypass. Crystal structures of hPol η•DNA•dNTP ternary complexes with O4-methyl- or O4-ethylthymidine in the template strand showed the nucleobase of the former lodged near the ceiling of the active site, with the syn-O4-methyl group engaged in extensive hydrophobic interactions. This unique arrangement for O4-methylthymidine with hPol η, inaccessible for the other analogs due to steric/conformational restriction, is consistent with differences observed for nucleotide incorporation and supports the concept that lesion conformation influences extension across DNA damage. Together, these results provide mechanistic insights on the mutagenicity of O4MedT and O4EtdT when acted upon by hPol η.

A randomised controlled trial using the Epidrum for labour epidurals.

The aim of our study was to determine if using the Epidrum to site epidurals improves success and reduces morbidity. Three hundred parturients requesting epidural analgesia for labour were enrolled. 150 subjects had their epidural sited using Epidrum and 150 using standard technique. We recorded subject demographics, operator experience, number of attempts, Accidental Dural Puncture rate, rate of failure to site epidural catheter, rate of failure of analgesia, Post Dural Puncture Headache and Epidural Blood Patch rates. Failure rate in Epidrum group was 9/150 (6%) vs 0 (0%) in the Control group (P = 0.003). There were four (2.66%) accidental dural punctures in the Epidrum group and none in the Control group (P = 0.060), and 2 epidurals out of 150 (1.33%) in Epidrum group were re-sited, versus 3/150 (2%) in the control group (P = 1.000). The results of our study do not suggest that using Epidrum improves success or reduces morbidity.

The relationship between intact PTH and biointact PTH (1-84) with bone and mineral metabolism in pre-dialysis chronic kidney disease (CKD).

OBJECTIVES: Abnormalities in PTH are implicated in the pathogenesis of bone abnormalities in chronic kidney disease (CKD)-mineral bone disorder (CKD-MBD). PTH concentrations are important in clinical decision and management. This emphasises the importance of providing an assay which measures biologically active PTH. We compared concentrations of intact PTH with biointact PTH (1-84) in CKD and end stage renal disease (ESRD) and investigated the relationship between the 2 PTH assays with bone and mineral laboratory parameters and bone mineral density (BMD) in CKD. DESIGN AND METHODS: We assessed 140 patients (61 in ESRD and 79 with CKD stages 1-4) in this cross-sectional study. We measured biointact PTH (1-84) as well as routine biochemical parameters on all subjects. In the CKD cohort, bone turnover markers; bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase (TRACP)-5b and bone mineral density (BMD) were also determined. RESULTS: In ESRD, intact PTH concentration was significantly higher compared to biointact PTH (1-84) (422 [443] v/s 266 [251] pg/mL, (p<0.001) with an average bias of 60%. In CKD, intact PTH concentration was also higher compared to biointact PTH (1-84) (79[55] v/s 68[49] pg/mL p<0.001) with an average bias of 18%. Only the biointact PTH (1-84) assay showed any significant correlation with serum calcium concentrations (r=-0.26, p<0.05) and phosphate (r=0.25, p<0.05) in CKD. Following multilinear regression analysis and adjustment for all significant co-variables, only eGFR, BAP and 25 (OH)vitamin remained significantly associated with intact PTH and biointact PTH (1-84). The strength of association was stronger between BAP and biointact PTH (1-84) (biointact PTH (1-84): p=0.007, intact PTH: p=0.01). In adjusted analyses, only biointact PTH (1-84) was significantly associated with BMD at the fore-arm (FARM) (p=0.049). CONCLUSIONS: The study confirms the differences between intact PTH and biointact PTH (1-84) in ESRD. Whilst there may be similarities in the diagnostic ability of both intact and biointact PTH (1-84), our data suggest that biointact PTH (1-84) assay may better reflect bone metabolism and BMD in CKD. Further longitudinal studies are needed.

Comparison of generic and proprietary sodium stibogluconate for the treatment of visceral leishmaniasis in Kenya.

OBJECTIVE: To compare the use of generic and proprietary sodium stibogluconate for the treatment of visceral leishmaniasis (kala-azar). METHODS: A total of 102 patients with confirmed kala-azar were treated in a mission hospital in West Pokot region, Kenya, with sodium stibogluconate (20 mg/kg/day for 30 days)--either as Pentostam (PSM) or generic sodium stibogluconate (SSG); 51 patients were allocated alternately to each treatment group. FINDINGS: There were no significant differences in baseline demographic characteristics or disease severity, or in events during treatment. There were 3 deaths in the PSM group and 1 in the SSG group; 2 patients defaulted in each group. Only 1 out of 80 test-of-cure splenic aspirates was positive for Leishmania spp.; this patient was in the SSG group. Follow-up after > or = 6 months showed that 6 out of 58 patients had relapsed, 5 in the SSG group and 1 in the PSM group. No outcome variable was significantly different between the two groups. CONCLUSION: The availability of cheaper generic sodium stibogluconate, subject to rigid quality controls, now makes it possible for the health authorities in kala-azar endemic areas to provide treatment to many more patients in Africa.

A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets.

We conducted a prospective randomized study of success rate and time to intubation using Trachlight and Surch-Lite lighted stylets versus a regular tracheal tube stylet, in a training setting. Participants, 18 paediatric transport paramedics, performed two intubations with each of the three devices, using an airway management trainer. There was no significant difference in mean time for intubation between the three devices. The times for external confirmation of correct tube placement were comparable using the two lighted stylets. External confirmation of the tube placement using the lighted stylets was quicker than laryngoscopic visualization. In darkness, with a nonfunctioning laryngoscope, intubations were successfully performed 100% of the time with the lighted stylet, but only 11% of the time with the regular stylet. All paramedics felt that a lighted stylet would be a useful airway management adjunct for the transport environment for complicated intubations or for use in very high or low levels of ambient light.

Towards computer assisted evaluation of plagiocephaly.

Plagiocephaly is a common asymmetry of the skull giving the impression that the subject, usually a neonate, has suffered a compressive force acting unilaterally. Normally innocuous, it is a postural deformity that can be suggestive of other significant abnormalities, e.g. joint dysplasia. Although intuitive measurements of plagiocephaly appear in the literature there is little evidence of analytical evaluation. This paper describes a measurement methodology based on black and white photography. A flat-bed scanner and a personal computer facilitated the transformation of the prepared photograph to standard tagged image file format at 256 grey scale. A utility was used to convert the file scan to a monochrome bitmap image which was displayed on the screen and subjected to an algorithm to compute the centroid of the cranial profile. Radials that emerge from the centroid to the cranial circumference at five degree intervals map to a signal display that represents the plagiocephaly.

Tracheal intubation in a mannikin: comparison of the Belscope with the Macintosh laryngoscope.

Tracheal intubation carries a risk of accidental oesophageal intubation; this is increased with inexperienced trainees, and in patients with a difficult airway. The recent introduction of an angulated laryngoscope, the Belscope, may permit a better view of the vocal cords and increase the accuracy of orotracheal intubation. To determine how easy it is to learn to use the Belscope compared with the traditional Macintosh laryngoscope, a group of medical students attempted to intubate a mannikin which had been modified to simulate a difficult intubation. Time to intubation was fast with both laryngoscopes, although faster with the Macintosh, but the Belscope produced an unexpected greater incidence of failed intubation.

Ventilation, thermal noise, and errors in cardiac output measurements after cardiopulmonary bypass.

BACKGROUND: The authors observed transient increases in the amplitude of respiratory variations in pulmonary artery blood temperature in many patients after cardiopulmonary bypass (CPB). This increased "thermal noise" may significantly influence measurements of thermodilution cardiac outputs (TDCO) performed during this time. METHODS: The authors recorded the peak-to-peak amplitude of respiratory variations in pulmonary artery blood temperature in 15 patients during the first 35 min after CPB. Possible relationships between the amplitude of these variations and the magnitude of temperature differences between commonly monitored body temperature sites (nasopharyngeal, rectal, bladder, and pulmonary artery) were also examined. In ten additional patients, the authors investigated the influence of these increased respiratory variations on TDCO measurements by correlating the maximum variation in three successive TDCO measurements with the peak-to-peak amplitude of the respiratory variations in pulmonary artery blood temperature. Potential error in TDCO measurements caused by these increased respiratory variations in pulmonary artery blood temperature were also examined using model calculations of the effects of respiratory variations in pulmonary artery blood temperature on measured TDCO thermal areas. RESULTS: In the first 15 patients, the mean amplitude of respiratory variations in pulmonary artery blood temperature after CPB (mean +/- SEM) were: (1) within 5 min after CPB, 0.037 +/- 0.004 degrees C; (2) 10 min after #1, 0.025 +/- 0.003 degrees C; (3) 20 min after #1, 0.019 +/- 0.003 degrees C; and (4) 30 min after #1, 0.012 +/- 0.002 degrees C. There were no significant correlations between the magnitude of the respiratory variation in pulmonary artery blood temperature and the observed temperature differences between body sites. Four patients had pulmonary artery blood temperature variations in excess of the maximum amplitude previously reported in man (0.05 degrees C). In the next ten patients, the maximum variation between three successive TDCO measurements taken at specified times in the respiratory cycle (end inspiration, end exhalation, and 3 s after end exhalation) was significantly correlated with the amplitude of respiratory variations in pulmonary artery blood temperature (r = 0.83, P < 0.001). Four patients with increased respiratory variations in pulmonary artery blood temperature had variations in TDCO measurements exceeding 2 l/min. Subsequent model calculations demonstrated that the magnitude of potential error in TDCO measurements is dependent on both the amplitude of the respiratory variations in pulmonary artery blood temperature and the baseline cardiac output. On the basis of these thermal area calculations, potential errors of 15-50% could be caused by respiratory variations in pulmonary artery blood temperature > 0.05 degrees C. CONCLUSIONS: The authors concluded that respiratory variations in pulmonary artery blood temperature are transiently increased in many patients after CPB, and that this increased "thermal noise" may cause significant errors in TDCO measurements.

Pre-oxygenation: an easy method for all elective patients.

The transparent plastic facemask has been investigated as a pleasant method of pre-oxygenation for elective non-high risk cases in 60 healthy ASA I or II patients randomly allocated to two groups. The patients in the pre-oxgenated group (n = 30) received 8 litre min-1 oxygen through a plastic facemask for 3 min whereas those in a control group (n = 30) were not pre-oxygenated. In all patients anaesthesia was induced with propofol 2.5 mg kg-1, fentanyl 1 ug kg-1 and atracurium 0.6 mg kg-1. Manual ventilation of the lungs using a Mapleson A breathing system was performed for 2 min with 50% oxygen in nitrous oxide prior to oral intubation. Arterial saturation in the pre-oxygenated group rose significantly from a mean baseline value of 96.4 (+/- 0.9)% to 99 (+/- 0.8)% (P < 0.01) and then remained stable both after induction and intubation: 99.1 (+/- 0.8)% and 98.9 (+/- 1.1)% respectively. In the control group arterial saturation dropped sharply within 20 s following induction to a mean of 89.8 (+/- 3.1)%, and it was 30 s before arterial saturation reached the equivalent value in the pre-oxygenated group as a result of manual inflation of the lungs. An 8 litre min-1 oxygen flow via a standard transparent plastic facemask is a simple, feasible and acceptable method for routine pre-oxygenation for all elective cases.

Inadvertent suppression of a fixed rate ventricular pacemaker using a peripheral nerve stimulator.

Electromagnetic interference usually produces only minor effects in patients with pacemakers. Nevertheless, the possibilities of serious and even fatal consequences of this complication must be recognised. This case reports an unusual anaesthetic source of interference, caused by activation of a popular nerve stimulator, resulting in cardiac arrest in a patient with a fixed-rate ventricular pacemaker.