Adherence to General Medical Council guidance regarding disclosure of alternative treatments during the consent process.

INTRODUCTION: General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis. METHODS: We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy. RESULTS: Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it (p<0.001). CONCLUSION: In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Effect of reduced atmospheric pressure on growth and quality of two lettuce cultivars.

Future space missions will likely include plants to provide fresh foods and bioregenerative life support capabilities. Current spacecraft such as the International Space Station (ISS) operate at 1 atm (101 kPa) pressure, but future missions will likely use reduced pressures to minimize gas leakage and facilitate rapid egress (space walks). Plants for these missions must be able to tolerate and grow reliably at these reduced pressures. We grew two lettuce cultivars, 'Flandria' a green bibb-type and 'Outredgeous,' a red, loose-leaf type, under three pressures: 96 kPa (ambient control), 67 kPa (2/3 atm), and 33 kPa (1/3 atm) for 21 days in rockwool using recirculating nutrient film technique hydroponics. Each treatment was repeated three times using a different hypobaric chamber each time. A daily light integral of 17.2 Moles Photosynthetically Active Radiation per day was provided with metal halide lamps set to deliver 300 µmol m-2s -1 photosynthetic photon flux (PPF) for a 16 h photoperiod at 22 °C. Oxygen was maintained at 21 kPa (equal to 21% at 1 atm) and CO2 at 0.12 kPa (equal to 1200 ppm at 1 atm). Leaf area for 'Outredgeous' was reduced 20% and 38% at 67 kPa and 33 kPa respectively; shoot fresh mass was reduced 22% and 41% at 67 kPa and 33 kPa respectively when compared to control plants at 96 kPa. These trends were not statistically significant at P ≥ 0.05. Leaf area for 'Flandria' showed no difference between 96 and 67 kPa but was reduced 31% at 33 kPa; shoot fresh mass was reduced 6% and 27% at 66 kPa and 33 kPa respectively compared to 96 kPa. There were 10% and 25% increases in anthocyanin concentration at 66 kPa and 33 kPa compared to 96 kPa, potentially increasing the bioprotective capacity of the plant. Previous studies with other cultivars of lettuce showed slight change in growth across this range of pressures, suggesting responses may vary among genotypes, hypobaric exposure treatments, and / or environmental conditions. Collectively, the findings suggest further testing is needed to understand the effects of atmospheric pressure on plant growth.

Type II Cryoglobulinaemia causing Monoclonal Gammopathy of Renal Significance.

A 53 year old female with a background of hypertension, hypothyroidism and Raynaud's was admitted with an acute ischaemic stroke and referred to the renal team after a routine urine dip revealed microscopic haematuria and nephrotic-range proteinuria. Blood tests revealed renal impairment, a monoclonal IgM kappa paraprotein, low complement C4 concentration and a positive rheumatoid factor. Active cryoglobulinaemia was suspected and testing demonstrated type II cryoglobulins secondary to the monoclonal IgM kappa paraprotein. Bone marrow biopsy was normal. Renal biopsy revealed cryoglobulinaemia associated membranoproliferative glomerulonephritis. Treatment with steroids and rituximab improved renal function and proteinuria. This case fits within the evolving spectrum of disorders now termed Monoclonal Gammopathy of Renal Significance and highlights the value of biopsying and treating these patients early.

Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes.

INTRODUCTION: Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants. METHODS: We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator. RESULTS: One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85). CONCLUSIONS: Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Effects of Various Commercially Available Enrichment Options on Handling and Chronic Stress Markers in Female ICR Mice.

Although social housing of mice generally is preferred, mice must be individually housed in some situations. In these cases, enhanced attention to environmental enrichment is encouraged, but few studies assess the wellbeing of mice provided various enrichments. In this study, we used female ICR mice to evaluate enrichment strategies that encouraged natural behaviors including foraging, exercise, sheltering, and socialization. After 3 mo of exposure to the assigned enrichment strategy, wellbeing was assessed by evaluating behavioral and physiologic differences between groups. The results suggested that the use of red-tinted igloos may decrease markers of mouse wellbeing. However, none of the selected strategies yielded measures of wellbeing indicating improvement as compared to individually housed mice with no enrichment (negative control). Furthermore, measures were not significantly different between paired mice and individually housed mice with no enrichment.

A strategic approach for investigating light recipes for 'Outredgeous' red romaine lettuce using white and monochromatic LEDs.

To optimize crop production/quality in space, we studied various "light recipes" that could be used in the Advanced Plant Habitat currently aboard the International Space Station (ISS). Lettuce (Lactuca sativa cv. 'Outredgeous') plants were grown for 28 days under seven treatments of white (W) LEDs (control), red (635 nm) and blue (460 nm) (RB) LEDs, W + blue (B) LEDs, W + green (520 nm) (G) LEDs, W + red (R) LEDs, W + far red (745 nm) (FR) LEDs, and RGB + FR LEDs with ratios similar to natural sunlight. Total PAR was maintained near 180 µmol m-2 s-1 with an 18 h photoperiod. Lettuce grown under RGB + FR produced the greatest leaf expansion and overall shoot biomass, while leaves from WB and RB showed the highest levels of pigmentation, secondary metabolites, and elemental nutrients. All other supplemental treatments had varying impacts on morphology that were dependent on crop age. The WG treatment increased fresh mass early in the cycle, while WR increased biomass later in the cycle. The plants grown under WFR exhibited elongation of petioles, lower nutrient content, and similar shoot biomass to the W control. The findings suggest that supplementing a broad spectrum, white light background with discrete wavelengths can be used to manipulate total yield, morphology, and levels of phytonutrients in lettuce at various times during the crop cycle.

Testicular atrophy following paediatric primary orchidopexy: A prospective study.

BACKGROUND: With the Nordic consensus statement advocating orchidopexy at an earlier age, the present study sought to investigate the outcomes of primary paediatric orchidopexy at a tertiary UK centre. OBJECTIVE: To prospectively assess testicular atrophy following primary orchidopexy for undescended testes in a paediatric population. Secondary outcomes were complication rates and whether outcomes were dependent on grade of operating surgeon. STUDY DESIGN: Prospective data regarding age at operation, classification of the undescended testis, length of follow-up, and subjective comparison of intraoperative and postoperative testicular volumes compared with the contralateral testis were collected. Testicular atrophy was defined as >50% loss of testicular volume or a postoperative testicular volume <25% of the volume of the contralateral testis. Patients were excluded for incomplete data and follow-up <6 months. RESULTS: Data for 234 patients were analysed. Testicular atrophy occurred in 2.6% of cases. There was no reported testicular re-ascent. All secondary acquired cases underwent a previous ipsilateral hernia repair. There was no significant difference in outcomes comparing the grade of surgeon (consultant n = 8, trainee/staff-grade surgeon n = 7-8). There was a trend towards postoperative catch-up growth in approximately one fifth of cases. DISCUSSION: Previous studies have reported a testicular atrophy rate of 5%. The present study reported a similar rate of 2.6%. In agreement with a previous publication, it was also found that testicular atrophy was not dependent on the grade of operating surgeon. The mechanism for testicular catch-up growth is not well understood. Animal studies have supported the hypothesis that increased temperature has a detrimental effect on testicular volume. However, follow-up in the present cohort was short (median 6.9 months), making interpretation of this finding difficult. It is acknowledged that clinical palpation alone to determine testicular volume potentially introduces intra-observer and inter-observer error. However, prospective studies using ultrasound to determine testicular volumes following orchidopexy have reported catch-up growth. CONCLUSION: This study represented one of the larger collections of prospective assessments of outcomes following primary orchidopexy. It was acknowledged that subjectively assessing testicular volume is not ideal; however, the data correlated with similar studies.

Basal body multipotency and axonemal remodelling are two pathways to a 9+0 flagellum.

Eukaryotic cilia/flagella exhibit two characteristic ultrastructures reflecting two main functions; a 9+2 axoneme for motility and a 9+0 axoneme for sensation and signalling. Whether, and if so how, they interconvert is unclear. Here we analyse flagellum length, structure and molecular composition changes in the unicellular eukaryotic parasite Leishmania during the transformation of a life cycle stage with a 9+2 axoneme (the promastigote) to one with a 9+0 axoneme (the amastigote). We show 9+0 axonemes can be generated by two pathways: by de novo formation and by restructuring of existing 9+2 axonemes associated with decreased intraflagellar transport. Furthermore, pro-basal bodies formed under conditions conducive for 9+2 axoneme formation can form a 9+0 axoneme de novo. We conclude that pro-centrioles/pro-basal bodies are multipotent and not committed to form either a 9+2 or 9+0 axoneme. In an alternative pathway structures can also be removed from existing 9+2 axonemes to convert them to 9+0.

When might an operative complication be regarded as acceptable? Part 2: Judicial factors that influence the finding of fault during surgical litigation.

In cases where surgeons face litigation over operative misadventure, the result of a trial is uncertain. In order to identify factors in cases of surgical litigation that have influenced the final decision of the courts, we have previously reviewed reported cases where the outcome turned on actions taken by surgeons. We now turn our attention to judicial attitudes to evidence that play a role in the determination of the case.

When might an operative complication be regarded as acceptable? Part 1: Surgical factors that influence courts when finding fault during litigation.

In cases where surgeons face litigation over operative misadventure, the result of a trial is uncertain. In order to identify factors in cases of surgical litigation that have influenced the final decision of the courts, we have reviewed recent reported cases, noting both surgical and evidential influences on outcome. Taken together, these reveal that among other influential factors, the acceptability of more than one reasonable operative approach, the court's approach to inappropriate delegation and the uncertainties of expert evidence all play a role in the determination of the case.

Effect of multilevel laboratory rat caging system on the well-being of the singly-housed Sprague Dawley rat.

Current regulations emphasize that good husbandry practices allow animals to engage in species appropriate postural adjustments without touching the enclosure walls. This study evaluated the well-being of rats housed in a commercially available multilevel rat caging system, with or without access to the upper level of the caging. The evaluation methodologies included assessment of behavioral observations in the home cage, physiological assessment of metabolism and immune function, and determination of the affective state using a spatial cognitive bias assay. The study determined that rats that were provided access to the full multilevel cage during testing after initial restriction to the lower level of the cage demonstrated behavioral changes consistent with a positive affective state, while those with no changes to their housing situation had no significant differences in their affective states. Rats that were consistently housed with access restricted to the lower level of the cage exhibited a tendency to increased neutrophil:lymphocyte ratios as compared with those provided with access to all levels of the multilevel cage. There were no differences in body weight demonstrated between the experimental groups. Overall use of the cage space, as documented through analysis of behavioral observations in the home cage, demonstrated no significant differences in preferred location in the cage during the light or dark cycles, though rats with access to both levels of the cage were significantly more active during the light cycle. The results of this study suggest that the use of a multilevel caging system may improve the well-being of rats used in research.

Adults who refuse blood transfusion in emergency, urgent and elective circumstances.

Surgeons dealing with an adult refusing a blood transfusion find themselves in an unenviable position, torn between wishing to preserve the patient's life while also respecting his or her wishes. This article looks at the legal framework for such circumstances as set out in the Mental Capacity Act 2005.

Candour for surgeons: the absence of spin.

Doctors are exhorted to be candid with their patients when clinical errors occur. This paper discusses the history of candour in surgical law as well as recommendations resulting from the Mid Staffordshire public inquiry. It also looks at why candour is necessary and where the threshold should lie. Provided surgeons understand that a duty of candour is engaged at a certain threshold of harm, then disclosure of misadventure to patients or their relatives becomes simply a matter for clinical judgement, just in the same way as a surgeon judges which potential operative complications need to be disclosed during the consenting process.

Seeking responsibility for the lost swab? Search elsewhere.

This article explores the possibility that the surgeon's control over his or her environment is not complete and that, in certain circumstances, the final swab count can be distinguished from the 'normal course of events'. We readily accept that most swabs and instruments are left inside patients simply as a result of substandard care but we cannot accept that this is invariably the case, and lessons from the common law are cited to illustrate the reasons why. We hope to persuade defendant lawyers that it might be worthwhile to tease out from surgeons under scrutiny how these factors may have influenced their practice on the day that a swab was retained.

Pain and somatic symptoms are sequelae of sexual assault: results of a prospective longitudinal study.

BACKGROUND: Cross-sectional studies have shown that chronic musculoskeletal pain and somatic symptoms are frequently reported by sexual assault (SA) survivors; however, prospective studies examining pain and somatic symptoms in the months after SA have not been performed. METHODS: Women SA survivors 18 years of age or older who presented for care within 48 h of SA were recruited. Pain in eight body regions (head and face, neck, breast, arms, abdomen, back, genital and pelvic, and legs) and 21 common somatic symptoms (e.g., headache, nausea, insomnia, persistent fatigue) were assessed (0-10 numeric rating scale in each body region) at the time of presentation, 1-week, 6-week and 3-month interview. Post-traumatic stress disorder (PTSD) symptoms were assessed at the 6-week and 3-month interview. RESULTS: Clinically significant new or worsening pain (CSNWP) symptoms were common among study participants 6 weeks after SA [43/74, 58% (95% CI, 47-69%)] and 3 months after SA [40/67, 60% (95% CI, 48-71%)] and generally occurred in regions not experiencing trauma. Women SA survivors also experienced an increased burden of many common somatic symptoms: 8/21 (38%) and 11/21 (52%) common somatic symptoms showed a significant increase in severity 6 weeks and 3 months after SA, respectively. Correlations between PTSD, CSNWP and somatic symptoms were only low to moderate, suggesting that these outcomes are distinct. CONCLUSIONS: New and/or clinically worsening pain and somatic symptoms, lasting at least 3 months, are sequelae of SA. Further studies investigating pain and somatic symptoms after SA are needed.

The experiences of internationally educated nurses in the southeastern United States of America.

BACKGROUND: US healthcare facilities have addressed nursing shortages in part by recruiting internationally educated nurses (IENs), and studies suggest IENs may make up a significant percentage of the nursing workforce in urban hospitals. Despite the economic recession of 2008-2012, international nurse migration is expected to continue. Little is known about IENs in the southeastern USA, and no studies have compared their perspectives to those of their US counterparts. OBJECTIVE: The purpose of this study was to gain a deeper understanding about the experiences of IENs compared to those of US registered nurses (RNs) practising in two urban hospitals in southeastern USA. METHODS: This study involved two rounds of semi-structured interviews of 82 IENs and US RNs. Interviews focused on themes relating to education, barriers to practice, intent to stay in nursing and IENs' migration experiences. FINDINGS AND DISCUSSION: Most IENs interviewed migrated to the USA after 1990 to join their family and do not plan to return to their home countries to practise. Most IENs initially received their Associate Degree in Nursing; many have obtained their Bachelor of Science in Nursing degree. IENs and newly licensed US RNs faced similar barriers when they began practising in the USA, but IENs faced additional challenges adjusting to the attitudes of US patients, the perceived lack of respect for nurses and delivering total patient care. CONCLUSIONS: IENs would benefit from orientation regarding the cultural differences in the USA. In other ways, their challenges are similar to those of US RNs; policies regarding education, recruitment and retention could target both groups together.

Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years.

PURPOSE: To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU). METHODS: (1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU. RESULTS: 312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success. CONCLUSIONS: This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.