Dedicated teams to optimize quality and safety of surgery: A systematic review.

BACKGROUND: A dedicated operating team is defined as a surgical team consisting of the same group of people working together over time, optimally attuned in both technical and/or communicative aspects. This can be achieved through technical and/or communicative training in a team setting. A dedicated surgical team may contribute to the optimization of healthcare quality and patient safety within the perioperative period. METHOD: A systematic review was conducted to evaluate the effects of a dedicated surgical team on clinical and performance outcomes. MEDLINE and Embase were searched on 23 June 2022. Both randomized controlled trials (RCTs) and non-randomized studies (NRSs) were included. Primary outcomes were mortality, complications and readmissions. Secondary outcomes were costs and performance measures. RESULTS: Fourteen studies were included (RCTs n = 1; NRSs n = 13). Implementation of dedicated operating teams was associated with improvements in mortality, turnover time, teamwork, communication and costs. No significant differences were observed in readmission rates and length of hospital stay. Results regarding duration, glitch counts and complications of surgery were inconclusive. Limitations include study conduct and heterogeneity between studies. CONCLUSIONS: The institution of surgical teams who followed communicative and/or technical training appeared to have beneficial effects on several clinical outcome measures. Dedicated teams provide a feasible way of improving healthcare quality and patient safety. A dose-response effect of team training was reported, but also a relapse rate, suggesting that repetitive training is of major concern to high-quality patient care. Further studies are needed to confirm these findings, due to limited level of evidence in current literature. PROSPERO REGISTRATION NUMBER: CRD42020145288.

Referral to and enrolment in cardiac rehabilitation after open-heart surgery in the Netherlands.

AIM: Although referral to phase 2 cardiac rehabilitation (CR) following open-heart surgery is recommended in professional guidelines, according to the literature, participation rates are suboptimal. This study investigates the referral and enrolment rates, as well as determinants for these rates, for phase 2 CR following open-heart surgery via sternotomy. METHODS: A cross-sectional survey study was conducted among patients who underwent open-heart surgery via sternotomy in a university hospital. Data on referral and enrolment rates and possible factors associated with these rates (age, sex, type of surgery, educational level, living status, employment, income, ethnicity) were collected by a questionnaire or from the patient's medical file. Univariate logistic regression analysis (odds ratio) was used to study associations of patient characteristics with referral and enrolment rates. RESULTS: Of the 717 eligible patients, 364 (51%) completed the questionnaire. Their median age was 68 years (interquartile range 61-74) and 82 (23%) were female. Rates for referral to and enrolment in phase 2 CR were 307 (84%) and 315 (87%), respectively. Female sex and older age were independently associated with both non-referral and non-enrolment. Additional factors for non-enrolment were surgery type (coronary artery bypass grafting with valve surgery and miscellaneous types of relatively rare surgery), living alone and below-average income. CONCLUSION: Phase 2 CR referral and enrolment rates for patients following open-heart surgery were well over 80%, suggesting adequate adherence to professional guidelines. During consultation, physicians and specialised nurses should pay more attention to certain patient groups (at risk of non-enrolment females and elderly). In addition, in-depth qualitative research to identify reasons for non-referral and/or non-enrolment is needed.

An uncommon side effect of thiamazole treatment in Graves' disease.

Thionamides (such as thiamazole/methimazole) are a common first line treatment for Graves' disease. Common side effects include rash, urticaria, and arthralgia. However, thionamide treatment has also been associated with a variety of auto-immune syndromes. Here, we describe a patient presenting with mild arthritis after starting thiamazole. Although severe presentation warrants acute withdrawal of the causative agent, our case suggests that milder forms can be successfully treated with anti-inflammatory drugs alone. Recognition of the syndrome is key to warrant timely and effective treatment.

The Bristow-Latarjet procedure, a historical note on a technique in comeback.

The Bristow-Latarjet procedure is a well-known surgical technique designed to treat shoulder instability. In this procedure, the coracoid process is transferred to the glenoid rim, to serve as augmentation of an associated bony defect. Because long-term results following a soft tissue procedure (Bankart repair) reveal that up to 21 and 33 % of the patients might experience recurrent instability and with the advent of the arthroscopic coracoid transfer, there is renewed interest in this procedure to treat shoulder instability. The aim of this study is to provide a historical overview, with emphasis on the original inventors Bristow and Latarjet, the complications and following modifications regarding the surgical approach, the coracoid transfer and the arthroscopic technique. Level of evidence V.

Bone mineral density in children and adolescents with Prader-Willi syndrome: a longitudinal study during puberty and 9 years of growth hormone treatment.

CONTEXT: Longitudinal data on bone mineral density (BMD) in children and adolescents with Prader-Willi Syndrome (PWS) during long-term GH treatment are not available. OBJECTIVE: This study aimed to determine effects of long-term GH treatment and puberty on BMD of total body (BMDTB), lumbar spine (BMDLS), and bone mineral apparent density of the lumbar spine (BMADLS) in children with PWS. DESIGN AND SETTING: This was a prospective longitudinal study of a Dutch PWS cohort. PARTICIPANTS: Seventy-seven children with PWS who remained prepubertal during GH treatment for 4 years and 64 children with PWS who received GH treatment for 9 years participated in the study. INTERVENTION: The children received GH treatment, 1 mg/m(2)/day (≅ 0.035 mg/kg/d). MAIN OUTCOME MEASURES: BMDTB, BMDLS, and BMADLS was measured by using the same dual-energy x-ray absorptiometry machine for all annual measurements. RESULTS: In the prepubertal group, BMDTB standard deviation score (SDS) and BMDLSSDS significantly increased during 4 years of GH treatment whereas BMADLSSDS remained stable. During adolescence, BMDTBSDS and BMADLSSDS decreased significantly, in girls from the age of 11 years and in boys from the ages of 14 and 16 years, respectively, but all BMD parameters remained within the normal range. Higher Tanner stages tended to be associated with lower BMDTBSDS (P = .083) and a significantly lower BMADLSSDS (P = .016). After 9 years of GH treatment, lean body mass SDS was the most powerful predictor of BMDTBSDS and BMDLSSDS in adolescents with PWS. CONCLUSIONS: This long-term GH study demonstrates that BMDTB, BMDLS, and BMADLS remain stable in prepubertal children with PWS but decreases during adolescence, parallel to incomplete pubertal development. Based on our findings, clinicians should start sex hormone therapy from the age of 11 years in girls and 14 years in boys unless there is a normal progression of puberty.

Eight years of growth hormone treatment in children with Prader-Willi syndrome: maintaining the positive effects.

BACKGROUND: The most important reason for treating children with Prader-Willi syndrome (PWS) with GH is to optimize their body composition. OBJECTIVES: The aim of this ongoing study was to determine whether long-term GH treatment can counteract the clinical course of increasing obesity in PWS by maintaining the improved body composition brought during early treatment. SETTING: This was a multicenter prospective cohort study. METHODS: We have been following 60 prepubertal children for 8 years of continuous GH treatment (1 mg/m(2)/d ≈ 0.035 mg/kg/d) and used the same dual-energy x-ray absorptiometry machine for annual measurements of lean body mass and percent fat. RESULTS: After a significant increase during the first year of GH treatment (P < .0001), lean body mass remained stable for 7 years at a level above baseline (P < .0001). After a significant decrease in the first year, percent fat SD score (SDS) and body mass index SDS remained stable at a level not significantly higher than at baseline (P = .06, P = .14, resp.). However, body mass index SDSPWS was significantly lower after 8 years of GH treatment than at baseline (P < .0001). After 8 years of treatment, height SDS and head circumference SDS had completely normalized. IGF-1 SDS increased to +2.36 SDS during the first year of treatment (P < .0001) and remained stable since then. GH treatment did not adversely affect glucose homeostasis, serum lipids, blood pressure, and bone maturation. CONCLUSION: This 8-year study demonstrates that GH treatment is a potent force for counteracting the clinical course of obesity in children with PWS.

The species sensitivity distribution approach compared to a microcosm study: a case study with the fungicide fluazinam.

We assessed the sensitivity of freshwater organisms (invertebrates and algae) to the fungicide Shirlan (active ingredient fluazinam) in single-species laboratory tests and in microcosms. Species sensitivity distribution (SSD) curves were constructed by means of acute toxicity data for 14 invertebrate species, since algae were much less sensitive. The EC(10)-based SSD gave a median HC(5) value of 0.6microgL(-1) and a 90% confidence interval of 0.1-1.9 microgL(-1). The EC(50)-based SSD gave a median HC(5) value of 3.9 microgL(-1) (90% confidence interval: 0.9-9.9 microgL(-1)). The microcosms were treated four times with Shirlan (concentration range: 0.4-250 microgL(-1)). Responses of the microcosm communities were followed. The 2 microgL(-1) treatment was the no-observed-effect concentration (NOEC(microcosm)). The 10 microgL(-1) treatment resulted in short-term effects on a few zooplankton taxa. Clear effects were observed at 50 and 250 microgL(-1). The responses in the microcosms were in line with the toxicity data for the tested lab species. The median EC(10)-based HC(5) and the lower limit EC(50)-based HC(5) were lower, and the median EC(50)-based HC(5) was slightly higher than the NOEC(microcosm). This is consistent with other studies that compared SSDs with responses in model ecosystems that received repeated applications of pesticides.

Scoliosis in Prader-Willi syndrome: prevalence, effects of age, gender, body mass index, lean body mass and genotype.

BACKGROUND: The reported prevalence of scoliosis in children with Prader-Willi syndrome varies from 15% to 86%. OBJECTIVE: To study the prevalence of scoliosis and the effects of age, gender, body mass index (BMI), total lean body mass (LBM), LBM of the trunk (trunkLBM) and genotype. DESIGN: Radiographs were taken, length and weight were measured (BMI standard deviation scores (BMI SDS) and body surface area (BSA)), and dual energy x-ray absorptiometry was performed, measuring LBM and trunkLBM. PATIENTS: 96 children, median (interquartile range) age 4.8 years (2.1 to 7.5), were included in a multicentre study. None received growth hormone treatment. MAIN OUTCOME MEASURES: Two types of scoliosis were identified: (1) long C-curve type scoliosis (LCS) and (2) idiopathic scoliosis (IS). Children were divided into age categories (infants, 0-3 years; juveniles, 3-10 years; adolescents, 10-16 years). RESULTS: The prevalence of scoliosis was 37.5% and increased with age (infants and juveniles, approximately 30%; adolescents, 80%); 44% of children with scoliosis had a Cobb angle above 20 degrees . Children with scoliosis were significantly older than those without. Children with LCS were younger and more hypotonic than those with IS: median (interquartile range) age 4.4 years (1.7-5.9) vs 11.1 years (6.5-12.1) (p = 0.002) and trunkLBM/BSA ratio 7080 (6745-7571) vs 7830 (6932-8157) (p = 0.043). CONCLUSIONS: The prevalence of scoliosis in children with Prader-Willi syndrome is high (37.5%). Many children with scoliosis (13%) had undergone brace treatment or surgery. The type of scoliosis is affected by age and trunkLBM/BSA ratio.

Ecological effects of spring and late summer applications of lambda-cyhalothrin on freshwater microcosms.

The aim of the study was to compare the effects of the pyrethroid insecticide lambda-cyhalothrin (treated at 10, 25, 50, 100, 250 ng active ingredient a.i./L) on a drainage ditch ecosystem in spring and late summer. Microcosms (water volume approximately 430 L) were established using enclosures in a 50-cm-deep experimental ditch system containing communities typical of macrophyte-dominated freshwater ecosystems. Effects on macroinvertebrates, zooplankton, phytoplankton, macrophytes, and community metabolism were assessed and evaluated using univariate and multivariate statistical techniques. The macroinvertebrate community responded most clearly to treatment and, as anticipated, insects and crustaceans were among the most sensitive organisms. Statistical analysis showed that the underlying community structure was significantly different between the spring and summer experiments. However, the most sensitive species (Chaoborus obscuripes and Gammarus pulex) were abundant in spring as well as in late summer. In spring and late summer, only slight and transient effects were observed at the community level in the 10-ng/L treatment. Overall, the study did not show substantial differences in the responses of sensitive taxa between spring and late summer treatments, and effects thresholds were similar irrespective of season of treatment.

Ordination techniques for analysing response of biological communities to toxic stress in experimental ecosystems.

The ordination techniques principal component analysis (PCA) and redundancy analysis (RDA) are considered to be useful tools for evaluating community responses in experimental ecotoxicology. Concepts and interpretation of these techniques are summarized. Application of PCA and RDA is illustrated in a case study. In this study, the effects of a single application of the insecticide Dursban(®) 4E (a.i. chlorpyrifos) on an aquatic macroinvertebrate community in microcosms were analysed. Four treatment (nominal chlorpyrifos concentration: 35 µg l(-1)) and four control microcosms were used. PCA visualized a change in species composition with time. Immediately after treatment, a major shift in species composition occurred in treated microcosms. RDA demonstrated that this shift was due to the treatment. RDA also showed that non-arthropods were generally insusceptible to chlorpyrifos; most arthropods were affected. Dynamics of separate taxa were visualized, giving indications of possible primary and secondary effects for these taxa. A Monte Carlo permutation test was used to decide whether treatment had a significant effect on the species composition and to investigate the state of recovery in time. In general, the RDA results gave an adequate condensation of detailed information on abundance and effects obtained by more conventional univariate statistical analysis for some individual taxa of the community. In combination with toxicity and ecological data, ordination techniques can provide insight into effects of toxic substances in complex biological communities.

Fate and effects of the insecticide Dursban 4E in indoor Elodea-dominated and macrophyte-free freshwater model ecosystems: I. Fate and primary effects of the active ingredient chlorpyrifos.

The fate of the insecticide Dursban 4E (active ingredient chlorpyrifos) and its effect on crustaceans and insects was studied in indoor experimental freshwater ecosystems that intended to mimick drainage ditches. A single dose (simulating aerial drift) was applied to achieve nominal chlorpyrifos concentrations of 5 or 35 micrograms/L. Two experiments were performed, one in which all model ecosystems were dominated by the macrophyte Elodea nuttallii, and one using systems devoid of macrophytes. In macrophyte-dominated systems, Elodea vegetation adsorbed a large proportion of the dose applied and hampered the mixing of the insecticide in the water (at least up till day 8). Only a small proportion became incorporated in the sediment. In open water systems the insecticide was rapidly mixed in the water, and the sediment played a very significant role as sink for chlorpyrifos. In both Elodea-dominated and open water systems 50% of the dose applied had disappeared on day 8 post-treatment. The rate of disappearance of chlorpyrifos was relatively rapid in water and macrophytes, and relatively slow in the sediment. Of the arthropods in the zooplankton Cladocera were more susceptible than Copepoda. Significant effects (p less than or equal to 0.05) on Cladocera occurred relatively late in Elodea-dominated systems (in week 4 post-application) in contrast to open water systems (week 1), which is in accordance with the observed differences in the fate of chlorpyrifos. Daphnia pulex, D. longispina and Simocephalus vetulus recovered in the model ecosystems when chlorpyrifos concentrations were lower than 0.1-0.2 micrograms/L, which is in agreement with results of laboratory protocol tests performed with these cladocerans. Among the macroscopic Arthropoda the apparent order of susceptibility was amphipods greater than insects greater than isopods. The isopod Asellus aquaticus was more sensitive to the application of the insecticide than the closely related species Proasellus coxalis. In treated open water systems the latter even increased significantly in numbers. Cage experiments in the model ecosystems performed with several species of Arthropoda indicate that laboratory protocol tests may give a reasonable prediction of short-term direct effects of chlorpyrifos for the same species inhabiting more complex aquatic systems.