Travel time to health facilities in areas of outbreak potential: maps for guiding local preparedness and response.

BACKGROUND: Repeated outbreaks of emerging pathogens underscore the need for preparedness plans to prevent, detect, and respond. As countries develop and improve National Action Plans for Health Security, addressing subnational variation in preparedness is increasingly important. One facet of preparedness and mitigating disease transmission is health facility accessibility, linking infected persons with health systems and vice versa. Where potential patients can access care, local facilities must ensure they can appropriately diagnose, treat, and contain disease spread to prevent secondary transmission; where patients cannot readily access facilities, alternate plans must be developed. Here, we use travel time to link facilities and populations at risk of viral hemorrhagic fevers (VHFs) and identify spatial variation in these respective preparedness demands. METHODS AND FINDINGS: We used geospatial resources of travel friction, pathogen environmental suitability, and health facilities to determine facility accessibility of any at-risk location within a country. We considered in-country and cross-border movements of exposed populations and highlighted vulnerable populations where current facilities are inaccessible and new infrastructure would reduce travel times. We developed profiles for 43 African countries. Resulting maps demonstrate gaps in health facility accessibility and highlight facilities closest to areas at risk for VHF spillover. For instance, in the Central African Republic, we identified travel times of over 24 h to access a health facility. Some countries had more uniformly short travel times, such as Nigeria, although regional disparities exist. For some populations, including many in Botswana, access to areas at risk for VHF nationally was low but proximity to suitable spillover areas in bordering countries was high. Additional analyses provide insights for considering future resource allocation. We provide a contemporary use case for these analyses for the ongoing Ebola outbreak. CONCLUSIONS: These maps demonstrate the use of geospatial analytics for subnational preparedness, identifying facilities close to at-risk populations for prioritizing readiness to detect, treat, and respond to cases and highlighting where gaps in health facility accessibility exist. We identified cross-border threats for VHF exposure and demonstrate an opportunity to improve preparedness activities through the use of precision public health methods and data-driven insights for resource allocation as part of a country's preparedness plans.

Randomized clinical trial of intraoperative superficial cervical plexus block versus incisional local anaesthesia in thyroid and parathyroid surgery.

BACKGROUND: Moderate wound pain and opiate analgesia requirement is reported following thyroid and parathyroid surgery. A randomized clinical trial was performed to investigate whether intraoperative superficial cervical plexus block (SCPB) would decrease postoperative pain and analgesia use. METHODS: Patients were randomized to incisional local anaesthesia (control) or incisional local anaesthesia plus intraoperative SCPB. The primary outcome measure was pain, assessed by a visual analogue scale (VAS). Secondary outcome measures were analgesia use (strong opiates defined as having potency at least as strong as that of oral morphine), respiratory rate and sedation score. Primary outcome measures were analysed with non-parametric tests, as well as with receiver operating characteristic (ROC) curves calculated as area under the curve (AUC) to discriminate between trial limbs. RESULTS: Twenty-nine patients were randomized to each group. Pain (VAS) scores were lower in patients who received intraoperative SCPB than in controls 30 min after surgery and subsequently (P < 0·020 at all time points), with a median pain score of zero on the day of operation in the SCPB group. Corresponding analysis of ROC curves showed differences between groups at 30 min (AUC = 0·722, P = 0·012), 90 min (AUC = 0·747, P = 0·005), 150 min (AUC = 0·803, P < 0·001) and 210 min (AUC = 0·849, P < 0·001) after surgery, and at 07.00 hours on postoperative day 1 (AUC = 0·710, P = 0·017). Fewer patients in the SCPB group required strong opiates (5 of 29 versus 16 of 29 in the control group; P = 0·003) and rescue opiates (6 of 29 versus 20 of 29; P < 0·001). CONCLUSION: Intraoperative SCPB reduces pain scores following thyroid and parathyroid surgery, and reduces the requirement for strong and rescue opiates. REGISTRATION NUMBER: 2009-012671-98 (https://www.clinicaltrialsregister.eu).

Total parathyroidectomy without autotransplantation for renal hyperparathyroidism.

BACKGROUND: Parathyroidectomy is the standard treatment for renal hyperparathyroidism although controversy exists about the optimal surgical procedure. Total parathyroidectomy without either autotransplantation or thymectomy is one suggested approach. This study reviewed the medium- to long-term results of this procedure. METHODS: A retrospective review was undertaken of patients undergoing total parathyroidectomy between August 2000 and March 2009. The procedure was performed by a single surgeon and median follow-up was 31 (range 1-120) months. RESULTS: Data were obtained on 115 patients with no re-explorations for bleeding or clinical recurrent laryngeal nerve injuries. The rate of postoperative hypocalcaemia on the day after surgery was 15.7 per cent. Thirty-three patients (28.7 per cent) had an undetectable parathyroid hormone level at the end of follow-up. Fourteen patients (12.2 per cent) developed recurrent hyperparathyroidism with a median parathyroid hormone level of 35.4 (range 5.4-200.0) pmol/l. The reoperation rate was 3.5 per cent. Thymectomy tissue, taken if all four glands could not be identified, revealed no parathyroid glands. CONCLUSION: Total parathyroidectomy alone has minimal associated morbidity or mortality, and a good medium- to long-term clinical outcome with a low recurrence rate.

An overview of the management of morbid obesity.

Obesity is a modern-day epidemic with serious physical, psychological and economic implications for the patients. Tackling obesity is now a priority for most healthcare providers. Managing such patients can be complex, emotional, time consuming and often frustrating. Obesity surgery, in its various forms, has revolutionised this struggle. With appropriate selection of patients, adequate resources and a multidisciplinary team involvement, obesity can now effectively be "cured". It is vital that those who deal with obese patients know how to access these services and understand the processes involved in the journey from initial assessment to postoperative follow-up. Obesity surgery has a major impact in reducing obesity-related comorbidities such as diabetes and hypertension and contributes to society by returning patients to work. Prevention must be at the heart of any strategy to manage obesity, but, for established cases, surgery is taking centre stage and will continue to flourish as new techniques and procedures are developed.

Informed consent in renal transplantation.

PURPOSE: This study was performed to assess how well completed the new consent forms are for patients undergoing renal transplantation. METHODOLOGY: 100 patients were randomly selected from the 160 who had a renal transplantation, at a single centre in the UK, over an 18 month period. The notes were located and the consent forms scrutinised. FINDINGS: Seven sets of notes could not be traced and 10 did not contain a relevant consent form. Forty eight per cent of completed forms mentioned the source of organ while 8% mentioned on which side the operation was to be performed. Twelve risks and complications were identified as being relevant to this procedure but no single form mentioned all 12. In most cases a senior member of the surgical team obtained consent. IMPLICATIONS: The demonstrated variability in the amount of detail on consent forms lends weight to the call for the use of procedure specific forms. While such variability does not necessarily equate with not gaining valid, informed consent, this form, at present, serves as the only record of what has been discussed with the patient. These findings should encourage all surgeons to complete the forms themselves, be as detailed as possible, and ensure that the form is filed in the patients' notes.

Alterations of brain and intestine serotonin levels in hamsters pretreated with dietary aflatoxin.

Male Syrian hamsters were fed 30.3 ppm mixed aflatoxins (AFT) for a 45-day period followed by a 123-day recovery period. Tests made at the end of the recovery period indicated a reduction in whole brain and duodenal serotonin and a slight but not statistically significant elevation in brain 5-hydroxyindoleacetic acid. There was a high incidence of liver cell hyperplasia in the aflatoxin fed animals. Following toxin withdrawal, the experimental animals showed significant gains in body weight but they never attained a body weight equal to the controls. Aflatoxin apparently interferes with serotonin production and the return to normal body weight even after withdrawal of the animal from the contaminated diet.

The importance of E-selectin as a marker for renal transplant rejection.

Vascular endothelial cells express membrane bound adhesion molecules which play a direct role in the localization and subsequent movement of leucocytes from the blood into sites of inflammation. E-Selectin is a cytokine induced adhesion molecule, known to be expressed by endothelial cells in inflammatory conditions, which binds to various leucocyte subpopulations. In a prospective study we have investigated the expression and distribution of E-selectin on renal allograft needle biopsies taken from 16 pretransplant kidneys and 119 post-transplant kidneys. Post-transplant biopsies were taken at times of graft dysfunction and at times of normal graft function. Formal histology was also performed and assessed independently. E-Selectin was found predominantly on the intertubular endothelium and on the endothelium of larger vessels. E-Selectin was present, at low intensity, in some pretransplant biopsies and also some post-transplant biopsies which were reported histologically as normal. In post-transplant biopsies taken for dysfunction E-selectin was present in the majority of cases. Expression was strong in biopsies showing acute cellular rejection and this was associated with a CD4 positive cellular infiltrate. Biopsies showing other causes of dysfunction, in particular acute tubular necrosis, also were E-selectin and CD4 positive with lower intensity than those with acute cellular rejection. These results suggest that E-selectin is a good marker for endothelial activation in renal transplant biopsies. Its presence in histologically apparently normal biopsies suggests that its in vivo kinetics may differ from previously reported in vitro kinetics. E-Selectin may be a potential target for therapeutic intervention.

Lack of correlation of soluble E-selectin level with renal transplant rejection.

E-Selectin is a 115-kDa cell surface glycoprotein transiently expressed on vascular endothelium in response to interleukin-1 and tumour necrosis factor-alpha with a peak in expression at four hours. Its distribution in transplant biopsies has been associated with inflammatory events such as allograft rejection. Recently, a soluble isoform of E-selectin has been detected in the culture medium of cytokine activated endothelial cells by an ELISA method. In this study soluble E-selectin levels in renal allograft recipients were compared with the incidence of rejection, acute tubular necrosis (ATN), cyclosporin A (CyA) toxicity, and use of orthoclone OKT3 (muromonab-CD3) to establish whether early endothelial activation and inflammatory damage could be detected. The mean soluble E-selectin level in normal volunteers was 89 ng/ml serum compared to 120 ng/ml for a group of chronic renal failure patients. Soluble E-selectin levels declined upon transplantation but this was not significant, nor was the difference in samples from patients experiencing rejection, ATN or CyA toxicity. A dramatic and sustained rise in soluble E-selectin levels was found within 24 hours of the first dose of OKT3 treatment. This study shows that soluble E-selectin does not provide early unequivocal indication of pathological sequelae in renal transplantation, although extensive endothelial activation can be demonstrated with OKT3 treatment.

Marketing dentistry: a pilot study in Dudley.

This study was an attempt to persuade non-users or irregular users of dental services to change their behaviour and visit the dentist more regularly. The task was divided into two main parts. One was a promotion campaign undertaken in the Borough of Dudley in the West Midlands and the other a professional development programme for the dentists practising in the same area. The professional development campaign was designed to make the practitioners aware of the barriers to dental care which are perceived by patients. It was undertaken through a series of workshops on various aspects of practice development and promotion to which the staff of all the dental practices in Dudley were invited. Thirty-nine out of a total of forty-one accepted the invitation and attended some or all of the programme. In addition to the workshops members of the research team visited each of the participating practices regularly to discuss aspects of the programme and to record progress. The practitioners had varied attitudes to marketing and varied learning styles, and therefore they had different expectations of the nature and purpose of professional development. The majority attended solely to learn about the promotion campaign. There were also varying perceptions of patient recruitment and retention. None saw this as a serious problem. However, even before the new National Health Service contract for general dental practitioners there was the growing realisation that in the future there would be competition between practices and that this could be a reason for considering recruitment and the retention of patients more carefully. This was considered by many of the dentists, but not all, to be a problem of patient behaviour, linked with a degree of fatalism, and that nothing much could be done about it. There was a reluctance to change and the fear of the risks involved led a number of the general dental practitioners to identify and emphasise the difficulties in making new developments rather than their benefits. Only one quarter of the practices made any changes and they tended to prefer quick solutions rather than basic development. The experience gained in this part of the study indicated that in the future professional development should be considered in terms of the dentist's perception of the costs and the benefits; direct costs, opportunity costs, and the prospect of effecting change.(ABSTRACT TRUNCATED AT 400 WORDS)

Shared medical appointments for bariatric surgery follow-up: a patient satisfaction questionnaire.

BACKGROUND: Shared medical appointments (SMAs) are group clinics where practitioners see several patients, with common health needs, at once. There is a great financial strain on the National Health Service (NHS) to provide bariatric surgery. The aim of this study was to review patient satisfaction with the SMA that is the default means of following up patients after bariatric surgery at one particular NHS trust. METHODS: A patient-validated questionnaire was designed and handed out at the end of the SMAs. Patients who attended an SMA earlier in 2011 were also retrospectively sent questionnaires via post. RESULTS: A total of 47 patients completed the questionnaire from seven different SMAs covering the period from January to July 2011. All patients underwent laparoscopic adjustable gastric banding. After attending an SMA, patients gave an overall mean satisfaction rating of 4.13 ± 0.163 (on a scale of 1 to 5, 1 = very poor and 5 = excellent) which represented an increase (p < 0.01) compared to preconceptions before the clinic (3.59 ± 0.175). A cost analysis estimated a yearly saving of £4,617 or 65.1% made by the SMAs compared to 1:1 appointments. CONCLUSIONS: The bariatric surgery SMA demonstrates high levels of patient satisfaction and is cost-effective.