The Influence of Clinical and Patient-Reported Outcomes on Post-surgery Satisfaction in Cholecystectomy Patients.

BACKGROUND: Patient-reported outcomes (PROMs) and post-operative satisfaction have become a growing focus of surgical outcome evaluation and are considered key components of the movement towards patient-centred care. The aim was to compare the association of traditional clinical outcome measures and PROMs with post-surgery satisfaction in cholecystectomy patients. METHODS: Patients who had undergone elective or emergency cholecystectomy for gallstone disease were sent validated PROM questionnaires, and telephone follow-up was performed in all cases. Categorical data were compared with the Chi-square and Fisher's exact tests. Satisfaction was investigated using a "top-box" approach, and multivariable logistic regression was performed for factors significantly (p < 0.05) associated with satisfaction in univariable analyses. RESULTS: A total of 234 patients underwent cholecystectomy between 1 March 2014 and 1 May 2014, and 147 patients (63%) completed the questionnaire. 104/147 (71%) reported being "very satisfied" with their surgical outcome. In univariable analyses, satisfaction showed significant association with an absence of hospital-recorded 30-day complications (OR = 4.11, 95% CI 1.29-13.84), but not re-attendance, readmission, or length of stay. In a multiple regression analysis, no traditional clinical outcome measures were associated with satisfaction. By contrast, self-perceived health (OR = 4.04, 95% CI 1.44-11.86), the absence of patient-reported wound pain (OR = 6.11, 95% CI 1.83-21.74), and a return to normal leisure activities (OR = 11.14, 95% CI 2.61-55.26) were associated with satisfaction. CONCLUSION: PROMs are the major determinants of patient satisfaction following cholecystectomy. When assessing outcomes following cholecystectomy, the measurement of clinical outcomes alone is inadequate and should be supplemented by the use of PROMs.

Patient experience and overall satisfaction after emergency abdominal surgery.

BACKGROUND: There is a growing recognition of the importance of patient experience in healthcare, however little is known in the context of emergency abdominal surgery. This study sought to quantify the association between patient experience and overall satisfaction. METHODS: Patient demographics, operation details and 30-day clinical outcome data of consecutive patients undergoing emergency abdominal surgery were collected. Data was collected using validated Patient Reported Experience Measures (PREMs) questionnaires. Categorical data were tested using Mann Whitney U test. Multivariable regression was used to determine independent factors associated with satisfaction. RESULTS: In a well-fitting multivariable analysis (R2 = 0.71), variables significantly associated with a higher global satisfaction score were "sufficient information given about treatment" (ß = 0.86, 95% CI 0.01-1.70, p = 0.047), "sufficient explanation of risks and benefits of surgery" (ß = 1.26, 95% CI 0.18-2.34, p = 0.020), "absence of night-time noise" (ß = 1.35, 95% CI 0.56-2.14, p = 0.001) and "confidence and trust in nurses" (ß = 1.51, 95% CI 0.54-2.49, p = 0.003). CONCLUSIONS: Overall patient satisfaction was strongly associated with perceptions of good communication and transfer of information. Confidence and trust in the clinical team is an important determinant of patient experience. Improving the ward environment by reducing noise at night may also improve the overall experience and satisfaction in emergency surgery.

Sexual health of adults working in pornographic films.

We report the frequency of sexually transmitted infections (STIs) diagnosed in performers in the adult pornographic film industry. Over a 13 month period, 445 STI screens were performed in 115 patients, 56 women and 59 men. All reported unprotected sex during filming. Seventy-five percent (86) had at least one sexual partner outside work, and 90% used condoms inconsistently with them. Women worked exclusively with women (23%), men only (38%) or both genders (39%). Almost all men (97%) worked exclusively heterosexually. Thirty-eight percent (44/115) were diagnosed with 77 STIs, including non-specific urethritis (51), gonorrhoea (10), chlamydia (6) and genital warts (6). Gonorrhoea was found exclusively at the pharynx in three heterosexual men. There were no cases of HIV, syphilis, hepatitis B or hepatitis C. Monthly screening and certification is a working requirement for this population but STIs are common in an industry where unprotected sex is the norm.

Prediction of intramuscular fat content and shear force in Texel lamb loins using combinations of different X-ray computed tomography (CT) scanning techniques.

Computed tomography (CT) parameters, including spiral computed tomography scanning (SCTS) parameters, intramuscular fat (IMF) and mechanically measured shear force were derived from two previously published studies. Purebred Texel (n = 377) of both sexes, females (n = 206) and intact males (n = 171) were used to investigate the prediction of IMF and shear force in the loin. Two and three dimensional CT density information was available. Accuracies in the prediction of shear force and IMF ranged from R2 0.02 to R2 0.13 and R2 0.51 to R2 0.71 respectively, using combinations of SCTS and CT scan information. The prediction of mechanical shear force could not be achieved at an acceptable level of accuracy employing SCTS information. However, the prediction of IMF in the loin employing information from SCTS and additional information from standard CT scans was successful, providing evidence that the prediction of IMF and related meat eating quality (MEQ) traits for Texel lambs in vivo can be achieved.

Is it time for the virtual chaperone in genitourinary medicine clinics?

The General Medical Council recommends that chaperones must be offered during intimate examinations. Implementation of these guidelines may serve to protect both patients and staff within the genitourinary (GU) medicine clinic, but is likely to have major ramifications from a practical, financial and staffing perspective. The Virtual Chaperone (VC) is an objective device making audio and visual recordings of patients' consultations and examinations. Information cannot be manipulated and is encrypted for security. It would not replace the human chaperone. This study investigated the attitudes of GU medicine staff and patients to the VC in an inner city sexual health clinic. Voluntary, anonymized questionnaires were distributed to all members of the multidisciplinary team and 200 patients. The patient response rate was 90% (n = 180). Only 40% of respondents felt the VC was acceptable in GU medicine clinics. Two-thirds felt unsure or were against the VC recording during consultations, and fewer wished the examination to be recorded. Most opted to switch off the video entirely. Almost 50% of respondents felt that the VC was designed to protect staff, whereas only 41% thought it would protect patients. The staff response rate was 69% (n = 35). Almost three-quarters of respondents were unsure or felt the device was unacceptable. Less than half would feel comfortable with the VC recording during consults. Overall, three-quarters of respondents were either unsure or did not support the introduction of the VC. There was a clear feeling (>80%) that the VC would protect staff and patients, 71% indicating that the trust would also benefit. Despite its success in other outpatient specialties, GU medicine staff and patients do not favour the introduction of the VC.

Accuracy of in vivo muscularity indices measured by computed tomography and their association with carcass quality in lambs.

Assessments of muscle mass and skeletal dimensions by Computed Tomography (CT) enable the development of new muscularity indices for the hind leg (HL) and lumbar region (LR) in lambs. Compared to previous CT muscularity indices, the accuracy was much higher with the new index in the HL (correlations between CT and dissection indices of 0.89 vs 0.51). The accurate measurement of femur length by CT used in the calculation of the new HL index made an important contribution to the higher accuracy of the index. The improvement in accuracy was smaller for the LR (0.55 vs 0.44). The association of CT muscularity indices and carcass quality in Texel and Scottish Blackface lambs showed that improved muscularity is not phenotypically correlated with detrimental effects on carcass composition. CT muscularity indices provide an alternative method to improve carcass conformation and leanness, using measurements that at a constant weight are independent of fatness.

Prediction of intramuscular fat content using CT scanning of packaged lamb cuts and relationships with meat eating quality.

Novel, multi-object X-ray computed tomography (CT) methodologies can individually analyse vacuum-packed meat samples scanned in batches of three or more, saving money and time compared to scanning live animals. If intramuscular fat (IMF), as a proxy for meat quality, can be predicted with similar accuracies as in live lambs, this method could be used to grade on quality, or to inform breeding programmes. Lamb loin cuts from commercial carcasses (n=303), varying in fat and conformation grade, were vacuum-packed and CT scanned, then tested for meat quality traits and by a trained taste panel. Tissue density values measured by CT, alongside carcass and loin weights, predicted IMF with moderate accuracy (R2 0.36), but did not accurately predict shear force or sensory traits. Juiciness and flavour increased linearly with IMF, whilst texture and overall liking increased to an optimum between 4 and 5% IMF. Samples predicted by CT as having >3% IMF scored significantly higher for sensory traits, than those predicted as <3% IMF.

Microscopy and culture for Trichomonas vaginalis: are both required?

Many genitourinary medicine clinics have stopped routinely performing both wet preparation microscopy and cultures to diagnose Trichomonas vaginalis (TV). Our directorate stopped microscopy when screening asymptomatic women. This audit considers whether both tests continue to be warranted for symptomatic female patients. The discrepancy between microscopy and culture results leads us to recommend that both remain necessary. Sampling standardization and improved documentation are discussed.

Influence of age and body mass on the response of adolescent male pigs to anaesthesia.

Age and body mass affect a human's response to drugs, including anaesthetics. In pigs, such effects, if they occur, are likely to be pronounced: commercial breeds have been selected for rapid growth, meaning rapid body composition and mass change with age. Thirty-six male pigs were anaesthetised for CT scanning on three occasions (S1-3) when aged 105, 137 and 166 days and when mean (±sd) masses were 57.2±4.4, 88.4±6.2 and 114.7±7.6 kg, respectively. Medetomidine (5 µg/kg), azaperone (1 mg/kg), ketamine (5 mg/kg) and midazolam (0.25 mg/kg) were combined and injected intramuscularly. The times when pigs became recumbent (R1) and remained so (RP) were recorded. If venous cannulation was not possible five minutes after recumbency, 2-3 per cent isoflurane in a 1:2 O2/N2O mixture was delivered by mask until cannulation was possible and then discontinued. If anaesthetic depth was inadequate for CT scanning, a full dose (midazolam 0.25 mg/kg, ketamine 2 mg/kg) or half dose of induction agents was administered intravenously. During recovery from anaesthesia, the times at first movement (M1), first standing attempt (S1) and successful sustained standing (SP) were recorded. The relationship between mass and time (minutes) from injection to each end point was assessed using regression analysis and linear mixed-effect models (LMEM); LMEM were used to assess isoflurane and intravenous anaesthetic effects. Analysis using LMEM showed no significant relationships between mass and the times from injection to the five end points. Isoflurane reduced the time to M1, S1 and SP (P<0.037); intravenous agents had no effect on S1 or SP (P>0.585) but increased the time from injection to M1 (P<0.001). In conclusion, age and mass do not influence the response of commercially bred pigs to the intravenous anaesthetic combination described.

Transmission of HIV to heterosexual partners of infected men and women.

Future heterosexual spread of HIV will in part depend on the efficiency of transmission from men to women and from women to men. We studied seventy-eight female sexual partners of men infected with HIV and 18 male sexual partners of infected women. Participants were interviewed concerning sexual practices, use of contraception and other risk factors for HIV infection. Fifteen out of 78 (19.2%) female partners and one out of eighteen (5.5%) male partners were seropositive for HIV antibody. All couples had practised vaginal intercourse. Seropositive female partners did not differ significantly from seronegative partners with regard to length of relationship, number of acts of vaginal intercourse, other sexual practices, stage of clinical disease in the index case, or numbers of other sexual partners in the last five years. In two women, seroconversion was documented after one act of unprotected sexual intercourse. The majority of infected female partners (eight out of 15) had sexual relationships with men who were asymptomatic and did not practice anal intercourse. Biological factors such as variability in infectivity of the index case and susceptibility of the contact, as well as behavioural variables may be important in determining transmission.

Opioid-mediated changes in nociceptive threshold during pregnancy and parturition in the sow.

This study aimed to investigate if pregnancy-induced hypoalgesia occurs in the sow, and to examine the role of endogenous opioids which are known to be released in response to nociception. Sixteen Large White x Landrace multiparous sows were tested in straw bedded pens (2.5 x 2.5 m) during weeks 4, 8 and 12 of pregnancy and over the farrowing period. Testing involved thermal stimulation of eight areas on the rear-quarters of the sows with a CO2 infra-red laser until a physical response was seen (tail flick, leg move or muscle twitch) or for a maximum of 16 s. Over the farrowing period testing was more frequent, and at 3.75 h after the birth of the first piglet, half the sows received an injection (i.m.) of an opioid antagonist naloxone (N) (1 mg kg(-1) body weight) with the remainder receiving a control dose of saline (S). Responses were recorded 15 and 30 min post-injection. There was no significant difference between response times over weeks 4, 8 and 12 of pregnancy (P = 0.152), however a significant rise was seen from week 12 to 5 days before parturition (P = 0.002). Response times continued to rise until the birth of the first piglet by which time the majority of sows had stopped responding within 16 s (P < 0.001). Response times fell over days 1, 2 and 7 post-partum. After administration of naloxone response times fell compared to control animals at 15 min (P < 0.001) and 30 min (P < 0.01) post-injection. These results suggest that nociceptive threshold increases during late pregnancy in the sow, perhaps as an endogenous defence against labour pain, and that during parturition this change in nociceptive threshold is, at least in part, opioid-mediated. Oxytocin is known to be inhibited by endogenous opioids at parturition, thus future research should consider the potential role of increased nociception at birth as a negative feedback to oxytocin release.

The effect of opioid antagonism and environmental restriction on plasma oxytocin and vasopressin concentrations in parturient gilts.

Oxytocin plays an important role at parturition due to its involvement in uterine contractions, foetal expulsion and the onset of maternal behaviour. The role of the related neurohypophysial hormone, vasopressin, is less clear; however, there is some evidence that it is also involved in maternal behaviour and its role in osmotic regulation is well established. The aim of this study was to investigate the inhibitory effects of endogenous opioids on these hormones during the expulsive phase of parturition in the pig, and to examine how opioid restraint interacts with environmental restriction. The subjects of this study were 31 Large Whitex Landrace primiparous sows (gilts). An indwelling jugular catheter was implanted under general anaesthesia at 12 days before the expected parturition day (EPD). From 5 days before the EPD 15 of the gilts were individually housed in a restrictive parturition crate without straw and 16 were individually housed in a straw-bedded pen. Blood samples were taken with increasing frequency towards and during parturition through a catheter extension to reduce disturbance. At 7.5 min after the birth of the first piglet half of the gilts in each environment received a dose of the opioid receptor antagonist naloxone (1 mg/kg, i.v.) with the remaining gilts receiving saline as a control. Overall, there was no effect of environment on either circulating oxytocin or vasopressin. However, both oxytocin and vasopressin were inhibited by endogenous opioids during the expulsive phase. The inhibitory effects of opioids on these hormones did not appear to have any adverse effects on the progress of parturition as judged by cumulative piglet birth intervals. The regulation of the opioid inhibition of oxytocin and vasopressin during parturition is discussed in relation to other neurotransmitters and whether opioid inhibition of these neurohypophysial hormones is part of the 'normal' physiological response to parturition or whether it is stress-induced.

A simple and rapid method for detecting human immunodeficiency virus by PCR.

A simple, sensitive and specific method using the polymerase chain reaction (PCR) for amplification of human immunodeficiency virus type 1 (HIV-1) is described. The method involves minimal manipulations. Peripheral blood mononuclear cells (PBMC) were prepared by a rapid Ficoll-Paque gradient method. Lymphocytes were lysed in PCR buffer containing Proteinase K and detergents, and subjected to amplification under stringent conditions, using two primer pairs. Amplified DNA sequences were hybridized with a 3'-end labelled probe, electrophoresed on agarose gels and visualised by ethidium bromide staining. Identification of amplified HIV-1 proviral DNA sequences was confirmed by autoradiography. HIV-1 sequences were amplified in all samples from 103 HIV-1 seropositive individuals, but not in 40 HIV-1 seronegative controls. The absence of contamination may be attributable in part to minimisation of manipulations before amplification.

Acute rheumatic fever in human immunodeficiency virus infection.

A 25-year-old homosexual man with a childhood history of rheumatic heart disease presented with painful joints, fever and chest pain. He was diagnosed as having acute rheumatic fever and was found to be HIV antibody-positive. His illness responded to conventional treatment but he had a persistently low CD4 lymphocyte count and was started on zidovudine. Interpretation of the significance of a low CD4 lymphocyte count is problematic in a patient with coincident rheumatic fever and HIV infection as both conditions can cause CD4 lymphopenia.

Lesbians and cervical screening.

Confusion exists in clinical practice about whether lesbians should be offered routine cervical smears. We found cervical smear abnormalities in a sample of 624 lesbians, including those who had never been sexually active with men. These findings suggest that lesbians should be routinely offered cervical cytology as part of the national screening programme. Evidence of human papilloma virus (HPV) infection in the 'exclusively lesbian' group indicates that sexual transmission of HPV may occur between women. The belief by some lesbians that they have less need for cervical smears, coupled with poor uptake of cervical screening by a significant proportion, demonstrates a need for education of lesbians and health service providers.

Co-trimoxazole desensitization in HIV-seropositive patients.

Co-trimoxazole (trimethoprim-sulphamethoxazole) is an effective prophylactic agent against Pneumocystis carinii pneumonia (PCP). However, it is associated with a high frequency of adverse reactions in immunocompromised patients which may preclude its use. Fourteen patients with a definite history of adverse reactions to co-trimoxazole on standard PCP prophylactic dosage were selected for desensitization using a regimen of gradual incremental exposure over an 11-day period. Eight (57.1%) were successfully desensitized and have continued on oral co-trimoxazole at maximum 21 months' follow-up. This report demonstrates that oral desensitization as an outpatient procedure is an effective and safe option for both primary and secondary PCP prophylaxis in HIV-seropositive patients with previous adverse drug reactions.

Disorders of fat distribution in HIV infection.

Alterations in body shape due to fat loss and/or redistribution have been described in HIV-infected individuals and associated with the use of antiretroviral (ARV) combination therapy. Certain of these changes have been referred to as peripheral lipodystrophy (LD) and we describe 12 patients who were recognized with this condition between September 1997 and February 1998. It occurred in 12.5% of patients on ARV combination therapy that included a protease inhibitor (PI). In early descriptions the emphasis was on the abdomen, which may be grossly enlarged. In our patients this feature was much less marked. Patients with LD were significantly older than those on PI therapy who did not develop this condition (P=0.016). Although all had raised triglyceride (TG) levels, the elevations were not severe (maximum=6.3 mmol/l). CD4 lymphocyte and viral load levels suggested an optimal response to ARV therapy at the time LD developed. Appearances may be disfiguring but no serious systemic consequences of LD have been observed. Most individuals have chosen to remain on their present ARV combinations. When LD occurs, it appears to be a marker of effective response to anti-HIV therapy.

The effect of environment on plasma cortisol and beta-endorphin in the parturient pig and the involvement of endogenous opioids.

Previous work has indicated that plasma cortisol increases during farrowing in the pig suggesting increasing physiological stress. The aim of this study was to determine changes in plasma cortisol and beta-endorphin over farrowing in the pig to obtain a more detailed profile of pituitary and adrenal release at this time and also to investigate the involvement of endogenous opioids in the mediation of the HPA axis. Indwelling jugular catheters were implanted, under general anaesthesia, in 31 Large White x Landrace gilts approximately 15 days before the expected parturition day (EPD). Gilts were moved into either a farrowing crate, without straw (n = 15), or a straw-bedded pen (n = 16) 5 days before the EPD. Samples were taken during the pre-farrowing period and then during farrowing itself. At 7.5 min after the birth of the first piglet (BFP), gilts either received naloxone, an opioid antagonist, (1 mg kg(-1) body weight, i.v.) or a control dose of saline. Plasma beta-endorphin increased following the BFP but remained fairly constant over the third and fourth hour of farrowing. Plasma cortisol continued to increase over the 4 h following the BFP. Changes seen in these hormones were generally insensitive to the environment and there was little evidence of opioid mediation of the HPA axis at parturition. From these results it is suggested that certain aspect(s) of parturition itself stimulate the HPA axis. However it is unknown if the rise in plasma cortisol is a result of some stress-inducing factor of the parturition process or whether it reflects a metabolic function. The study also demonstrates the lack of any inhibitory mediation of the HPA axis by endogenous opioids at parturition.

Investigation of the relationship between farrowing environment, sex steroid concentrations and maternal aggression in gilts.

Maternal oestrogen and progesterone have been shown to be important in the initiation of maternal behaviour. Thirty-three Large White x Landrace gilts, housed in groups during pregnancy, were observed and aggressive interactions recorded. Individuals had jugular catheters implanted 14.5 (s.e. 0.34) days before their expected parturition date (EPD). Five days before EPD gilts were randomly allocated and moved to either a conventional farrowing crate (C; without straw, 16 gilts) or a pen (P; 2.1 x 3.1 m2; with straw bedding, 17 gilts). Blood samples were taken at frequencies determined by the proximity to farrowing onset. Piglets were removed at birth and returned 2 h after placental expulsion. The reaction of each gilt to her piglets was monitored. Gilts savaging piglets were sedated with azaperone (n = 8). There was no overall effect of farrowing environment on oestradiol and progesterone concentrations. The pre-farrowing ratio of progesterone to oestradiol was higher for (P) gilts (0.45 vs. 0.25, (P) vs. (C); S.E.D. 0.085, P < 0.05) as was their overall maximum oestradiol level (3.39 vs. 2.29 ng/ml, (P) vs. (C); S.E.D. 0.39, P < 0.01). In contrast to progesterone, oestradiol patterns varied considerably between individuals. Dominance rank value during pregnancy, but not levels of aggression, correlated positively to pre-farrowing oestradiol concentrations. Treatment with azaperone was not related to farrowing environment, piglet weight or litter size. Azaperone treated gilts showed a higher pre-farrowing oestradiol to progesterone ratio (0.55 vs. 0.29, +/- azaperone; S.E.D. 0.10, P < 0.05), significantly higher levels of oestradiol post-partum (0.7 vs. 0.19 ng/ml, +/- azaperone; S.E.D. 0.20, P < 0.001) and significantly lower levels of aggression during pregnancy (1.68 vs. 2.23 aggressive interactions/h, +/- azaperone; S.E.D. 0.15, P < 0.001). The results indicate that there are no major effects of farrowing environment on sex steroid concentrations. Maternal aggression under these conditions appears to be negatively related to aggression during pregnancy, but this is not reflected in plasma concentrations of sex steroids around parturition.