Examination of Anesthetic Practitioners’ Decisions for the Design of a Cognitive Tool for Airway Management

The goal of this research was to examine the decisions made by anesthesia providers in emergency and routine clinical situations relating to airway management. A key function of anesthesia is to ensure oxygen can be delivered to the lungs via a patient’s airway. Failure to maintain adequate oxygen levels leads to brain damage and death. The anesthetic work environment is complex. Occasionally, stressful situations occur when difficulties in airway management arise. Members of the anesthesia team must then engage in complex cognitive activities such as rapid, collaborative decision-making. It is suggested that cognitive aids may support decision-making in these situations, although this has not yet been evaluated empirically from a Cognitive Systems Engineering perspective. This ongoing research combined two studies using Cognitive Task Analysis methods as part of a Decision-Centered Design process: observations and Critical Decision Method interviews. These will inform subsequent research phases concerning the development and evaluation of design concepts.

High Resolution CT and Bronchography in the Assessment of Bronchiectasis

To elucidate the reliability of CT in the assessment of bronchiectasis, a retrospective study of high resolution CT and bronchography was carried out. A segment by segment comparison of 259 segmental bronchi from 70 lobes of 27 lungs in 19 patients was performed using bronchography as standard. CT was positive in 87 of 89 segmental bronchi with bronchiectasis giving a false-negative rate of 2%. CT was negative in 169 of 170 segmental bronchi without bronchiectasis at bronchography, giving a false-positive rate of 1%. There was agreement between the two modalities in identifying the different types of bronchiectasis.

German, European or American burn guidelines - Is one superior to another?

Adequate medical care of severe burn injuries requires special organizational infrastructure and high educational standards, with an appropriate number of health care professionals. Guidelines were written by the German Society for Burn Treatment (DGV), the European Burns Association (EBA) and the American Burn Association (ABA) to assist with the delivery of such care. Current DGV (2010), EBA (2013) and ABA (2001/2006/2008) guidelines are compared, focusing on similarities, differences, conciseness and completeness. This publication presents advantages and disadvantages of each of them. DGV guidelines outline understandable treatment recommendations for first aid measures, clinical procedures and wound care. Extensive rehabilitation guidelines with clearly defined indications and precise infrastructure requirements for a Burn Centre are stated. Negative aspects are the presence of multiple documents containing redundant and confusing information. EBA guidelines offer the most comprehensive treatment recommendations with multidisciplinary approaches. Overall, infrastructural requirements are weighted much higher than staff qualification demands - in contrast to ABA guidelines. However, lack of conciseness and complicated criteria regarding transfer of patients to a Burn Center - including imprecise indications for rehabilitation treatment - have to be mentioned as disadvantages. ABA guidelines have a clear focus on staff qualifications and easy-to-understand transfer criteria. Another focus is on detailed clinical procedures. However, these guidelines lack burn definition and precise treatment recommendations for rehabilitation. The reviewed guidelines provide standardized treatment recommendations for burn patients. Despite their usefulness, they all have weaknesses and discrepancies. Findings should be used to improve each of them.

Endometriosis and fertility: women's accounts of healthcare

STUDY QUESTION

What do women with endometriosis recall being told about their fertility by their healthcare providers?

SUMMARY ANSWER

Women recalled being given varied information and advice, and gave examples of empathic and individualized care from doctors but also reported opportunities for enhancing clinical practice.

WHAT IS KNOWN ALREADY

There is evidence of an association between endometriosis and infertility. However, the strength of this association and the mechanisms that underlie it are not yet known nor are the implications for optimum healthcare.

STUDY DESIGN, SIZE, DURATION

This study used in-depth cross-sectional qualitative research methods.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged at least 18 years who lived in Victoria, Australia, and who had been surgically diagnosed with endometriosis were invited to participate in in-depth interviews about their experience of endometriosis. Twenty-six women of diverse backgrounds and experiences of endometriosis were interviewed from January to September 2014. Interviews were transcribed and analysed thematically using a data-driven approach.

MAIN RESULTS AND THE ROLE OF CHANCE

All women encountered medical professionals who were aware of the association between endometriosis and infertility, and who were proactive in ensuring fertility was addressed within endometriosis care. Women recalled being given varied, often conflicting, information about the consequences for their fertility of an endometriosis diagnosis. While some recounted positive experiences with the way their doctor communicated with them about endometriosis and fertility, all women reported adverse experiences such as receiving insufficient or inappropriate information or having their doctor prioritize their fertility over other aspects of their care, including quality of life and symptom relief, without first consulting them.

LIMITATIONS, REASONS FOR CAUTION

The perspectives of the women's doctors were not sought. The findings may not translate to settings that differ from a predominantly Anglo-Saxon country with both universal public and private healthcare systems.

WIDER IMPLICATIONS OF THE FINDINGS

Women's fertility needs and priorities differ for many reasons; there can be no 'one size fits all' approach to care. Women may benefit most from endometriosis care in which they are first asked about their fertility needs and preferences and in which medical uncertainty is acknowledged.

STUDY FUNDING/COMPETING INTERESTS

K.Y. receives a scholarship from the National Health and Medical Research Council and Australian Rotary Health. J.F. is supported by a Monash Professional Fellowship and the Jean Hailes Professional Fellowship which is funded by Perpetual Trustees Pty Ltd. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Reasons for palliative treatments in stage III non-small-cell lung cancer: what contribution is made by time-dependent changes in tumour or patient status?

INTRODUCTION

Stage iii lung cancer is the most advanced stage of lung cancer for which the potential of curative treatment is often discussed. However, a large proportion of patients are treated with palliative intent. An understanding of the time-dependent and -independent factors contributing to the choice of palliative-intent treatment is needed to help optimize patient outcomes.

METHODS

This retrospective cohort study of patients with stage iii non-small-cell lung cancer (nsclc) newly diagnosed between 1 January 2008 and 31 December 2012 at the Cancer Centre of Southeastern Ontario collected data including patient demographics, clinical characteristics, tumour characteristics, treatment, and outcomes.

RESULTS

Of 237 patients with stage iii nsclc included in the study, 130 were not treated with radical or curative intent (55%). Major time-independent variables cited for palliative-intent treatment included extreme age (5%), comorbidity (27%), patient choice (5%), and poor lung function (5%). Time-dependent variables included tumour progression on imaging (15%), weight loss (33%), performance status (32%), and the occurrence of a major complication such as hemoptysis, lung collapse, or pulmonary embolism (7%). A significant number of patients (20%) experienced a decline in performance status-to 2, 3, or 4 from 0 or 1-over the course of the diagnostic journey, and 12% experienced a transition from no weight loss to more than 10% weight loss.

CONCLUSIONS

A significant proportion of patients receive palliative therapy for stage iii nsclc because of changes that occur during the diagnostic journey. Shortening or altering that pathway to avoid tumour growth or patient deterioration during care could allow for more patients to be treated with curative intent.

Causes of death and subsequent treatment after initial radical or palliative therapy of stage III non-small-cell lung cancer

INTRODUCTION

Stage iii lung cancer is the most advanced stage of lung cancer for which radical (potentially curative) treatment is often discussed. Understanding the reasons for mortality and subsequent treatments in patients with stage iii non-small-cell lung cancer (nsclc) is important.

METHODS

This retrospective cohort study extracted demographic, clinical, treatment, and outcomes data for patients with newly diagnosed stage iii nsclc diagnosed between 1 January 2008 and 31 December 2012 at a single institution.

RESULTS

The study included 237 patients with stage iii nsclc, 130 of whom were not treated with radical or curative intent (55%). Median survival in the entire cohort was 14 months from diagnosis. For patients treated with radical-intent therapy, causes of death varied with the time period. The hazard rate for death was approximately 2.8 per 100 person-months of follow-up over the entire disease course and was highest between 6 months and 24 months. Over the entire time period, local causes accounted for 29% of deaths; systemic non-central nervous system metastases, for 25%; and brain metastases, for 14%. For patients treated with palliative intent, the overwhelming cause of death was local disease complications or progression (56% of deaths). Only 12% of patients in the palliative treatment group who progressed received subsequent chemotherapy; 23% of patients in the radical group who progressed received palliative chemotherapy. The most frequent subsequent treatment in both groups was radiation therapy.

CONCLUSIONS

The eventual life-ending event in stage iii nsclc varied for the patients who qualified for, and were treated with, radical or curative intent and for the patients who received palliative-intent therapy. Utilization of systemic chemotherapy in patients not fit for radical therapy is low.

Endoglin is required in Pax3-derived cells for embryonic blood vessel formation

Mutations in endoglin, a TGFβ/BMP coreceptor, are causal for hereditary hemorrhagic telangiectasia (HHT). Endoglin-null (Eng-/-) mouse embryos die at embryonic day (E)10.5-11.5 due to defects in angiogenesis. In part, this is due to an absence of vascular smooth muscle cell differentiation and vessel investment. Prior studies from our lab and others have shown the importance of endoglin expression in embryonic development in both endothelial cells and neural crest stem cells. These studies support the hypothesis that endoglin may play cell-autonomous roles in endothelial and vascular smooth muscle cell precursors. However, the requirement for endoglin in vascular cell precursors remains poorly defined. Our objective was to specifically delete endoglin in neural crest- and somite-derived Pax3-positive vascular precursors to understand the impact on somite progenitor cell contribution to embryonic vascular development. Pax3Cre mice were crossed with Eng+/- mice to obtain compound mutant Pax3(Cre/+);Eng+/- mice. These mice were then crossed with homozygous endoglin LoxP-mutated (Eng(LoxP/LoxP)) mice to conditionally delete the endoglin gene in specific lineages that contribute to endothelial and smooth muscle constituents of developing embryonic vessels. Pax3(Cre/+);Eng(LoxP/)(-) mice showed a variety of vascular defects at E10.5, and none of these mice survived past E12.5. Embryos analyzed at E10.5 showed malformations suggestive of misdirection of the intersomitic vessels. The dorsal aorta showed significant dilation with associated vascular smooth muscle cells exhibiting disorganization and enhanced expression of smooth muscle differentiation proteins, including smooth muscle actin. These results demonstrate a requirement for endoglin in descendants of Pax3-expressing vascular cell precursors, and thus provides new insight into the cellular basis underlying adult vascular diseases such as HHT.

Diseases of captive yellow seahorse Hippocampus kuda Bleeker, pot-bellied seahorse Hippocampus abdominalis Lesson and weedy seadragon Phyllopteryx taeniolatus (Lacépède)

Seahorses, pipefish and seadragons are fish of the Family Syngnathidae. From 1998 to 2010, 172 syngnathid cases from the Toronto Zoo were submitted for post-mortem diagnostics and retrospectively examined. Among the submitted species were yellow seahorses Hippocampus kuda Bleeker (n=133), pot-bellied seahorses Hippocampus abdominalis Lesson (n=35) and weedy seadragons Phyllopteryx taeniolatus (Lacépède; n=4). The three most common causes of morbidity and mortality in this population were bacterial dermatitis, bilaterally symmetrical myopathy and mycobacteriosis, accounting for 24%, 17% and 15% of cases, respectively. Inflammatory processes were the most common diagnoses, present in 117 cases. Seven neoplasms were diagnosed, environmental aetiologies were identified in 46 cases, and two congenital defects were identified.

Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series

BACKGROUND

Laparoscopic approaches for the resection of low rectal cancer and the extralevator technique for abdominoperineal excision are both becoming increasingly popular. There are little published data regarding the combined application of these techniques to the resection of low rectal tumours. The aim of this study was to assess the feasibility of such an approach and to appraise short-term outcomes in a consecutive series of patients undergoing laparoscopic extralevator abdominoperineal excision (ELAPE).

METHODS

Consecutive patients undergoing laparoscopic ELAPE at our institution between 2008 and 2011 were identified from a prospectively maintained database. The abdominal phase of the operation was performed laparoscopically, and following extralevator resection, the perineum was reconstructed using a biologic mesh. All patients were enrolled in an enhanced recovery programme.

RESULTS

Of 166 patients undergoing radical resection of rectal cancer at our institution between 2008 and 2011, 28 underwent laparoscopic ELAPE. Median age was 70 years, median body mass index was 27.5 kg/m(2), and 71% were male. The conversion rate to laparotomy was 18%. Three patients (10.8%) had circumferential resection margins <1 mm; no intraoperative tumour perforation occurred. The median length of stay was 7 days, with a 30-day readmission rate of 21% and no 30-day mortality. Post-operative perineal wound complications occurred in 25%. At median 38-month follow-up (range 23-66 months), overall survival was 75%, disease-free survival was 71%, and there were three local recurrences (11%).

CONCLUSIONS

Laparoscopic extralevator abdominoperineal excision can be safely performed without compromising short-term outcomes.

Paediatric hand fractures

This retrospective study reviews the demographics, morphology and management of paediatric hand fractures. Notes of all children with hand injuries attending a plastic surgery paediatric trauma clinic over a one-year period were reviewed. Non-bony injuries were excluded. A total of 303 fractures in 283 patients were included. Fracture incidence rose after the age of seven, peaking at 14 years of age; 76% of fractures occurred in males. Sporting injuries accounted for 47% of fractures. Physeal fractures were present in 39% of cases. Open fractures accounted for only 4% of all fractures. Management was primarily conservative. Only 5% of cases required surgical fixation; 6% of patients experienced complications.