Twelve tips for developing and implementing an effective critical care simulation programme

Simulation training in healthcare settings has become a valuable training tool. It provides an ideal formative assessment for interdisciplinary teaching. It provides a high fidelity and highly immersive environment where healthcare staff and students can practice developing their skills in a safe and controlled manner. Simulation training allows staff to practice skills that better prepare them for clinical emergencies, therefore possibly optimising clinical care. While the benefits of simulation education are well understood, establishing a programme for use by critical care staff is complex. Complexities include the highly specialised scenarios that are not typically encountered in non-critical care areas, as well as the need for advanced monitoring equipment, ventilation equipment etc. These 12 tips are intended to assist healthcare educators in navigating the complexities in the establishment of a critical care simulation programme, providing advice on selecting target audiences, learning outcomes, creating a critical care simulation environment and recommendations on evaluation and development of the programme.

Collating evidence to support the validation of a simulated laparotomy incision and closure-training model

BACKGROUND

It is essential to evaluate the functionality of surgical simulation models, in order to determine whether they perform as intended. In this study, we assessed the use of a simulated laparotomy incision and closure-training model by collating validity evidence to determine its utility as well as pre and post-test interval data.

METHOD

This was a quantitative study design, informed by Messick's unified validity framework. In total, 93 participants (surgical trainees ​= ​80, experts ​= ​13) participated in this study. Evaluation of content validity and the models' relationships with other variables was conducted, along with a pre and post-test confidence assessment.

RESULTS

The model was deemed realistic and useful as a teaching tool, providing strong content validity evidence. In assessment of relationships with other variables, the expert group out-performed the novice group conclusively. Pre and post-test evaluation reported a statistically significant increase in confidence levels.

CONCLUSION

We present strong validity evidence of a novel laparotomy incision and closure simulation-training model.

Assessing operative competence in core surgical training: A reliability analysis

BACKGROUND

This study quantifies the number of observations required to reliably assess the operative competence of Core Surgical Trainees (CSTs) in Ireland, using the Supervised Structured Assessment of Operative Performance (SSAOP) tool.

METHODS

SSAOPs (April 2016-February 2021) were analysed across a mix of undifferentiated procedures, as well as for three commonly performed general surgery procedures in CST: appendicectomy, abdominal wall hernia repair, and skin/subcutaneous lesion excision. Generalizability and Decision studies determined the number of observations required to achieve dependability indices ≥0.8, appropriate for use in high-stakes assessment.

RESULTS

A total of 2,294 SSAOPs were analysed. Four assessors, each observing 10 cases, can generate scores sufficiently reliable for use in high-stakes assessments. Focusing on a selection of core procedures yields more favourable reliability indices.

CONCLUSION

Trainers should conduct repeated assessments across a smaller number of procedures to improve reliability. Programs should increase the assessor mix to yield sufficient dependability indices for high-stakes assessment.

A qualitative evaluation of a telehealth healthy lifestyle intervention for people with serious mental illness

OBJECTIVES

There are high levels of nutritional and metabolic, cardiovascular, and respiratory tract diseases among people diagnosed with serious mental illness (SMI). Consequently, we developed a pragmatic, affordable nutritional and exercise intervention: Choices4Health. Due to the COVID-19 pandemic, we modified this intervention so it could be delivered online. The aim of this study was to explore the experience of participating in online Choices4Health, in a real-world clinical setting, from the perspectives of service users with SMI.

METHODS

The study aim was addressed using thematic analysis. Service users who had attended online Choices4Health, received a SMI diagnosis (defined as a schizophrenia spectrum disorder or an affective disorder), and resided in a South Dublin catchment were invited to participate. Nine participants were purposefully sampled. Semi-structured interviews were conducted by telephone. Data analysis was guided by thematic analysis procedures.

RESULTS

Six themes were generated: Being ready and not overburdened (Engagement); Gaining knowledge and implementing it (Learning and doing); Viewing the intervention as appropriate and effective (Targeted impact); Being at home with others online (Belonging); Having a positive affective attitude towards the intervention (Feeling); and Perceiving problems with intervention delivery (Recommended change).

CONCLUSIONS

Findings suggest that online Choices4Health is, broadly speaking, acceptable from a service user perspective, but that further refinement is required to address specific issues participants identified. These relate to follow-up or programme extension, technology access, in-person contact preference, and participant inclusion criteria. Further research is required into online Choices4Health efficacy, innovations to reduce digital exclusion, and managing group dynamics in telehealth interventions.

WE3.9 Operative competence should be assessed on a procedure-specific basis: analysis of submitted Supervised Structured Assessments of Operative Performance (SSAOPs) by Core Surgical Trainees in Ireland using Generalisability Theory

Introduction

Competency-based training programmes require reliable summative assessment methods. The aim of this study is to assess the reliability of the Supervised Structured Assessment of Operative Performance (SSAOP) tool in determining the operative competence of core surgical trainees in Ireland.

Methods

SSAOP scores from April 2016 - February 2021 were analysed. Reliability analyses for assessment of laparoscopic appendicectomy were compared to those across all submitted procedural assessments. Generalizability and decision studies determined the number of assessments and observers needed to achieve a reliability coefficient (G) of ≥0.7 and ≥0.8 (appropriate for low- and high-stakes assessment respectively).

Results

2,294 SSAOPs were analysed; 85 were completed for laparoscopic appendicectomy. G ≥0.70 is achieved using a single assessor observing a minimum of 3 laparoscopic appendicectomy cases, though G ≥0.70 cannot be achieved for assessments across a wider group of procedures without large numbers of assessors and cases. G ≥0.80 can be achieved with a minimum of two random assessors each observing 3 cases using the Overall Performance rating, or by two assessors and 6 assessments using the ‘Total Checklist’ score. Reliable assessment of a trainee's skill across all procedures, regardless of sub-specialty, could only be achieved using 89 cases and 7 assessors using the Overall Performance rater, or 67 cases and 9 assessors using the Total Checklist.

Conclusion

Operative competence should be assessed on a procedure-specific basis. Assessing overall competence across procedures is not feasible in practice. Trainers and trainees should focus on repeated assessments observing index procedures suitable for a given trainee's stage of training.

Vaccine-induced thrombosis and thrombocytopenia (VITT) in Ireland: A review of cases and current practices

Since the beginning of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) virus pandemic, several highly effective and safe vaccines have been produced at remarkable speed. Following global implementation of vaccination programmes, cases of thrombosis with thrombocytopenia following administration of adenoviral vector-based vaccines started being reported. In this review we discuss the known pathogenesis and epidemiology of so-called vaccine induced thrombocytopenia and thrombosis (VITT). We consider the available guidelines, diagnostic laboratory tests and management options for these patients. Finally, we discuss important unanswered questions and areas for future research in this novel pathoclinical entity.

Predictors of attendance at diabetic retinopathy screening among people with type 2 diabetes: Secondary analysis of data from primary care

AIMS

To estimate the uptake of diabetic retinopathy screening among adults with type 2 diabetes and to identify and compare factors associated with attendance at the national diabetic retinal screening programme, and other screening services provided by ophthalmic surgeons, community ophthalmologists and optometrists.

METHODS

An observational retrospective cohort study was carried out using data from the 2016 audit of care delivered by general practices (n = 30) enrolled in a structured diabetes care initiative. Attendance at any screening in the previous 12 months, and attendance across different types of service (national programme and other screening services) was calculated. Logistic regression was performed to examine predictors associated with (1) attendance at any screening and (2) attendance at the national programme (RetinaScreen). Sociodemographic, clinical, and lifestyle factors were examined as predictors.

RESULTS

Data were available for 1106 people with type 2 diabetes aged ≥18 years. Overall, 863 (78%) of patients had a record of screening attendance in the previous 12 months. Of those screened, 494 (57.2%) attended RetinaScreen only, 258 (28.7%) attended other screening services only, and 111 (12.9%) attended both services. Statistically significant predictors of attendance at any screening were tablet/injectable controlled diabetes, attendance at a diabetes nurse specialist (DNS) in the past 12 months and a blood glucose level which was not on target (HbA1c >7.0% or >53 mmol/mol). In addition to these factors, when examining predictors of attendance at the national screening programme specifically, females were less likely to attend.

CONCLUSIONS

Most patients managed in a structured diabetes care programme in primary care attended screening. Those with on target blood glucose control, those who were on oral or injectable medication or had been seen by a DNS were more likely to attend for annual screening. Of those who attended screening, almost one-third attended other screening services and so were not availing of the national programme, which is free, quality assured and has an integrated treatment arm.

Use of powered air-purifying respirators during surgical interventions

This clinical study confirms user acceptability of PAPR during surgery both at operating room team level as well as by groups of surgeons, anaesthesiologists and nursing level. While some care is needed in the use of this equipment, surgery can be performed safely with satisfactory user experience.

Therefore PAPR is useable for surgery but scope exists for improvement.

Prospective Analysis of Decision Making During Joint Cardiology Cardiothoracic Conference in Treatment of 107 Consecutive Children with Congenital Heart Disease

The complexity and potential biases involved in decision making have long been recognised and examined in both the aviation and business industries. More recently, the medical community have started to explore this concept and its particular importance in our field. Paediatric cardiology is a rapidly expanding field and for many of the conditions we treat, there is limited evidence available to support our decision-making. Variability exists within decision-making in paediatric cardiology and this may influence outcomes. There are no validated tools available to support and examine consistent decision-making for various treatment strategies in children with congenital heart disease in a multidisciplinary cardiology and cardiothoracic institution. Our primary objective was to analyse the complexity of decision-making for children with cardiac conditions in the context of our joint cardiology and cardiothoracic conference (JCC). Two paediatric cardiologists acted as investigators by observing the weekly joint cardiology-cardiothoracic surgery conference and prospectively evaluating the degree of complexity of decision-making in the management of 107 sequential children with congenital heart disease discussed. Additionally, the group consensus on the same patients was prospectively assessed to compare this to the independent observers. Of 107 consecutive children discussed at our JCC conference 32 (27%) went on to receive surgical intervention, 20 (17%) underwent catheterisation and 65 (56%) received medical treatment. There were 53 (50%) cases rated as simple by one senior observer, while 54 (50%) were rated as complex to some degree. There was high inter-observer agreement with a Krippendorff's alpha of ≥ 0.8 between 2 observers and between 2 observers and the group consensus as a whole for grading of the complexity of decision-making. Different decisions were occasionally made on patients with the same data set. Discussions revisiting the same patient, in complex cases, resulted in different management decisions being reached in this series. Anchoring of decision-making was witnessed in certain cases. Potential application of decision making algorithms is discussed in making decisions in paediatric cardiology patients. Decision-making in our institution's joint cardiology-cardiothoracic conference proved to be complex in approximately half of our patients. Inconsistency in decision-making for patients with the same diagnosis, and different decisions made for the same complex patient at different time points confounds the reliability of the decision-making process. These novel data highlight the absence of evidence-based medicine for many decisions, occasional lack of consistency and the impact of anchoring, heuristics and other biases in complex cases. Validated decision-making algorithms may assist in providing consistency to decision-making in this setting.

Patient acceptability and experiences of therapeutic switching of proton pump inhibitors within the National Preferred Drugs initiative in Ireland

INTRODUCTION

A 'Preferred Drugs' initiative was introduced into Ireland in 2013. This identified a single recommended drug to be prescribed to patients requiring treatment from a particular class of drugs.

AIMS

This study investigates how patients on established proton pump inhibitor (PPI) therapy experienced the therapeutic switching of their medication to the 'preferred drug', and the extent to which they regarded it as an acceptable practice.

METHODS

The experiences of 61 patients on established proton pump inhibitor (PPI) therapy were sought before and after their drug was switched to the 'preferred drug'.

RESULTS

Eighty per cent of patients were happy to switch medications. When asked for their opinions on medications in general, 71% felt doctors should prescribe the least expensive medication, 84% agreed that all licensed medications were safe while 67% felt their GP changing medication for cost reasons was safe. After 8 weeks, 20% of patients had switched back to their old PPI. When asked how they felt about their medication change, 74% felt happy or pleased.

CONCLUSIONS

The majority of patients in our study were satisfied to have their medication switched. However, prescribers should be mindful that 1 in 5 patients encountered problems as a result of the switching process.

Nuchal Translucency Quality Review (NTQR) program: first one and half million results

OBJECTIVE

To evaluate the performance of first-trimester nuchal translucency (NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review (NTQR) program.

METHODS

After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median (MoM) for crown-rump length (CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation.

RESULTS

Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM (r = -0.34) and positively with the slope (r = 0.22).

CONCLUSION

Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected.

Inflammatory bowel disease and thromboembolism. Is inflammation at the centre of the clot?

Thromboembolic events are well recognised in patients with inflammatory bowel disease (IBD). We present three cases which highlight the need for vigilance with respect to this complication. We also propose that consideration be given to re-evaluating disease activity in those patients who develop thromboembolic complications.

A quick, least-invasive, inexpensive and reliable method for sampling Gadus morhua postlarvae for genetic analysis

The present study describes the successful design and testing of a quick, least-invasive, reliable and inexpensive sampling procedure for Atlantic cod Gadus morhua. This protocol can be easily applied to postlarval fish following a simple three-step procedure, without availing of commercial DNA extraction kits, while ensuring survival of sampled individuals.

Coping with stress in surgery: the difficulty of measuring non-technical skills

BACKGROUND

Non-technical skills are relevant to surgical performance but are difficult to quantify. The aim of this study was to investigate the relationship between self-efficacy, which is a measure of stress-coping ability, and surgical performance.

METHODS

Two hundred and sixteen basic surgical trainees were assessed on their performance of three bench model-type open and laparoscopic surgical tasks. They also completed a 10-item General Self-Efficacy (GSE) questionnaire to assess their stress-coping abilities. Their assessment scores were correlated with the GSE scores.

RESULTS

The mean GSE score of 31.39 was higher than the recorded population norms. There was no significant correlation between GSE and surgical performance for open or laparoscopic tasks.

CONCLUSION

Junior surgical trainees have high self-belief scores, but these abilities are difficult to measure and quantify. More refined methods may be necessary to measure non-technical skills relevant to surgery.

Sestamibi scan-directed, minimally invasive video-assisted parathyroidectomy: an effective treatment for solitary parathyroid adenoma

BACKGROUND

Solitary adenomas have been shown to be responsible for almost 90% of cases of primary hyperparathyroidism.

AIM

The purpose of this study was to determine the utility of sestamibi scanning pre-operatively to guide minimally invasive video-assisted (MIVA) parathyroidectomy.

METHODS

We reviewed 40 patients who underwent parathyroidectomy between 2003 and 2004. All patients underwent a pre-operative sestamibi scan.

RESULTS

Thirty-three (82%) patients had a localized solitary adenoma on sestamibi scan. Of these patients 29 underwent attempted MIVA parathyroidectomy. MIVA parathyroidectomy was successful in 22 patients. When pre-operative sestamibi scanning was correlated with pathological diagnosis it was shown to have a sensitivity of 82% and positive predictive value of 94%.

CONCLUSION

Pre-operative sestamibi scan localization of a parathyroid adenoma offers a 94% positive predictive value for adenoma location. This facilitates MIVA parathyroidectomy to be used effectively to treat primary hyperparathyroidism in the majority of patients.

The application of a use case/task based approach in the development of software for a portable neuromuscular stimulator device

This paper describes the use of a use case/task based method in the development of a portable neuromuscular stimulator device. The developed unit allows a variety of stimulus delivery algorithms to be incorporated dependent on the patient's requirements. The developed system consists of a stimulator unit, stimulator firmware, external sensors, a programmer unit, two stimulation channels and electrodes. A clinician specifies a suitable algorithm for a particular patient and then selects the relevant stimulus parameters for that algorithm using the programmer unit. The stimulator unit's architecture supports the addition of future algorithms. The device was developed in accordance with the European Medical Devices Directive 93/42/EEC resulting in the need for a well-defined development lifecycle during the design and development of the neuromuscular stimulator. This development lifecycle must place emphasis on the need to identify potential hazards. Therefore, the adoption of a use case/task driven approach as one of the strategies in eliciting the requirements, both functional and non-functional and specification stages of the development lifecycle resulted in a more rigid hazard/risk analysis leading ultimately to a more robust final system. A comprehensive review of the literature has revealed that use cases have been in use in other contexts but not so in a biomedical context. Therefore, this is a novel strategy to the development of a device in this field. A brief background on the historical development of drop foot stimulators shall be presented thereby displaying the benefits of the programmability feature of our stimulator.

The need for a national strategy for chronic pain management in Ireland

BACKGROUND

Chronic pain is defined as pain on a daily basis for more than six months. It affects 13% of the Irish population. Despite its prevalence and the impact on patient's quality of life there is no national strategy for this problem.

AIM

To determine the need for a national strategy for chronic pain in Ireland.

METHODS

The cost of low back pain (LBP) (common chronic pain condition), the level of education and research and current chronic pain clinic resources were investigated.

RESULTS

The cost of LBP in Ireland is enormous: disability payments from the Department of Social and Family Affairs amounted to euros 348 million and insurance payments cost euros 10.5 million. The number of teaching hours timetabled for pain education in the schools of Medicine, Physiotherapy, Dentistry, Nursing and Psychology in Ireland's six universities varied significantly (e.g. 11.5-72 hrs in nursing). Research grants awarded from state organisations were limited to one over a four-year period. No current chronic pain clinics comply with recommended International Association for the Study of Pain (IASP) guidelines.

CONCLUSION

A national strategy is needed to reduce costs, standardise teaching and increase pain clinic resources to maximise patient care.

Complex regional pain syndrome: the case for spinal cord stimulation (a brief review)

Complex regional pain syndrome is a disabling disorder with an unknown mechanism which is extremely resistant to conventional pharmaceutical and therapeutic therapies. In this paper we present the underlying theories of this disorder. We present spinal cord stimulation as an alternative to conventional interventions in the management of this disabling condition spinal cord stimulation significantly improves pain, reduces narcotic intake and improves activity levels and overall quality of life. There is now a significant body of evidence to support the utilization of spinal cord stimulation in the management of complex regional pain syndrome.

A review of technological approaches to venous ulceration

Leg ulceration is a chronic condition affecting about 1-2% of the adult population. The main causes of leg ulceration are venous hypertension, arterial insufficiency, diabetes, or a combination of these aetiologies (causes) or malignancy. Venous ulcers account for approximately 80% of all leg ulcers and are a result of venous hypertension. The current mainstay of treatment of venous ulcers is the application of graduated compression bandaging to the limb. In spite of the application of the best evidence-based therapy, healing rates for venous leg ulcers remain disappointing, at 50-70% after 12 weeks of treatment, depending on initial size and chronicity of the ulcer. Thus, a large number of ulcers are unhealed by this time, and many patients suffer from long-term leg ulceration, some remaining for years, and those that heal often recur. There is an obvious need to develop new treatments that would improve healing rates. This review provides a complete overview of the anatomy of venous circulation and the physiology pertaining to it, the pathophysiology of venous disease, the pathogenesis of ulceration, and a review of treatments currently employed in healing venous leg ulcers and their supporting evidence. The aim of this article is to encourage a fresh look at this chronic problem and stimulate ideas on how healing rates can be improved.

Osteomyelitis of the ischiopubic synchondrosis: imaging findings

Osteomyelitis of the ischiopubic synchondrosis in children is not rare and presents a diagnostic problem because of the diversity of presentation and the deceptive nature of symptoms. Radiological assessment is extremely difficult because of the variation in normal ossification on radiography and normal physiological uptake on radioisotope bone scan. We present two cases of osteomyelitis of the ischiopubic synchondrosis and describe findings on radiographs, isotope bone scan, computed tomography (CT) and magnetic resonance imaging (MRI). MRI changes have not been described in any of the case reports in the English literature. Aspiration and biopsy remain the gold standard for diagnosis. However, MRI appearances can significantly increase diagnostic confidence prior to intervention.

Efficacy of spinal cord stimulation for neuropathic pain following idiopathic acute transverse myelitis: a case report

Spinal cord stimulation (SCS) involves the electrical stimulation of dorsal structures within the spinal cord, and is the most widespread application of neurostimulation for the relief of chronic pain. Idiopathic acute transverse myelitis (IATM) is an acute monophasic lesion of the spinal cord that presents with symptoms associated with loss of cord function. The incidence of chronic pain secondary to this condition is unknown, but is considered rare. We report the efficacy of SCS for relief of severe neuropathic pain in both lower limbs secondary to IATM, which had failed to respond to conventional pain therapies.

What cost chronic pain?

Chronic non-malignant pain costs the American economy $40 billion a year. An attempt to quantify the total cost to the Irish economy of 95 patients attending a Multi-Disciplinary Pain Clinic was made. The cost to the Health Services was estimated and added to the amount of Social Welfare payments received and the lost earnings of each patient. The results indicated that the 95 patients cost 1.9 million pounds at the time of referral. A subgroup of 22 patients who were younger and unemployed, accounted for 1.5 million pounds. Allocation of resources to treat these patients is necessary.

Pain clinic attenders: an audit

An audit of the first 135 referrals to a new Multidisciplinary Pain Clinic was conducted. Demographic data, pain experience and pain effects were recorded. Chronic Non-Malignant Pain was the diagnosis found most frequently. In that group, the mean duration of pain was seven years, the mean number of surgical operations was 1.95 and the mean number of medications being consumed at the time of presentation 3.5. Impaired occupational, social and recreational functioning was noted. Twice as many women were affected as men and all educational and socio-economic groups were represented. Patient profiles were similar to data published on chronic pain patients attending the Mayo Clinic, Minnesota, USA.

ABC of emergency radiology. The ankle

The os trigonum is a common normal variant of the talus and is due to a separate ossification centre arising from the posterior tubercle. The appearance may resemble an old ununited fracture fragment. However, it is triangular, well corticated, in a classic location, and usually bilateral, which enables it to be distinguished from a fracture. Transverse, sclerotic, linear lines located at the metaphysis of growing long bones are due to short periods of growth arrest and have no clinical importance (fig 5). They may be confused with compression fractures, but again these lines are usually bilateral. Fibrous cortical defects are the most commonly seen benign lesions of long bones and are usually identified incidentally in radiographs taken for another reason. The defect is limited to the cortex, commonly found at the metaphysis, but may be located in the diaphysis as the bone grows. The lesion is well corticated (sclerotic margins) and usually does not produce signs or symptoms.

The ABC of emergency radiology. The foot

Images

Metabolic bone disease. Morphometry

The history of the development of radiologic morphometric techniques is traced, emphasizing their pathophysiologic background and relevance to possible therapies. The techniques are described and longitudinal and comparative studies assessed. Technical limitations of the various methods are presented.

Metastatic ependymoma of the sacrum

Ependymomas originating in the sacrum or extraspinal parasacral soft tissues are rare tumors. The majority are of the myxopapillary type and may be locally destructive. Even though metastases are not uncommon in retrosacral ependymomas, they have been rarely described in intrasacral locations. A case is reported of a large intrasacral ependymoma with metastases to several vertebrae. Radiologic and pathologic studies are presented. Treatment options are discussed.

Metastatic ependymoma of the sacrum

Ependymomas originating in the sacrum or extraspinal parasacral soft tissues are rare tumors. The majority are of the myxopapillary type and may be locally destructive. Even though metastases are not uncommon in retrosacral ependymomas, they have been rarely described in intrasacral locations. A case is reported of a large intrasacral ependymoma with metastases to several vertebrae. Radiologic and pathologic studies are presented. Treatment options are discussed.

Rheumatoid arthritis of the cervical spine: early and progressive radiographic features

One hundred thirty-three cervical spine radiographs of 50 patients with rheumatoid arthritis were examined. The patients were a representative random sample chosen from among 675 patients followed up for more than 10 years. The frequency of occurrence for each radiographic finding was correlated with the duration of rheumatoid arthritis. The six radiographic findings that occurred in 30% or more of patients with a disease duration of less than 10 years included odontoid erosions, subaxial subluxation, superficial apophyseal joint erosions, apophyseal joint sclerosis at levels C-4 through C-7, and diskovertebral joint narrowing and osteophytosis at C-4 through C-7. Familiarity with these early findings in the cervical spine may be helpful in both diagnosing and managing rheumatoid arthritis. Subaxial subluxation and superficial apophyseal joint erosions did not progressively increase in frequency with increasing duration of disease, but the other four features did. Other features that were uncommon in early disease became significantly more frequent in later decades.

Effects of halothane, isoflurane and enflurane on ventilation in children

The ventilatory effects of halothane in eight children were compared with those of isoflurane in eight children and enflurane in six children. All studies were completed before surgery commenced, and the children received no preoperative medication. The depression of ventilation produced by the three agents increased in a dose-related fashion as the alveolar concentrations were increased, and the depression of ventilation that they produced in oxygen was greater than that produced by equipotent concentrations in nitrous oxide. While the increase in ventilatory frequency and the decrease in TE associated with increasing concentrations of halothane were statistically significant (P less than 0.05), the increase in frequency associated with isoflurane was not, although it was sufficient to maintain the end-tidal and arterialized venous PCO2 in the isoflurane group at a value which did not differ significantly from that in the halothane group. Profound depression of ventilation was produced in the children by enflurane, clearly because no increase in ventilatory frequency was associated with its use. It was evident that the ventilatory effects of the three volatile agents in unstimulated children are very similar to those described elsewhere in the adult. There was no difference of any clinical significance between the degree of depression of ventilation produced by halothane and isoflurane in children.