The application of human reliability analysis to carpal tunnel decompression

INTRODUCTION

Many surgical procedures are prone to human error, particularly in the learning phase of skills acquisition. Task standardisation has been suggested as an approach to reducing errors, but it fails to account for the human factors associated with learning. Human reliability analysis (HRA) is a structured approach to assess human error during surgery. This study used HRA methodologies to examine skills acquisition associated with carpal tunnel decompression.

METHODS

The individual steps or subtasks required to complete a carpal tunnel decompression were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was carried out by consensus of subject matter experts. This identified the potential human errors at each subgoal, the level of risk associated with each task and how these potential errors could be prevented.

RESULTS

Carpal tunnel decompression was broken down into 46 subtasks, of which 21 (45%) were medium risk and 25 (55%) were low risk. Of the 46 subtasks, 4 (9%) were assigned high probability and 18 (39%) were assigned medium probability. High probability errors (>1/50 cases) included selecting incorrect tourniquet size, failure to infiltrate local anaesthetic in a proximal-to-distal direction and completion of the World Health Organization (WHO) surgical sign-out. Three (6%) of the subtasks were assigned high criticality, which included failure to aspirate before anaesthetic injection, whereas 21 (45%) were assigned medium criticality. Remedial strategies for each potential error were devised.

CONCLUSIONS

The use of HRA techniques provides surgeons with a platform to identify critical steps that are prone to error. This approach may improve surgical training and enhance patient safety.

Mild obstructive sleep apnoea in females: post hoc analysis of the MERGE randomised controlled trial

Background

A post hoc analysis of the MERGE trial was conducted, to investigate whether sex differences are evident at the mildest end of the disease spectrum, for symptoms associated with obstructive sleep apnoea (OSA) and the response to continuous positive airway pressure (CPAP) treatment.

Methods

MERGE participants with mild OSA (apnoea-hypopnoea index 5-15 events·h-1; American Academy of Sleep Medicine 2012 criteria) were randomised to either CPAP plus standard care (sleep hygiene counselling) or standard care alone for 3 months. Quality of life (QoL) was measured by questionnaires completed before and after the 3 months. This post hoc analysis of participants of the MERGE trial compared the symptom presentation, and response to CPAP, between the sexes.

Results

233 patients were included; 71 (30%) were female. Females were more symptomatic at baseline in all QoL questionnaires. Specifically, females had lower 36-item Short-Form Health Survey (SF-36) Vitality scores (mean±sd 39.1±10.1 versus 44.8±10.3) and higher Epworth Sleepiness Scale (ESS) scores (mean±sd 11.0±4.2 versus 9.5±4.4). Both sexes experienced snoring, but more females reported fatigue and more males reported witnessed apnoeas. All symptoms improved with CPAP for both sexes; however, females had larger improvements in SF-36 Vitality scores, which was the primary outcome of the MERGE trial (mean change 9.4 (95% CI 6.8-12.0) versus 6.0 (95% CI 4.3-7.7); p=0.034), and ESS (mean change -4.1 (95% CI -5.1- -3.0) versus -2.5 (95% CI -3.1- -1.8); p=0.015), after adjustment for baseline scores and CPAP usage.

Conclusions

Sex differences are apparent in patients with mild OSA. Females experience worse QoL symptoms than males at presentation to the sleep clinic; however, these improve significantly with CPAP treatment.

Efficacy of vibrotactile positional therapy devices on patients with positional obstructive sleep apnoea: a systematic review and meta-analysis

INTRODUCTION

Vibrotactile positional therapy (PT) devices are a new treatment modality for positional obstructive sleep apnoea (POSA). This review aimed to determine the effect of vibrotactile PT on the Apnoea Hypopnoea Index (AHI) and the percentage of time spent in the supine position (%Tsupine) in patients with POSA, compared with baseline. Secondary aims were to investigate the effect on daytime sleepiness, quality of life and sleep quality.

METHODS

A systematic review and meta-analysis was performed of randomised controlled trials (RCTs) and cohort studies that investigated the effect of vibrotactile PT in POSA patients. Searches were performed via MEDLINE, CENTRAL and Embase up to 29 October 2022.

RESULTS

1119 studies were identified, 18 studies met the inclusion criteria (10 RCTs, 8 cohort studies). The use of vibrotactile PT significantly reduced the AHI at follow-up compared with baseline (mean difference (95% CI) -9.19 events/hour (-11.68 to -6.70); p<0.00001). The mean %Tsupine was also significantly reduced (mean difference (95% CI) -32.79% (-38.75% to -26.83%); p<0.00001). The percentage changes in the AHI and %Tsupine were 43% and 70%, respectively. Secondary outcomes were daytime sleepiness, quality of life and sleep indices. These showed minimal change, although follow-up was short.

CONCLUSION

Vibrotactile PT devices are effective in treating POSA; reducing both AHI and %Tsupine. The effect on sleep quality, daytime sleepiness and disease-specific quality of life was minimal. However, there were limited data and follow-up was often brief, meaning that further research is needed to determine the effect of vibrotactile PT on patient-centred outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020188617.

Virtual consultations for patients with obstructive sleep apnoea: a systematic review and meta-analysis

BACKGROUND

The coronavirus disease 2019 pandemic has accelerated the adoption of virtual care strategies for the management of patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS).

RESEARCH QUESTION

What is the effectiveness of virtual consultations compared to in-person consultations for the management of continuous positive airway pressure (CPAP) therapy in adult patients with OSAHS?

METHODS

A systematic review and meta-analysis (PROSPERO; CRD42022297532) based on six electronic databases plus manually selected journals was conducted in January 2022. Two researchers independently selected, quality appraised and extracted data. The co-primary outcomes were patient-reported sleepiness, assessed by the Epworth Sleepiness Scale (ESS), and reported cost-effectiveness.

RESULTS

12 studies (n=1823 adults) were included in the review. Seven studies (n=1089) were included in the meta-analysis which showed no difference in the magnitude of improvement in patient-reported sleepiness scores between virtual and in-person consultations (mean difference -0.39, 95% CI -1.38-0.60; p=0.4), although ESS scores improved in both groups. Virtual care strategies modestly increased CPAP therapy adherence and were found to be less costly than in-person care strategies in the three Spanish trials that reported cost-effectiveness.

CONCLUSION

The findings of this review suggest that virtual care delivered by telephone or video consultations is as effective as in-person consultations for improving subjective sleepiness in patients with OSAHS treated with CPAP. This clinical management strategy may also improve CPAP adherence without increasing the costs, supporting its potential as a follow-up management strategy, where patients prefer this approach.

Diagnosis of Sleep Apnoea Using a Mandibular Monitor and Machine Learning Analysis: One-Night Agreement Compared to in-Home Polysomnography

Background

The capacity to diagnose obstructive sleep apnoea (OSA) must be expanded to meet an estimated disease burden of nearly one billion people worldwide. Validated alternatives to the gold standard polysomnography (PSG) will improve access to testing and treatment. This study aimed to evaluate the diagnosis of OSA, using measurements of mandibular movement (MM) combined with automated machine learning analysis, compared to in-home PSG.

Methods

40 suspected OSA patients underwent single overnight in-home sleep testing with PSG (Nox A1, ResMed, Australia) and simultaneous MM monitoring (Sunrise, Sunrise SA, Belgium). PSG recordings were manually analysed by two expert sleep centres (Grenoble and London); MM analysis was automated. The Obstructive Respiratory Disturbance Index calculated from the MM monitoring (MM-ORDI) was compared to the PSG (PSG-ORDI) using intraclass correlation coefficient and Bland-Altman analysis. Receiver operating characteristic curves (ROC) were constructed to optimise the diagnostic performance of the MM monitor at different PSG-ORDI thresholds (5, 15, and 30 events/hour).

Results

31 patients were included in the analysis (58% men; mean (SD) age: 48 (15) years; BMI: 30.4 (7.6) kg/m2). Good agreement was observed between MM-ORDI and PSG-ORDI (median bias 0.00; 95% CI −23.25 to + 9.73 events/hour). However, for 15 patients with no or mild OSA, MM monitoring overestimated disease severity (PSG-ORDI &lt; 5: MM-ORDI mean overestimation + 5.58 (95% CI + 2.03 to + 7.46) events/hour; PSG-ORDI &gt; 5–15: MM-ORDI overestimation + 3.70 (95% CI −0.53 to + 18.32) events/hour). In 16 patients with moderate-severe OSA (n = 9 with PSG-ORDI 15–30 events/h and n = 7 with a PSG-ORD &gt; 30 events/h), there was an underestimation (PSG-ORDI &gt; 15: MM-ORDI underestimation −8.70 (95% CI −28.46 to + 4.01) events/hour). ROC optimal cut-off values for PSG-ORDI thresholds of 5, 15, 30 events/hour were: 9.53, 12.65 and 24.81 events/hour, respectively. These cut-off values yielded a sensitivity of 88, 100 and 79%, and a specificity of 100, 75, 96%. The positive predictive values were: 100, 80, 95% and the negative predictive values 89, 100, 82%, respectively.

Conclusion

The diagnosis of OSA, using MM with machine learning analysis, is comparable to manually scored in-home PSG. Therefore, this novel monitor could be a convenient diagnostic tool that can easily be used in the patients’ own home.

Clinical Trial Registration

https://clinicaltrials.gov, identifier NCT04262557

Nasal versus oronasal masks for home non-invasive ventilation in patients with chronic hypercapnia: a systematic review and individual participant data meta-analysis

BACKGROUND

The optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoventilation syndrome (OHS).

METHODS

We searched Medline and Cochrane Central Register of Controlled Trials for prospective randomised controlled trials (RCTs) of at least 1 month's duration, published between January 1994 and April 2019, that assessed NIV efficacy in patients with OHS and COPD. The main outcomes were diurnal PaCO₂, PaO₂ and NIV adherence (PROSPERO CRD42019132398).

FINDINGS

Of 1576 articles identified, 34 RCTs met the inclusion criteria and IPD were obtained for 18. Ten RCTs were excluded because only one type of mask was used, or mask data were missing. Data from 8 RCTs, including 290 IPD, underwent meta-analysis. Oronasal masks were used in 86% of cases. There were no differences between oronasal and nasal masks for PaCO₂ (0.61 mm Hg (95% CI -2.15 to 3.38); p=0.68), PaO₂ (-0.00 mm Hg (95% CI -4.59 to 4.58); p=1) or NIV adherence (0·29 hour/day (95% CI -0.74 to 1.32); p=0.58). There was no interaction between the underlying pathology and the effect of mask type on any outcome.

INTERPRETATION

Oronasal masks are the most used interface for the delivery of home NIV in patients with OHS and COPD; however, there is no difference in the efficacy or tolerance of oronasal or nasal masks.

Camptodactyly and DiGeorge syndrome: A rare hand anomaly

The most common deletion syndrome is 22q11.2 and it effects an estimated 1 in 3000 live births. Major features of this multisystem condition include congenital abnormalities, developmental delay, learning difficulties, immunodeficiency, endocrine anomalies and an array of psychiatric disorders. However, variability in phenotype and severity may cause the diagnosis to be overlooked. Early clinical recognition and treatment of DiGeorge syndrome has been shown to increase early life survival, decrease complications and enhance overall quality of life.

Skeletal anomalies are infrequently described in 22q11.2 but a subset of patients exhibit upper and lower limb deformities. We present the case of a 5 year-old girl with bilateral fifth digit camptodactyly caused by a fibrous band, and the surgical management of this condition. The current report adds to the body of evidence that camptodactyly is a rare clinical feature of 22q11.2 deletion syndrome, and may serve as a diagnostic aid in these patients.

Guidelines for Patient-CenteredOpioid Prescribing and Optimal FDA-Compliant Disposal of Excess Pills after Inpatient Operation: Prospective Clinical Trial

BACKGROUND

To optimize responsible opioid prescribing after inpatient operation, we implemented a clinical trial with the following objectives: prospectively validate patient-centered opioid prescription guidelines and increase the FDA-compliant disposal rate of leftover opioid pills to higher than currently reported rates of 20% to 30%.

STUDY DESIGN

We prospectively enrolled 229 patients admitted for 48 hours or longer after elective general, colorectal, urologic, gynecologic, or thoracic operation. At discharge, patients received a prescription for both nonopioid analgesics and opioids based on their opioid usage the day before discharge: if 0 oral morphine milligram equivalents (MME) were used, then five 5-mg oxycodone pill-equivalents were prescribed; if 1 to 29 MME were used, then fifteen 5-mg oxycodone pill-equivalents were prescribed; if 30 or more MME were used, then thirty 5-mg oxycodone pill-equivalents were prescribed. We considered patients' opioid pain medication needs to be satisfied if no opioid refills were obtained. To improve FDA-compliant disposal of leftover pills, we implemented patient education, convenient drop-box, reminder phone call, and questionnaire.

RESULTS

Our opioid guideline satisfied 93% (213 of 229) of patients. Satisfaction was significantly higher in lower opioid usage groups (p = 0.001): 99% (99 of 100) in the 0 MME group, 90% (91 of 101) in the 1 to 29 MME group, and 82% (23 of 28) in the 30 or more MME group. Overall, 95% (217 of 229) of patients used nonopioid analgesics. Sixty percent (138 of 229) had leftover pills; 83% (114 of 138) disposed of them using an FDA-compliant method and 51% (58 of 114) used the convenient drop-box. Of 2,604 prescribed pills, only 187 (7%) were kept by patients.

CONCLUSIONS

This clinical trial prospectively validated a patient-centered opioid discharge prescription guideline that satisfied 93% of patients. FDA-compliant disposal of excess pills was achieved in 83% of patients with easily actionable interventions.

Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative

BACKGROUND

Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized.

METHODS

A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees.

RESULTS

During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year.

CONCLUSIONS

Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.

Association of Decreased Postsurgical Opioid Prescribing With Patients' Satisfaction With Surgeons

Importance

Opioid overdose is the leading cause of injury-related death in the United States. Several studies have shown that surgeons overprescribe opioids, and guidelines for appropriate opioid prescribing are available. Concern about patient-reported satisfaction scores may be a barrier to surgeons adopting guideline-directed prescribing.

Objective

To determine whether decreased opioid prescribing is associated with a decrease in patient-reported satisfaction with their surgeon.

Design, Setting, and Participants

Retrospective analysis of clinician satisfaction scores at Dartmouth-Hitchcock Medical Center obtained in 2 periods: 1 before (period A) and 1 after (period B) an educational intervention that resulted in decreased opioid prescribing. The analysis included 11 surgeons who performed 5 common outpatient general surgical operations on 996 patients. Data were analyzed between March and August 2018.

Main Outcomes and Measures

Patient-reported overall satisfaction rating of the surgeon (scale, 0-10). This was collected by a nonstudy-related, routine general institutional survey of approximately 40% of all outpatient encounters.

Results

Of the total number of patients, 67% were women (667 of 996), and the mean patient age was 58 years. Comparing period A with B, the proportion of patients prescribed opioids decreased from 90.2% (n = 367 of 407) to 72.8% (n = 429 of 589) (P < .001). The mean number of opioid pills per prescription decreased from 28.3 to 13.3 (P < .001) and significantly decreased for each of the 11 surgeons. One hundred five of 996 patients (10.5%) undergoing index operations responded to the survey. There was no difference in the mean clinician satisfaction ratings from period A vs B (9.70 vs 9.65; P = .69). During the study periods, 640 total surveys were collected referencing these surgeons (including outpatient encounters associated with operations other than the 5 index cases). There was no difference in the mean satisfaction ratings from period A vs period B (9.55 vs 9.59; P = .62). When individual clinicians were analyzed, none had a significant difference in overall satisfaction rating from period A vs period B.

Conclusions and Relevance

Despite a marked decrease in the proportion of patients receiving opioids and in the number of pills prescribed, there was no significant change in clinician satisfaction ratings.

Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): a multicentre, randomised controlled trial

BACKGROUND

The evidence base for the treatment of mild obstructive sleep apnoea is limited and definitions of disease severity vary. The MERGE trial investigated the clinical effectiveness of continuous positive airway pressure in patients with mild obstructive sleep apnoea.

METHODS

MERGE, a multicentre, parallel, randomised controlled trial enrolled patients (≥18 years to ≤80 years) with mild obstructive sleep apnoea (apnoea-hypopnoea index [AHI] ≥5 to ≤15 events per h using either AASM 2007 or AASM 2012 scoring criteria) from 11 UK sleep centres. Participants were assigned (1:1) to either 3 months of continuous positive airway pressure plus standard care (sleep counselling), or standard care alone, by computer-generated randomisation; neither participants nor researchers were blinded. The primary outcome was a change in the score on the Short Form-36 questionnaire vitality scale in the intention-to-treat population of patients with mild obstructive sleep apnoea diagnosed using the American Academy of Sleep Medicine 2012 scoring criteria. The study is registered with ClinicalTrials.gov, NCT02699463.

FINDINGS

Between Nov 28, 2016 and Feb 12, 2019, 301 patients were recruited and randomised. 233 had mild obstructive sleep apnoea using AASM 2012 criteria and were included in the intention-to-treat analysis: 115 were allocated to receive continuous positive airway pressure and 118 to receive standard care. 209 (90%) of these participants completed the trial. The vitality score significantly increased with a treatment effect of a mean of 10·0 points (95% CI 7·2-12·8; p<0·0001) after 3 months of continuous positive airway pressure, compared with standard care alone (9·2 points [6·8 to 11·6] vs -0·8 points [-3·2 to 1·5]). Using the ANCOVA last-observation-carried-forward analysis, a more conservative estimate, the vitality score also significantly increased with a treatment effect of a mean of 7·5 points (95% CI 5·3 to 9·6; p<0·0001) after 3 months of continuous positive airway pressure, compared with standard care alone (7·5 points [6·0 to 9·0] vs 0·0 points [-1·5 to 1·5]). Three serious adverse events occurred (one allocated to the continuous positive airway pressure group) and all were unrelated to the intervention.

INTERPRETATION

3 months of treatment with continuous positive airway pressure improved the quality of life in patients with mild obstructive sleep apnoea. These results highlight the need for health-care professionals and providers to consider treatment for patients with mild obstructive sleep apnoea.

FUNDING

ResMed Ltd.

Influence of socioeconomic factors on litigation in surgery: Addressing the gap in malpractice literature

The practice of medicine is occasionally volatile and increasingly litigious. Within the specialities, plastic surgery has a high risk, with negative outcomes seen as dissatisfaction, as compared to actual physical harm. To date, most research has focused on potential triggers for litigation, such as poor communication and perceived behavioural deficiencies among physicians. Few studies have addressed patient characteristics or socioeconomic factors. The 'Influence of Socio-Economic Factors on Attitudes Towards Surgery' questionnaire was designed to reflect these goals. It was distributed for a 12-month period to patients in an Emergency Department waiting room. Three hundred twelve completed questionnaires were submitted for analysis. Within the study population, we identified certain socioeconomic trends among those with a low threshold to pursue litigation. Patients with a low threshold to sue were more likely to be male, aged 25-55 years, currently unemployed, without dependents and divorced. However, these parameters did not reach statistical significance. Although these characteristics are interesting, they cannot reliably identify or predict those with a low threshold for litigation. For now, the clinical focus should remain on careful adherence to best practice in an effort to reduce the risk of potential litigation.

Association of the Use of a Mandatory Prescription Drug Monitoring Program With Prescribing Practices for Patients Undergoing Elective Surgery

Importance

Most states have adopted the routine use of a prescription drug monitoring program (PDMP) to curb overprescribing of opioids. The American College of Surgeons promotes the use of these programs as a "guiding principle to curb the opioid epidemic." However, there is a paucity of data on the effects of the use of these programs for surgical patient populations.

Objective

To determine the association of the mandatory use of a PDMP with the opioid prescribing practices for patients undergoing general surgery.

Design, Setting, and Participants

A prospective observational cohort study was conducted at an academic hospital in New Hampshire among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017.

Exposures

New state legislation mandated the use of a PDMP and opioid risk-assessment tool for all patients receiving an outpatient opioid prescription in New Hampshire beginning January 1, 2017. The electronic medical prescribing system was modified to facilitate and support compliance with the new requirements.

Main Outcomes and Measures

Change in opioid prescribing practices after January 1, 2017, and time to complete PDMP requirements.

Results

Among the 1057 patients (569 women [53.8%] and 488 men [46.2%]; mean [SD] age, 56.8 [15.4] years), the percentage of patients prescribed opioids after surgery did not decrease significantly (429 of 536 [80.0%] before the new requirements vs 401 of 521 [77.0%] after the requirements; P = .29). The mean number of opioid pills prescribed decreased from 30.8 to 24.0 (22.1%) in the 6 months prior to the mandatory PDMP requirement; the rate of decrease was actually less (from 22.8 to 21.9 pills [3.9%]) in the 6 months after the legislation. These new requirements did not identify any high-risk patients who subsequently were not prescribed opioids. The query and opioid abuse risk calculator together took a median time of 7 minutes (range, 2-17 minutes) to complete.

Conclusions and Relevance

A mandatory PDMP query requirement was not significantly associated with the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures. In no cases was a high-risk patient identified, leading to avoidance of an opioid prescription. A PDMP can be a useful adjunct in certain settings, but this study found that it did not have the intended effect in a population undergoing elective surgical procedures. Legislative efforts to mandate PDMP use should be targeted to populations in which benefit can be demonstrated.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.¹ This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.

Redefining Cut-Points for High Symptom Burden of the Global Initiative for Chronic Obstructive Lung Disease Classification in 18,577 Patients With Chronic Obstructive Pulmonary Disease

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) can be classified into groups A/C or B/D based on symptom intensity. Different threshold values for symptom questionnaires can result in misclassification and, in turn, different treatment recommendations. The primary aim was to find the best fitting cut-points for Global initiative for chronic Obstructive Lung Disease (GOLD) symptom measures, with an modified Medical Research Council dyspnea grade of 2 or higher as point of reference.

METHODS

After a computerized search, data from 41 cohorts and whose authors agreed to provide data were pooled. COPD studies were eligible for analyses if they included, at least age, sex, postbronchodilator spirometry, modified Medical Research Council, and COPD Assessment Test (CAT) total scores.

MAIN OUTCOMES

Receiver operating characteristic curves and the Youden index were used to determine the best calibration threshold for CAT, COPD Clinical Questionnaire, and St. Georges Respiratory Questionnaire total scores. Following, GOLD A/B/C/D frequencies were calculated based on current cut-points and the newly derived cut-points.

FINDINGS

A total of 18,577 patients with COPD [72.0% male; mean age: 66.3 years (standard deviation 9.6)] were analyzed. Most patients had a moderate or severe degree of airflow limitation (GOLD spirometric grade 1, 10.9%; grade 2, 46.6%; grade 3, 32.4%; and grade 4, 10.3%). The best calibration threshold for CAT total score was 18 points, for COPD Clinical Questionnaire total score 1.9 points, and for St. Georges Respiratory Questionnaire total score 46.0 points.

CONCLUSIONS

The application of these new cut-points would reclassify about one-third of the patients with COPD and, thus, would impact on individual disease management. Further validation in prospective studies of these new values are needed.

Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures

BACKGROUND

There is a paucity of data to inform appropriate opioid prescribing for patients who are discharged after a hospital admission for a surgical procedure.

STUDY DESIGN

We studied 333 inpatients discharged to home after bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery. Chronic opioid users or patients who had complications were excluded. Home opioid usage was quantified in 90% of the remaining patients by questionnaires and phone surveys.

RESULTS

Eighty-five percent of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Fifteen opioid pills satisfied the opioid needs of 88% of patients discharged on postoperative day (POD) 1. For patients discharged after POD 1, in multivariate analysis, the number of opioid pills used at home was associated with the number taken the day before discharge (p < 0.0001) and patient age (p = 0.006), but not the type of surgery. Forty-one percent of patients took no opioids the day before discharge, 33% took 1 to 3, and 26% took more than 4 pills. Eighty-five percent of patients' home opioid requirements would be satisfied using the following guideline: if no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge. If these guidelines were used, the number of opioid pills prescribed would decrease by 40%.

CONCLUSIONS

For patients admitted after surgical procedures, post-discharge opioid use is best predicted by usage the day before discharge. Use of this guideline could decrease opioid prescriptions substantially and effectively treat patients' pain.

Analysis of sentinel node positivity in primary cutaneous melanoma: an 8-year single institution experience

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a standard method for determining the pathologic status of the regional lymph nodes.

AIMS

The aim of our study was to determine the incidence and clinicopathologic factors predictive of SLN positivity, and to evaluate the prognostic importance of SLNB in patients with cutaneous melanoma.

METHODS

We performed a retrospective analysis of a prospectively maintained database of all patients who underwent SLNB for primary melanoma at our institution from 2005 to 2012. Statistical analysis was performed using χ 2 and Fischer exact test.

RESULTS

In total, 318 patients underwent SLNB, of which 65 were for thin melanoma (≤1 mm). There were 36 positive SLNB, 278 negative SLNB and in four cases the SLN was not located. The incidence rate for SLNB was 11.3% overall and 1.5% in thin melanomas alone. Statistical analysis identified Breslow thickness >1 mm (P = 0.006), Clark level ≥ IV (P = 0.004) and age <75 years (P = 0.035) as the strongest predictors of SLN positivity. Our overall false negativity rate was 20% (9/45) with one case of false-negative SLNB in thin melanomas.

CONCLUSION

Breslow thickness of the primary tumour remains the strongest predictor of SLN positivity. Our findings point to a possible limited role for SLNB in thin melanoma due to its low positivity rate, associated false-negative rate and related morbidity.

New reconstruction for bone integration of non-vascularized autogenous bone graft with better bony union and revascularisation

INTRODUCTION

Phalangeal defects are often seen after tumor resection, infections, and in complex open hand fractures. In many cases, reconstruction is difficult and amputation is performed to avoid prolonged rehabilitation that is often associated with a poor outcome. In these cases, the maintenance of length and function presents a reconstructive challenge.

METHODS

We reviewed 11 patients who underwent extensive phalangeal reconstruction with non-vascularized bone graft from the iliac crest using a key-in-slot-joint technique to provide acceptable function and bony union.

RESULTS

In each case, non-vascularized bone graft with a length of 1.4-6.0 cm was used to reconstruct the phalanx. Follow-up ranged from 6 weeks to 5 months, and in all cases, there was bony union after 6 weeks. We evaluated range of motion, function, and as well pain and grip strength of the fingers.

CONCLUSIONS

This case series suggests that a key-in-slot technique allows non-vascularized bone graft to be used in complex large phalangeal bone defects. Due to better bone contact, a sufficient perfusion and revascularisation of the non-vascularized bone graft can be achieved for a quicker and stable bony union. This method appears to be an alternative to amputation in selected cases with a satisfactory soft-tissue envelope.

A Five-Year Review of Tag Rugby Hand Injuries

Tag rugby is one of the fastest growing sports in Ireland. It is a soft-contact team game that is loosely based on the rugby league format except players try to remove Velcro tags from their opponents' shorts rather than engage in a typical rugby tackle. The purpose of this study was to examine all tag rugby associated hand injuries over a five-year period in three large tertiary referral hospitals in Ireland. Using the patient corresponding system, 228 patients with hand injury related tag rugby injuries were observed from 2010 to 2015. There were 138 males and 90 females in the study and over 40% of patients required surgery. Most of the patients were young professionals with an average age of 30. Twenty-five patients worked in the financial services whilst there were 23 teachers. Fractures accounted for 124 of the 228 injuries and mallet injuries accounted for 53. Eighty percent of all injuries occurred during the tackle. The mean number of days missed from work was 9.1±13.8 days. These injuries resulted in an average of seven hospital appointments per patient. Considering it is a soft-contact sport, it is surprising the number of hand injuries that we have observed. Although safety measures have been introduced to decrease the number of hand injuries in recent years, there is a need for further improvements. Better player education about seeking prompt medical attention once an injury occurs, coupled with longer shorts worn by players may improve measures for the sport.

Standards in Operation Notes--Is It Time to Re-Emphasise Their Importance?

Guidelines exist for operation notes from the Royal College of Surgeons of England but compliance has been shown to be variable. The authors performed a closed loop audit of compliance with RCS standards in an Irish Plastic Surgery department. Thirty random operation notes were selected from a conserved pool of authors--before and after an educational intervention to increase awareness of the RCS guidelines. Following education, improvements were noted but also deteriorations--time increased from 12 (40%) to 16 (53%), emergency/elective status from none (0%) to 11 (36%), and operative diagnosis from seven (23%) to 21 (70%). However notably among the findings, surgeon's name decreased from 30 (100%) to 26 (86%), findings from 27 (90%) to 21 (53%) and tissue altered from 27 (90%) to 20 (66%). As some specialities are developing operation note standards specific to individual procedures, the findings are compared with previous similar published work.

The Irish contribution to the plastic surgery literature: 21 years of publications

INTRODUCTION

The Republic of Ireland has always had an influence on medicine and has produced many renowned doctors who have helped shape its history. Furthermore, many clinical articles that have originated from Ireland have changed clinical practice throughout the world. The Irish have also had an impact on the plastic surgery literature yet it has never specifically been analyzed before. The purpose of this study was to identify and analyze all papers that have originated from the plastic surgery units in the Republic of Ireland in the medical literature over the past 21 years.

METHODOLOGY

Twenty-four well-known plastic surgery, hand surgery and burns journals were selected for this study. By utilizing Scopus, the largest abstract and citation database of peer-reviewed literature, we analyzed each of our chosen 24 journals looking for Irish publications. Each paper was examined for article type, authorship, year of publication, institution of origin and level of evidence.

RESULTS

Papers from the Republic of Ireland were published in 20 of the 24 journals over the past 21 years. A total of 245 articles from Ireland were published in the plastic surgery, hand surgery and burns literature over the 21-year period. Of these, 111 were original articles and 73 were case reports. The institution that published the most papers over the past 21 years was University Hospital Galway (66 publications) followed by Cork University Hospital with 54 papers. The journal with the most Irish articles was the Journal of Plastic, Reconstructive and Aesthetic Surgery with 56 papers. 2014 was the year with the most publications (28 papers). Authorship numbers also increased over time as the average number of authors in 1994 was 3.5, whereas it was 5.54 in 2014.

DISCUSSION

The number of publications per year continues to increase along with authorship numbers. This mirrors the trend in other specialties. Publications are now no longer required for selection on to a higher surgical training scheme. There is now a fear that the academic output of trainees will decrease as a consequence. To prevent this, each unit must actively support and encourage research activity with their trainees.

Patent foramen ovale is not associated with hypoxemia in severe chronic obstructive pulmonary disease and does not impair exercise performance

RATIONALE

Patent foramen ovale (PFO) may be disadvantageous in chronic obstructive pulmonary disease (COPD). It is unknown whether right-to-left shunting through PFO increases during exercise impairing exercise performance.

OBJECTIVES

To determine whether (1) PFO prevalence is greater in hypoxemic versus less hypoxemic patients with COPD, (2) PFO is associated with clinically relevant impairment, and (3) right-to-left shunting increases during exercise and impairs exercise performance.

METHODS

Patients with COPD and age-matched control subjects underwent contrast transthoracic echocardiography and transcranial Doppler to identify PFO. Patients with COPD with no shunt and patients with large PFO underwent cardiopulmonary exercise tests with contrast transcranial Doppler, esophageal, and gastric balloon catheters.

MEASUREMENTS AND MAIN RESULTS

PFO prevalence was similar in 50 patients with COPD and 50 healthy control subjects (46% vs. 30%; P = 0.15). Large shunts were more common in patients with COPD (26% vs. 6%; P = 0.01). In an expanded COPD cohort, PFO prevalence was similar in 31 hypoxemic (Pao2 ≤ 7.3 kPa) and 63 less hypoxemic (Pao2 > 8.0 kPa) patients with COPD (39% vs. 52%; P = 0.27). Patients with intrapulmonary shunting had lower Pao2 than both patients with PFO and those with no right-to-left shunt (7.7 vs. 8.6 vs. 9.3 kPa, respectively; P = 0.002). Shunting significantly increased during exercise in patients with COPD with PFO. Endurance time at 60% Vo2max was 574 (178) seconds for patients with PFO and 534 (279) seconds for those without (P = ns).

CONCLUSIONS

Hypoxemic patients with COPD do not have a higher prevalence of PFO. Patients with COPD with PFO do not perform less well either on a 6-minute walk or submaximal exercise testing despite increased right-to-left shunting during exercise.

Randomized trial of 'intelligent' autotitrating ventilation versus standard pressure support non-invasive ventilation: impact on adherence and physiological outcomes

BACKGROUND AND OBJECTIVE

Effective non-invasive ventilation (NIV) therapy is dependent on optimal ventilator settings to maximize clinical benefit and patient tolerance. Intelligent volume-assured pressure support (iVAPS) is a hybrid mode of servoventilation, providing constant automatic adjustment of pressure support (PS) to achieve a target ventilation determined by the patient's requirements. In a randomized crossover trial, we tested the hypothesis that iVAPS, with automated selection of ventilator settings, was non-inferior to standard PS ventilation, with settings determined by an experienced health-care professional, for controlling nocturnal hypoventilation in patients naive to NIV.

METHODS

Eighteen patients referred to a ventilator clinic with chronic obstructive or restrictive lung disease and newly diagnosed nocturnal hypoventilation (10 male, median (interquartile range): age 54(41-61) years, mean daytime PaO2 9.25(8.59-10.31) kPa, -PaCO2 6.38(5.93-6.65) kPa were randomized to iVAPS and standard PS. Polysomnography with transcutaneous CO2 monitoring was performed at baseline and 1 month after each treatment period. Nightly hours of therapy were recorded by the ventilator.

RESULTS

iVAPS delivered a lower median PS compared with standard PS (8.3(5.6-10.4) vs 10.0(9.0-11.4) cmH2 O; P = 0.001) for the same ventilatory outcome (mean overnight: SpO2 96(95-98) vs 96(93-97)%; P = 0.13 and PtcCO2 6.5(5.8-6.8) vs 6.2(5.8-6.9); P = 0.54). There was no difference in outcome between ventilator modes for spirometry, respiratory muscle strength, sleep quality, arousals or O2 desaturation index. Adherence was greater with iVAPS (5:40(4:42-6:49) vs 4:20(2:27-6:17) hh:mm/night; P = 0.004).

CONCLUSIONS

iVAPS servoventilation with automation of ventilation settings is as effective as PS ventilation initiated by a skilled health-care professional in controlling nocturnal hypoventilation and produced better overnight adherence in patients naive to NIV.

Lung function indices for predicting mortality in COPD

Chronic obstructive pulmonary disease (COPD) is characterised by high morbidity and mortality. It remains unknown which aspect of lung function carries the most prognostic information and if simple spirometry is sufficient.

Survival was assessed in COPD outpatients whose data had been added prospectively to a clinical audit database from the point of first full lung function testing including spirometry, lung volumes, gas transfer and arterial blood gases. Variables univariately associated with survival were entered into a multivariate Cox proportional hazard model.

604 patients were included (mean±sd age 61.9±9.7 years; forced expiratory volume in 1 s 37±18.1% predicted; 62.9% males); 229 (37.9%) died during a median follow-up of 83 months. Median survival was 91.9 (95% CI 80.8–103) months with survival rates at 3 and 5 years 0.83 and 0.66, respectively. Carbon monoxide transfer factor % pred quartiles (best quartile (>51%): HR 0.33, 95% CI 0.172–0.639; and second quartile (51–37.3%): HR 0.52, 95% CI 0.322–0.825; versus lowest quartile (<27.9%)), age (HR 1.04, 95% CI 1.02–1.06) and arterial oxygen partial pressure (HR 0.85, 95% CI 0.77–0.94) were the only parameters independently associated with mortality.

Measurement of gas transfer provides additional prognostic information compared to spirometry in patients under hospital follow-up and could be considered routinely.

Transfer factor not GOLD stage is the most powerful predictor of survival in patients with COPDhttp://ow.ly/mGmjG

Breathlessness and skeletal muscle weakness in patients undergoing lung health screening in primary care

Earlier diagnosis of COPD is a major public health challenge as symptoms may be attributed to the normal consequences of aging. The optimum strategy for identifying patients with COPD remains to be determined. People aged 35 and over (n = 1896) on a GP practice register were randomised to either invitation or an opportunistic lung health check which included spirometry, quadriceps strength and MRC dyspnoea score. Then, 101 participants subsequently completed the General Practice Physical Activity Questionnaire. A total of 335 attended over a 15-week period; 156 were in the invitation group and 179 from the opportunist group. In 25 persons, spirometry was unsatisfactory or contraindicated. Spirometry was normal in 204(65.8%) and restrictive in 36(11.6%). 70(22.6%) had airflow obstruction, corresponding to Global Initiative for Chronic Lung Disease (GOLD) stages I-IV in 18(5.8%), 35(11.3%), 14(4.5%) and 3(1.0%), respectively. The opportunist group were significantly more likely to have airflow obstruction 30.1% vs 14.3% (p = 0.001). Breathlessness was reported commonly (40.5%) and quadriceps strength correlated significantly with MRC dyspnoea score independent of age, sex, pack-years smoked, fat-free mass and FEV(1) percent predicted. This relationship was also present in the subgroup of healthy participants (n = 143). 51.5% of participants screened were classified as "inactive" and this group were weaker and more breathless than those who were more active. Airflow obstruction was more common in those screened opportunistically. Breathlessness and inactivity are common in patients taking part in spirometry screening. Breathlessness is significantly associated with leg strength independent of spirometry and should be amenable to interventions to increase physical activity.

Singing classes for chronic obstructive pulmonary disease: a randomized controlled trial

BACKGROUND

There is some evidence that singing lessons may be of benefit to patients with chronic obstructive pulmonary disease (COPD). It is not clear how much of this benefit is specific to singing and how much relates to the classes being a group activity that addresses social isolation.

METHODS

Patients were randomised to either singing classes or a film club for eight weeks. Response was assessed quantitatively through health status questionnaires, measures of breathing control, exercise capacity and physical activity and qualitatively, through structured interviews with a clinical psychologist.

RESULTS

The singing group (n=13 mean(SD) FEV1 44.4(14.4)% predicted) and film group (n=11 FEV1 63.5(25.5)%predicted) did not differ significantly at baseline. There was a significant difference between the response of the physical component score of the SF-36, favouring the singing group +12.9(19.0) vs -0.25(11.9) (p=0.02), but no difference in response of the mental component score of the SF-36, breathing control measures, exercise capacity or daily physical activity. In the qualitative element, positive effects on physical well-being were reported in the singing group but not the film group.

CONCLUSION

Singing classes have an impact on health status distinct from that achieved simply by taking part in a group activity.

TRIALS REGISTRATION

Registration Current Controlled Trials - ISRCTN17544114.

Respiratory muscle fatigue following exercise in patients with interstitial lung disease

BACKGROUND

It is not known whether respiratory muscle fatigue occurs as a consequence of exercise in patients with interstitial lung disease (ILD) and, if so, to what extent it is related to changes in dynamic lung volumes.

OBJECTIVES

To assess the development of respiratory muscle fatigue in patients with ILD and relate it to the respiratory pattern during exercise.

METHODS

Sixteen ILD patients (11 women) performed incremental, symptom-limited cycle ergometry with inspiratory capacity manoeuvres used to measure changes in end-expiratory lung volume (EELV). Twitch transdia-phragmatic pressure (TwPdi) and twitch gastric pressure (TwT10Pga), in response to magnetic stimulation, were used to assess the development of fatigue.

RESULTS

TwPdi did not differ significantly before and after exercise (21.8 ± 8 vs. 20.2 ± 8 cm H2O; p = 0.10), while TwT10Pga fell from 28.6 ± 18 to 25.2 ± 14 cm H2O (p = 0.02). EELV fell from 2.18 ± 0.65 to 1.91 ± 0.59 liters following exercise (p = 0.04). The fall in TwT10Pga correlated with peak oxygen uptake at peak of exercise (r = -0.52, p = 0.041), increase in heart rate (r = 0.53, p = 0.032) and with the decrease of EELV during exercise (r = 0.57, p = 0.021). Abdominal muscle fatiguers (n = 9, 56%), defined as having a ≥10% fall in TwT10Pga, had a fall in EELV of 22 ± 22% compared to 0.7 ± 8% in non-fatiguers (p = 0.016).

CONCLUSION

Abdominal muscle fatigue develops during exercise in some ILD patients in association with increased expiratory muscle activity manifested by reduced EELV.

Health status assessment in routine clinical practice: the chronic obstructive pulmonary disease assessment test score in outpatients

BACKGROUND

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is a simple, self-completion questionnaire developed to measure health status in patients with COPD, which is potentially suitable for routine clinical use.

OBJECTIVES

The purpose of this study was to establish the determinants of the CAT score in routine clinical practice.

METHODS

Patients attending the clinic completed the CAT score before being seen. Clinical data, including, where available, plethysmographic lung volumes, transfer factor and arterial blood gas analysis, were recorded on a pro forma in the clinic.

RESULTS

In 224 patients (36% female), mean forced expiratory volume in 1 s (FEV₁) was 40.1% (17.9) of predicted (%pred); CAT score was associated with exacerbation frequency [0-1/year 20.1 (7.6); 2-4/year 23.5 (7.8); >4/year 28.5 (7.3), p < 0.0001; 41/40/19% in each category] and with Medical Research Council (MRC) dyspnoea score (r² = 0.26, p < 0.0001) rising approximately 4 points with each grade. FEV(1) %pred had only a weak influence. Using stepwise regression, CAT score = 2.48 + 4.12 [MRC (1-5) dyspnoea score] + 0.08 (FEV(1) %pred) + 1.06 (exacerbation rate/year)] (r² = 0.36, p < 0.0001). The CAT score was higher in patients (n = 54) with daily sputum production [25.9 (7.5) vs. 22.2 (8.2); p = 0.004]. Detailed lung function (plethysmography and gas transfer) was available in 151 patients but had little influence on the CAT score.

CONCLUSION

The CAT score is associated with clinically important variables in patients with COPD and enables health status measurement to be performed in routine clinical practice.

Effect of acute exacerbations on skeletal muscle strength and physical activity in cystic fibrosis

BACKGROUND

Skeletal muscle weakness is an important complication of chronic respiratory disease. The effect of acute exacerbations on strength in patients with cystic fibrosis is not known.

METHODS

Quadriceps (QMVC) and respiratory muscle strength were measured in patients at the time of acute admission, at discharge and one month later. Patients wore an activity monitor during admission and at one month. Convalescent values were compared to the stable clinic population.

RESULTS

Data were available for 13 acute admissions and 25 stable CF outpatients. Strength and other parameters including daily step count did not differ significantly between the stable and one month post-admission groups. At admission, QMVC was 16.7 (8.3)% lower than at convalescence, whereas inspiratory muscle strength did not change significantly. Reduction in QMVC did not correlate with activity levels or with markers of systemic inflammation.

CONCLUSION

Further research is needed to identify the mechanisms responsible for the reduction in QMVC.

ACUTE CALCIFIC TENDINITIS OF THE FINGER — A CASE REPORT

Acute calcific tendinitis of the hand is rare and often misdiagnosed as infection, fracture or periarthritis. It frequently occurs in peri-menopausal women and is caused by deposits of hydroxyapatite crystals. We describe acute calcific tendinitis of the flexor digitorum superficialis insertion in an elderly man taking oral anticoagulants. The differential diagnoses and recommended treatment are discussed.

An inverting circumferential suture for flexor tenorraphy

Zone two flexor tendon repair remains challenging with significant outcome variation using recognised techniques. Tendon adhesion formation results in poor outcomes and rehabilitation regimes aim to limit this. Some repairs augment strength, but increasing bulk mitigates against movement. This novel epitendinous technique causes tendon inversion with potential gliding benefits and improved outcomes. 60 porcine tendons were randomised to a 2-stranded modified Kessler or a 4-stranded Adelaide repair, then sudivided into three different circumferential technique groups: locked running, Silfverskiold, or a new inverting repair. Tendon load to failure (LTF), 2 mm gap formation, bulking effect and method of failure were analysed during digital tensiometry. Four-stranded repairs demonstrated better LTF than 2-stranded techniques. The inverting epitendinous and Silfverskiold repairs showed higher LTF characteristics than the locked running suture, and better tissue holding capacity. The inverting repair has similar properties to commonly used suturing methods and the conformation creates a smooth inverted repair.

Singing teaching as a therapy for chronic respiratory disease--a randomised controlled trial and qualitative evaluation

Background

Despite optimal pharmacological therapy and pulmonary rehabilitation, patients with COPD continue to be breathless. There is a need to develop additional strategies to alleviate symptoms. Learning to sing requires control of breathing and posture and might have benefits that translate into daily life.

Methods

To test this hypothesis we performed a randomised controlled trial, comparing a six week course of twice weekly singing classes to usual care, in 28 COPD patients. The experience of singing was assessed in a qualitative fashion, through interviews with a psychologist. In addition, we surveyed patients with chronic respiratory conditions who participated in a series of open singing workshops.

Results

In the RCT, the physical component score of the SF36 improved in the singers (n = 15) compared to the controls (n = 13); +7.5(14.6) vs. -3.8(8.4) p = 0.02. Singers also had a significant fall in HAD anxiety score; -1.1(2.7) vs. +0.8(1.7) p = 0.03. Singing did not improve single breath counting, breath hold time or shuttle walk distance. In the qualitative element, 8 patients from the singing group were interviewed. Positive effects on physical sensation, general well-being, community/social support and achievement/efficacy emerged as common themes. 150 participants in open workshops completed a questionnaire. 96% rated the workshops as "very enjoyable" and 98% thought the workshop had taught them something about breathing in a different way. 81% of attendees felt a "marked physical difference" after the workshop.

Conclusion

Singing classes can improve quality of life measures and anxiety and are viewed as a very positive experience by patients with respiratory disease; no adverse consequences of participation were observed.

Trial Registration

Current Controlled Trials - ISRCTN17544114.

An assessment of skin preparation in upper limb surgery

Postoperative wound infections remain a major source of upper limb morbidity. The effectiveness of peri-operative human upper limb preparation was determined using a clear fluid antiseptic and an iodine-based solution over 60 and 90 seconds. Less area was missed using iodine over both times and increasing clear solution preparation time from 60 to 90 seconds improved coverage. Surgical experience had little outcome relevance and a 90-second preparation time with either solution was insufficient, with fingers being the sites most commonly missed.

Topographic organization of projections from the amygdala to the visual cortex in the macaque monkey

The topography of amygdaloid projections to the visual cortices in the macaque monkey was examined by injecting the fluorescent tracers Fast Blue and Diamidino Yellow at different locations in the occipital and temporal lobes and mapping the distribution of retrogradely labeled cells in the amygdala. Injections involving regions from rostral area TE to caudal area V1 all resulted in labeled cells within the basal nucleus of the amygdala. Relatively few double-labeled cells were observed even when the two injections were separated by less than 3 mm. The projections were rostrocaudally organized such that projections to caudal visual areas originated from dorsal and caudal portions of the magnocellular division of the basal nucleus while projections to more rostrally situated visual areas originated in more rostral and ventral portions of the basal nucleus. When injections involved rostral and medial portions of area TE, retrogradely labeled cells were observed in the accessory basal and lateral nuclei in addition to the basal nucleus. These data confirm that the amygdala gives rise to feedback projections to all levels of the "ventral stream" visual pathway. The projections do not appear to be diffusely distributed since few double-labeled cells were observed. The largest cells of the basal nucleus, those located in the magnocellular division, project the farthest in the visual system and innervate all occipital and temporal levels. The smaller cells, in the intermediate and parvicellular regions, project to more rostral and medial portions of the visual cortex. These results suggest that the amygdala may have substantial modulatory control over sensory processing at all stages of the ventral-stream visual cortical hierarchy.

Severe injury triggers antigen-specific T-helper cell dysfunction

Although it is established that post-injury immune dysfunction involves alterations in T-cell function, the effects of injury on T-cell function in vivo are poorly understood. This study uses a mouse injury model and an antigen immunization approach to investigate the influence of injury on antigen-specific T-helper cell function. We report here that injury triggered a significant reduction in antigen-specific T-helper-1 (Th1)-dependent IgG2a antibody formation, while IgM, IgG1, and IgE production was unchanged. In addition, injury caused a reduction in cytokine production (IL-2, IFNgamma and IL-10) by antigen-stimulated T-cells. We also demonstrate that interleukin 12 (IL-12), a cytokine that promotes Th1 cell differentiation, restored IgG2a antibody formation and corrected the injury-induced reduction in antigen-stimulated cytokine production. Taken together, these findings indicate that severe injury induces a dramatic reduction in Th1 cell function in vivo and suggest that therapies designed to restore Th1 cell function may be beneficial to the injured host.

Enhancing diagnostic ultrasound programs utilizing wide-area image management technology

Diagnostic ultrasound in remote sites is limited by attendant delay in interpretation and reporting. Technology advances were incorporated in an ultrasound program based in Churchill, Manitoba, and designed to meet the needs of the Central Canadian Arctic. Still-frame ultrasound images are digitized via a sonographer's picture archiving and communications system (PACS) workstation, and as they are collected they are transmitted over a dial-up Internet protocol network in Dicom 3.0 format to a tertiary care center. Received images are routed to a physician's PACS workstation, where they can be reviewed prior to the patient leaving the remote clinic. The impact of existing technology on a northern ultrasound program is discussed. The implications of technology enhancement are reviewed, with specific reference to remote low bandwidth sites.

The effect of hysterectomy on ano-rectal physiology

Hysterectomy is associated with severe constipation in a subgroup of patients, and an adverse effect on colonic motility has been described in the literature. The onset of irritable bowel syndrome and urinary bladder dysfunction has also been reported after hysterectomy. In this prospective study, we investigated the effect of simple hysterectomy on ano-rectal physiology and bowel function. Thirty consecutive patients were assessed before and 16 weeks after operation. An abdominal hysterectomy was performed in 16 patients, and a vaginal procedure was performed in 14. The parameters measured included the mean resting, and maximal forced voluntary contraction anal pressures, the recto-anal inhibitory reflex, and rectal sensation to distension. In 8 patients, the terminal motor latency of the pudendal nerve was assessed bilaterally. Pre-operatively, 8 patients were constipated. This improved following hysterectomy in 4, worsened in 2, and was unchanged in 2. Symptomatology did not correlate with changes in manometry. Although, the mean resting pressure was reduced after hysterectomy (57 mmHg-53 mmHg, P = 0.0541), the maximal forced voluntary contraction pressure was significantly decreased (115 mmHg-105 mmHg, P = 0.029). This effect was more pronounced in those with five or more previous vaginal deliveries (P = 0.0244, n = 9). There was no significant change in the number of patients with an intact ano-rectal inhibitory reflex after hysterectomy. There was no change in rectal sensation to distension, and the right and left pudendal nerve terminal motor latencies were unaltered at follow-up. Our results demonstrate that hysterectomy causes a decrease in the maximal forced voluntary contraction and pressure, and this appears to be due to a large decrease in a small group of patients with previous multiple vaginal deliveries.

Burn injury primes naive CD4+ T cells for an augmented T-helper 1 response

BACKGROUND

The mechanisms responsible for altered T-cell responses and cytokine production after injury are not well understood. We used T-cell receptor (TCR) transgenic mice to study burn injury effects on naive versus antigen-activated CD4+ T cells in vivo.

METHODS

One week after sham or burn injury, lymph node cells were prepared from TCR transgenic mice and stimulated with TCR transgene-specific antigens. T-cell proliferation was measured and culture supernatants were tested for interleukin-2 (IL-2), interferon-gamma (IFN-gamma), IL-4, and IL-10 by enzyme-linked immunosorbent assay (ELISA). Burn injury effects on antigen-activated T cells were studied by immunizing TCR transgenic or wild-type mice at the time of injury.

RESULTS

The antigen-stimulated proliferation of native CD4+ T cells was unaffected by burn injury and no increase in T-helper 2 (Th2)-type cytokine production was observed. Instead, burn injury augmented INF-gamma production by naive CD4+ transgenic T cells, and IL-2 production was marginally reduced. Thus, burn injury primed native T cells for an enhanced Th1-type response. In contrast, antigen-specific proliferation, IL-2, and IFN-gamma production by T cells harvested from immunized wild-type mice were suppressed. Unexpectedly, high mortality was observed when burn-injured TCR transgenic mice were immunized.

CONCLUSION

Our results show that burn injury has differential effects on naive and antigen-activated CD4+ T cells and can prime naive CD4+ T cells.

Coexistent Hirschsprung's disease and esophageal achalasia in male siblings

Achalasia of the esophagus developed in two male siblings soon after birth, and they were successfully treated by surgery. Persistent signs resulted in the later diagnosis of Hirschsprung's disease. One required subtotal colectomy and ileoanal anastomosis, and the other is managing well on conservative treatment. Genetic analysis of the genes encoding the RET protooncogene, endothelin-3, and the endothelin-3 receptor did not show any defect. Familial achalasia of the esophagus in combination with Hirschsprung's disease has never been reported.

Major injury induces increased production of interleukin-10 by cells of the immune system with a negative impact on resistance to infection

OBJECTIVE

The purpose of this study was to compare the production of interleukin-10 (IL-10) by peripheral blood mononuclear cells (PBMC) from injured patients and control subjects to determine the responsible cell types and to relate IL-10 production to the occurrence of sepsis. A mouse model of burn injury was used to confirm the human findings and to assess the importance of IL-10 in the lowered resistance to infection after injury.

SUMMARY BACKGROUND DATA

Severe injury is associated with depressed immune responses. Although IL-10 is known to inhibit several aspects of immune reactivity, the role of IL-10 in postinjury immune suppression remains controversial.

METHODS

Peripheral blood mononuclear cells from 14 burn and 12 trauma patients and 16 healthy individuals were studied at serial intervals for IL-10 production stimulated by a T-cell mitogen, phytohemagglutinin, and by bacterial lipopolysaccharide. To determine the source of IL-10, CD4+ and CD8+ lymphocyte subsets were obtained by selective depletion of PBMC with antibody-coated magnetic beads and were stimulated by anti-CD3 antibody to induce IL-10 secretion. In addition, IL-10 production by patients' PBMC in the first 10 days after injury was assessed for correlation with subsequent septic events. Anti-CD3-stimulated IL-10 production also was determined for CD4- and CD8-enriched lymphocyte subsets obtained by antibody and complement depletion of splenocytes harvested from groups of burn and sham burn mice at day 10 after injury, the time of maximal susceptibility to a septic challenge, cecal ligation and puncture (CLP). Finally, to test the importance of IL-10 in immune suppression in vivo, groups of burn and sham burn mice were treated with anti-IL-10 monoclonal antibody or control immunoglobulin G (IgG) on days 1 and 3 postinjury and were observed for survival after CLP on day 10.

RESULTS

Patients' PBMC produced significantly more IL-10 than did controls' PBMC 7 to 14 days after injury. Patients' CD4+ (T-helper) but not CD8+ (T-cytotoxic) lymphocytes also showed increased IL-10 production versus those of control subjects early after injury. Increased PBMC IL-10 production in the first 10 days postinjury correlated significantly (p < 0.05) with subsequent septic events. Burn mouse CD4-enriched but not CD8-enriched splenocytes produced more IL-10 than did sham burn splenocyte subsets on day 10 after injury. Burn mice treated with anti-IL-10 antibody but not with control IgG had significantly increased survival after CLP.

CONCLUSION

Serious injury in humans and in a mouse burn model is followed by increased stimulated production of IL-10 by cells of the immune system. The CD4+ T-helper cells appear to be a major source of IL-10 after injury. In injured patients, increased IL-10 production is correlated with subsequent septic events, and in the burn mouse, IL-10 appears to induce decreased resistance to infection.

Anti-interleukin-10 antibody restores burn-induced defects in T-cell function

BACKGROUND

Studies have shown that susceptibility to sepsis after severe injury correlated with reduced production of T-helper 1 (Th1) cytokines (interleukin-2 [IL-2] and interferon-gamma [IFN-gamma]) and a persistence of T-helper 2 (Th2) cytokines (IL-4 and IL-10). The mechanisms responsible for this effect are not clear. We used a T-dependent antigen to study both the effect of burn injury on antigen-specific Th functions in vivo and the effect of anti-IL-10 antibody on these functions.

METHODS

Male A/J mice were anesthetized and given a 25% scald burn or a sham burn. On day 0 all mice were immunized with 100 micrograms trinitrobenzene sulfonic acid (TNP) haptenated ovalbumin (TNP-OVA) in complete Freund's adjuvant. Mice (10 per group) were given 250 micrograms monoclonal rat antimurine IL-10 antibody (anti-IL-10 MAB) or control rat immunoglobin G (IgG) on day 0 and 100 micrograms anti-IL-10 MAB or IgG on day 2. On day 10 the mice were killed to obtain serum and spleen cells. TNP-specific serum antibody isotype titers were determined by enzyme-linked immunosorbent assay (ELISA). Splenocyte proliferation and cytokine-production in response to TNP-OVA or to anti-CD3 MAB were determined by tritiated thymidine incorporation and by ELISA, respectively.

RESULTS

Burn injury resulted in depressed levels of the TNP-specific IgG2a antibody isotype (Th1 dependent), whereas TNP-specific IgG1 and IgE (Th2 dependent) levels were not decreased in burn versus sham burn mice. Anti-IL-10 MAB but not IgG restored the IgG2a response. Burn injury also resulted in reduced TNP-OVA-specific proliferation of splenocytes, whereas anti-CD3 proliferation was equivalent in burn and sham mice. TNP-OVA-specific IL-2 and IFN-gamma production were significantly reduced by burn injury. Anti-IL-10 MAB restored TNP-OVA-specific proliferation and antigen-specific IL-2 and interferon-gamma production by splenocytes from burn mice.

CONCLUSIONS

Burn injury induces the loss of antigen-specific Th1 cell function, and IL-10 acts as a trigger to down-regulate Th1 activity after injury.

Is circulating endotoxin the trigger for the systemic inflammatory response syndrome seen after injury?

OBJECTIVE

Patients with severe traumatic or burn injury and a mouse model of burn injury were studied early after injury to determine the relation of plasma endotoxin (lipopolysaccharide [LPS]) to the production of proinflammatory cytokines and subsequent resistance to infection.

SUMMARY BACKGROUND DATA

Elevated levels of plasma LPS have been reported in patients after serious injury. It has been suggested that circulating LPS may be a trigger for increased proinflammatory cytokine production and may play a role in the septic syndromes seen in a substantial portion of such patients. Yet, despite multiple reports of leakage of LPS from the gut and bacterial translocation after injury in animal models, there is little direct evidence linking circulating LPS with production of inflammatory mediators.

METHODS

The authors studied serial samples of peripheral blood from 10 patients with 25% to 50% surface area burns and 8 trauma patients (injury Severity Score, 25-57). Patients were compared with 18 healthy volunteers. The study was focused on the first 10 days after injury before the onset of sepsis or the systemic inflammatory response syndrome. Plasma samples were assayed for LPS, and adherent cells from the blood were studied for basal and LPS-stimulated production of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), and interleukin-6 (IL-6). The correlation of increased plasma LPS with TNF-alpha production was studied as was the association of increased plasma LPS and increased TNF-alpha production with subsequent septic complications. We also studied a mouse model of 25% burn injury. Burn mice were compared with sham burn control subjects. Plasma samples were assayed at serial intervals for LPS, and adherent cells from the spleens were studied for basal- and LPS-stimulated production of TNF-alpha, IL-1 beta, and IL-6. Expression of the messenger RNAs for IL-1 beta and TNF-alpha also was measured. The relation of increased TNF-alpha production with mortality from a septic challenge, cecal ligation and puncture (CLP), was determined. Finally, the effect of administration of LPS to normal mice on subsequent mortality after CLP and on TNF-alpha production was studied.

RESULTS

Elevated plasma LPS (> 1 pg/mL) was seen in 11 of the 18 patients within 10 days of injury and in no normal control subjects. In this period, patients as compared with control subjects showed increased stimulated production of TNF-alpha, IL-1 beta, and IL-6. Increased TNF-alpha production was not correlated with elevated plasma LPS in the same patients. Neither increased plasma LPS nor increased TNF-alpha production early after injury was correlated with subsequent development of systemic inflammatory response syndrome or sepsis in the patients. Burn mice, as compared with sham burn control subjects, showed elevated plasma LPS levels chiefly in the first 3 days after injury. Increased stimulated production of proinflammatory cytokines by adherent splenocytes from the burn mice also was seen at multiple intervals after injury and did not correlate with mortality from CLP. Increased production of TNF-alpha and IL-1 beta was associated with increased expression of messenger RNAs for these cytokines. Finally, two doses of 1 ng LPS administered 24 hours apart to normal mice had no effect on mortality from CLP performed 7 days later nor on the production of TNF-alpha at the time of CLP.

CONCLUSIONS

These findings call into question the idea that circulating LPS is the trigger for increased proinflammatory cytokine production, systemic inflammatory response syndrome, and septic complications in injured patients.