One-year retrospective analysis of anti-FXa apixaban and rivaroxaban levels demonstrates utility for management decisions in various urgent and nonurgent clinical situations

OBJECTIVES

Quantification of direct oral anticoagulant (DOAC) plasma levels can guide clinical management, but insight into clinical scenarios surrounding DOAC-calibrated anti-FXa assays is limited.

METHODS

Apixaban- and rivaroxaban-calibrated chromogenic anti-Xa assays performed over a 1-year period were retrospectively analyzed. Patient demographics, DOAC history, concomitant medications, and renal/liver comorbidities were obtained. Indications for testing and associated clinical actions were reviewed. Machine learning (ML) models predicting clinical actions were evaluated.

RESULTS

In total, 371 anti-FXa apixaban and 89 anti-FXa rivaroxaban tests were performed for 259 and 67 patients in recurring urgent (acute bleeding, unplanned procedures) and nonurgent situations, including several scenarios not captured by existing testing recommendations (eg, drug monitoring, recurrent thromboembolic events, bleeding tendency). In urgent settings, andexanet reversal was guided by radiologic and clinical findings over DOAC levels in 14 of 32 instances, while 51% of apixaban patients qualified for nonreversal strategies through the availability of levels. Levels also informed procedure/intervention timing and supported management decisions when DOAC clearance or DOAC target levels were in question. The importance of clinical context was emphasized by exploratory ML models predicting particular clinical actions.

CONCLUSIONS

Although clinical situations are complex, DOAC testing facilitates clinical decision-making, including reversal, justifying more widespread implementation of these assays.

Development and validation of GLVS (Generic Laparoscopic Video Scoring System), a tool for assessment of laparoscopic skills in gynaecology using videotaped procedures: Are edited videos representative of their full-length version?

Background

Anonymized videotaped endoscopic procedures can be used for the assessment of surgical competence, but a reliable non-procedure-specific scoring system is needed for gynaecology.

Objectives

To design and evaluate the validity of the Generic Laparoscopic Video Scoring System (GLVS), a novel tool in the assessment of various gynaecological laparoscopic procedures.

Materials and Methods

Seventeen anonymized unedited video recordings of various gynaecological laparoscopic procedures and the 4-minute-long edited versions of the same videos were independently scored by two experts, twice, using GLVS.

Main outcome measures

Internal consistency reliability, test-retest, and inter-rater reliability of GLVS. We also compared the scored achieved by edited videos with those of the full-length version of the same videos.

Results

The mean score achieved by 4-minute-long edited videos was similar to that of the unedited version (p= 0.13 - 0.19). There was excellent correlation between the pooled scores for edited and unedited versions (intra-class correlation coefficient = 0.86). GLVS had excellent internal consistency reliability (Cronbach's alpha 0.92-0.97). Test-retest and inter-rater reliability were generally better for edited 4-minute-long videos compared to their full-length version. Test-retest reliability for edited videos was excellent for scorer 1 and good for scorer 2 with intra-class correlation coefficient (ICC) of 0.88 and 0.62 respectively. Inter-rater reliability was good for edited videos (ICC=0.64) but poor for full-length versions (ICC= -0.24).

Conclusion

GLVS allows for objective surgical skills assessment using anonymized shortened self-edited videos of basic gynaecological laparoscopic procedures. Shortened video clips of procedures seem to be representative of their full-length version for the assessment of surgical skills.

What’s new?

We devised and undertook a validation study for a novel tool to assess surgical skills using surgical video clips. We believe this addition clearly delineates the unique contributions of our study.

Development and validation of the communication and language assessment questionnaire for persons with multiple sclerosis (CLAMS)

BACKGROUND

There is growing recognition that communication and language can be compromised in persons with multiple sclerosis (MS). However, patient-reported outcome measures (PROMs) designed to measure communication and language function in MS are currently lacking.

OBJECTIVES

This study aimed to develop and validate a novel PROM, the Communication and Language Assessment questionnaire for persons with Multiple Sclerosis (CLAMS).

METHODS

One-hundred and ninety-nine participants were recruited internationally through online channels. Participants completed an online questionnaire consisting of 41-items generated from the: (1) La Trobe Communication Questionnaire (LCQ), (2) Speech pathology-specific questionnaire for persons with Multiple Sclerosis (SMS), and (3) published research describing communication and language in MS. These items were then submitted to preliminary psychometric evaluation, including principal component analysis, internal consistency, test-retest reliability, criterion validity, and analyses of floor and ceiling effects. Criterion validity was assessed by comparing the CLAMS with the Communication Participation Item Bank (CPIB).

RESULTS

The final CLAMS contained 11-items. Internal consistency was high (α = 0.944) and test-retest reliability. All items produced an intra-class correlation coefficient ≥ 0.70. No floor or ceiling effects were present. A statistically significant strong correlation between the CLAMS and the CPIB was identified (r = -0.750, p = ≤ 0.001).

CONCLUSION

The CLAMS is a reliable and valid PROM that assesses self-perceived communication and language function in MS. This tool can be used for research and clinical purposes to measure intervention outcomes, monitor symptom evolution, evaluate service delivery, facilitate patient-centred care, and as an adjunct to clinical assessment.

Self-efficacy and embodiment associated with Alexander Technique lessons or with acupuncture sessions: A longitudinal qualitative sub-study within the ATLAS trial

Background and purpose

A large randomised controlled trial found that the provision of either Alexander Technique lessons or acupuncture, for those with chronic neck pain, resulted in significantly increased self-efficacy when compared with usual care alone. In turn, enhanced self-efficacy was associated with significant reductions in neck pain at 6 and 12 months. In this analysis we explore the perspectives of participants within the trial, with the aim of gaining a better understanding of how these interventions had an impact.

Methods

We used a longitudinal qualitative approach; in-depth interviews, informed by a topic guide, were conducted with a sample of the trial population. Participants were interviewed twice: at around six months (n = 30) and twelve months (n = 26) after trial entry. Analysis was guided by the principles of grounded theory, and key themes were developed.

Results

Five key themes emerged: pre-trial experiences of biomedical treatment against which subsequent interventions were compared; emergence of tangible benefits from the interventions; factors that contributed to the observed benefits, notably growing self-care and self-efficacy; a developing sense of embodiment as an integral part of the transformative process; and contribution of these factors to sustaining benefits over the longer term.

Conclusions

In-depth interviews revealed a rich array of experiences. They gave insight into the positive impact of the interventions on development of self-care, self-efficacy and embodiment. These findings complement the quantitative trial data, providing a more nuanced understanding of the factors that underpin the previously quantified improvement in self-efficacy and its association with longer-term reductions in pain.

Self-efficacy and self-care-related outcomes following Alexander Technique lessons for people with chronic neck pain in the ATLAS randomised, controlled trial

Introduction

ATLAS was a pragmatic randomised (1:1:1 ratio), controlled trial recruiting patients with chronic neck pain (N = 517) and evaluating one-to-one Alexander Technique lessons, or acupuncture, each plus usual care, compared with usual care alone. The primary outcome (12-month Northwick Park Neck Pain Questionnaire [NPQ]) demonstrated significant and clinically meaningful reductions in neck pain and associated disability for both interventions compared with usual care alone. Here we describe pre-specified, self-efficacy and other self-care-related outcomes for the Alexander group compared with usual care.

Methods

Participants reported on 11 self-efficacy/self-care-related outcome measures at 6 and 12 months. Linear or logistic regression models evaluated changes in parameters and impact on NPQ. Alexander teachers reported on lesson content.

Results

Lesson content reflected standard UK practice. The Alexander group (n = 172) reported significantly greater improvements, compared with usual care alone (n = 172), in most of the self-efficacy/self-care measures (9/11 measures at 6 months, and 8/11 at 12 months), including the ability to reduce pain in daily life. At 6 months, 81% (106/131) of Alexander participants reported significant improvement in the way they lived and cared for themselves (versus 23% for usual care), increasing to 87% (117/135) at 12 months (usual care: 25%). NPQ scores at both 6 and 12 months were related to improvement in self-efficacy and ability to reduce pain during daily life.

Conclusions

Alexander Technique lessons led to long-term improvements in the way participants lived their daily lives and managed their neck pain. Alexander lessons promote self-efficacy and self-care, with consequent reductions in chronic neck pain.

An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain: A randomized trial (ATLAS)

Objectives

To assess the cost-effectiveness of acupuncture and usual care, and Alexander Technique lessons and usual care, compared with usual GP care alone for chronic neck pain patients.

Methods

An economic evaluation was undertaken alongside the ATLAS trial, taking both NHS and wider societal viewpoints. Participants were offered up to twelve acupuncture sessions or twenty Alexander lessons (equivalent overall contact time). Costs were in pounds sterling. Effectiveness was measured using the generic EQ-5D to calculate quality adjusted life years (QALYs), as well as using a specific neck pain measure–the Northwick Park Neck Pain Questionnaire (NPQ).

Results

In the base case analysis, incremental QALY gains were 0.032 and 0.025 in the acupuncture and Alexander groups, respectively, in comparison to usual GP care, indicating moderate health benefits for both interventions. Incremental costs were £451 for acupuncture and £667 for Alexander, mainly driven by intervention costs. Acupuncture was likely to be cost-effective (ICER = £18,767/QALY bootstrapped 95% CI £4,426 to £74,562) and was robust to most sensitivity analyses. Alexander lessons were not cost-effective at the lower NICE threshold of £20,000/QALY (£25,101/QALY bootstrapped 95% CI -£150,208 to £248,697) but may be at £30,000/QALY, however, there was considerable statistical uncertainty in all tested scenarios.

Conclusions

In comparison with usual care, acupuncture is likely to be cost-effective for chronic neck pain, whereas, largely due to higher intervention costs, Alexander lessons are unlikely to be cost-effective. However, there were high levels of missing data and further research is needed to assess the long-term cost-effectiveness of these interventions.

Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial

BACKGROUND

Management of chronic neck pain may benefit from additional active self-care-oriented approaches.

OBJECTIVE

To evaluate clinical effectiveness of Alexander Technique lessons or acupuncture versus usual care for persons with chronic, nonspecific neck pain.

DESIGN

Three-group randomized, controlled trial. (Current Controlled Trials: ISRCTN15186354).

SETTING

U.K. primary care.

PARTICIPANTS

Persons with neck pain lasting at least 3 months, a score of at least 28% on the Northwick Park Questionnaire (NPQ) for neck pain and associated disability, and no serious underlying pathology.

INTERVENTION

12 acupuncture sessions or 20 one-to-one Alexander lessons (both 600 minutes total) plus usual care versus usual care alone.

MEASUREMENTS

NPQ score (primary outcome) at 0, 3, 6, and 12 months (primary end point) and Chronic Pain Self-Efficacy Scale score, quality of life, and adverse events (secondary outcomes).

RESULTS

517 patients were recruited, and the median duration of neck pain was 6 years. Mean attendance was 10 acupuncture sessions and 14 Alexander lessons. Between-group reductions in NPQ score at 12 months versus usual care were 3.92 percentage points for acupuncture (95% CI, 0.97 to 6.87 percentage points) (P = 0.009) and 3.79 percentage points for Alexander lessons (CI, 0.91 to 6.66 percentage points) (P = 0.010). The 12-month reductions in NPQ score from baseline were 32% for acupuncture and 31% for Alexander lessons. Participant self-efficacy improved for both interventions versus usual care at 6 months (P < 0.001) and was significantly associated (P < 0.001) with 12-month NPQ score reductions (acupuncture, 3.34 percentage points [CI, 2.31 to 4.38 percentage points]; Alexander lessons, 3.33 percentage points [CI, 2.22 to 4.44 percentage points]). No reported serious adverse events were considered probably or definitely related to either intervention.

LIMITATION

Practitioners belonged to the 2 main U.K.-based professional associations, which may limit generalizability of the findings.

CONCLUSION

Acupuncture sessions and Alexander Technique lessons both led to significant reductions in neck pain and associated disability compared with usual care at 12 months. Enhanced self-efficacy may partially explain why longer-term benefits were sustained.

PRIMARY FUNDING SOURCE

Arthritis Research UK.

Effect of passive polarizing three-dimensional displays on surgical performance for experienced laparoscopic surgeons

Background

Although the potential benefits of stereoscopic laparoscopy have been recognized for years, the technology has not been adopted because of poor operator tolerance. Passive polarizing projection systems, which have revolutionized three-dimensional (3D) cinema, are now being trialled in surgery. This study was designed to see whether this technology resulted in significant performance benefits for skilled laparoscopists.

Methods

Four validated laparoscopic skills tasks, each with ten repetitions, were performed by 20 experienced laparoscopic surgeons, in both two-dimensional (2D) and 3D conditions. The primary outcome measure was the performance error rate; secondary outcome measures were time for task completion, 3D motion tracking (path length, motion smoothness and grasping frequency) and workload dimension ratings of the National Aeronautics and Space Administration (NASA) Task Load Index.

Results

Surgeons demonstrated a 62 per cent reduction in the median number of errors and a 35 per cent reduction in median performance time when using the passive polarizing 3D display compared with the 2D display. There was a significant 15 per cent reduction in median instrument path length, an enhancement of median motion smoothness, and a 15 per cent decrease in grasper frequency with the 3D display. Participants reported significant reductions in subjective workload dimension ratings of the NASA Task Load Index following use of the 3D displays.

Conclusion

Passive polarizing 3D displays improved both the performance of experienced surgeons in a simulated setting and surgeon perception of the operative field. Although it has been argued that the experience of skilled laparoscopic surgeons compensates fully for the loss of stereopsis, this study indicates that this is not the case.

Continuous infusion of local anaesthetic following laparoscopic hysterectomy--a randomised controlled trial

OBJECTIVE

To estimate whether a continuous infusion of intraperitoneal local anaesthetic for 48 hours following laparoscopic hysterectomy reduced the need for opioids delivered with a patient-controlled analgesia pump.

DESIGN

Double-blind randomised placebo-controlled trial.

SETTING

District general hospital in the UK.

POPULATION

Women undergoing a laparoscopic hysterectomy for a benign indication.

METHODS

Women were randomised to receive either 0.5% levobupivicaine or 0.9% normal saline via an ON-Q elastomeric pump for 48 hours postoperatively. The amount of opioids used via the patient-controlled analgesia pump was recorded and pain was measured using an 11-point Box Scale.

MAIN OUTCOME MEASURES

The primary outcome was the amount of patient-administered morphine used over the first 48 postoperative hours. Secondary outcomes were length of hospital stay, oral analgesia use and level of patient-reported pain.

RESULTS

Sixty women participated and completed the trial. There was no difference (P = 0.59) in the median amount of patient-administered morphine used between the levobupivicaine (23 mg) and placebo (18.5 mg) groups; median group difference 3.0 (95% CI -7.0 to 14.0). There was also no difference in the length of hospital stay with 40% of the treatment group remaining in hospital >48 hours compared with 30% of the placebo group (P = 0.08). Pain scores at all postoperative time points remained similar, with a median group difference in pain scores of 1.0 (95% CI -1.0 to 2.0) at the end of the first postoperative day.

CONCLUSIONS

Continuous infusion of 0.5% levobupivicaine into the peritoneal cavity following laparoscopic hysterectomy does not have any opioid-sparing effects.

Alexander Technique Lessons, Acupuncture Sessions or usual care for patients with chronic neck pain (ATLAS): study protocol for a randomised controlled trial

BACKGROUND

Chronic neck pain is a common condition in the adult population. More research is needed to evaluate interventions aiming to facilitate beneficial long-term change. We propose to evaluate the effect of Alexander Technique lessons and acupuncture in a rigorously conducted pragmatic trial with an embedded qualitative study.

METHODS/DESIGN

We will recruit 500 patients who have been diagnosed with neck pain in primary care, who have continued to experience neck pain for at least three months with 28% minimum cut-off score on the Northwick Park Neck Pain Questionnaire (NPQ). We will exclude patients with serious underlying pathology, prior cervical spine surgery, history of psychosis, rheumatoid arthritis, ankylosing spondylitis, osteoporosis, haemophilia, cancer, HIV or hepatitis, or with alcohol or drug dependency currently or in the last 12 months, or actively pursuing compensation or with pending litigation.The York Trials Unit will randomly allocate participants using a secure computer-based system. We will use block randomisation with allocation to each intervention arm being unambiguously concealed from anyone who might subvert the randomisation process.Participants will be randomised in equal proportions to Alexander Technique lessons, acupuncture or usual care alone. Twenty 30-minute Alexander Technique lessons will be provided by teachers registered with the Society of Teachers of the Alexander Technique and twelve 50-minute sessions of acupuncture will be provided by acupuncturists registered with the British Acupuncture Council. All participants will continue to receive usual GP care.The primary outcome will be the NPQ at 12 months, with the secondary time point at 6 months, and an area-under-curve analysis will include 3, 6 and 12 month time-points. Adverse events will be documented. Potential intervention effect modifiers and mediators to be explored include: self-efficacy, stress management, and the incorporation of practitioner advice about self-care and lifestyle. Qualitative material will be used to address issues of safety, acceptability and factors that impact on longer term outcomes.

DISCUSSION

This study will provide robust evidence on whether there are significant clinical benefits to patients, economic benefits demonstrating value for money, and sufficient levels of acceptability and safety.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15186354.

Provision of individualised obstetric risk advice to increase health facility usage by women at risk of a complicated delivery: a cohort study of women in the rural highlands of West Ethiopia

OBJECTIVE

To determine whether the provision of individualised obstetric risk advice would increase health facility usage in women at life-threatening risk of a complicated delivery in Ethiopia, where maternal mortality has remained high and static for a decade and where, although the government has increased the number of health facilities, 90% of women deliver their babies at home.

DESIGN

A prospective cohort study.

SETTING

Rural Ethiopian highlands.

POPULATION

A total of 294 pregnant women at 32 weeks or more of gestation.

METHODS

Before being provided with individualised risk advice, women were asked about their birth plans, and in particular, their planned delivery place. Those identified as being at risk of a complicated delivery were followed up to find out whether they altered their birth plans.

MAIN OUTCOME MEASURE

A change in birthplace.

RESULTS

Women identified as being at high risk of a complicated delivery significantly changed their plans (P < 0.01), with 34 (89%) women delivering in hospital. Women with a medium risk did not significantly change their birth plans (P = 0.082), with 35 (36%) delivering at home. Women with a high parity were less likely to change their birth plans compared with primigravid women (odds ratio 0.53; 95% confidence interval 0.34-0.83) and high-risk women were more likely to change their plans compared with medium-risk women (odds ratio 6.2; 95% confidence interval 1.8-21.6).

CONCLUSIONS

Providing simple, individualised advice about the risks of a complicated delivery leads to high-risk women delivering in hospital. Embedding this into the current antenatal care system in Ethiopia could significantly decrease maternal mortality.

Primary repair of obstetric uterine rupture can be safely undertaken by non-specialist clinicians in rural Ethiopia: a case series of 386 women

We report 386 consecutive cases of uterine rupture over a 10-year period, revealing a case fatality rate of 4.8%, which is significantly less than the 16-37% fatality rate published in the literature. Primary uterine repair, which was carried out by non-specialised doctors in 43% of cases, was the treatment for 98% of women, and appears to be simple and effective. The main predictor of death from uterine rupture was a treatment delay of more than 12 hours from the presumed time of rupture (OR 7.7; 95% CI 1.02-58.4).

Transvaginal sonography vs. clinical examination in the preoperative diagnosis of deep infiltrating endometriosis

OBJECTIVE

The aim of this study was to compare the diagnostic performance of clinical vaginal examination with that of transvaginal sonography (TVS) in the presurgical diagnosis of deep infiltrating endometriosis.

METHODS

One-hundred and fifty-five women with symptoms suggestive of endometriosis were included. One-hundred and twenty-nine patients met the inclusion criteria and were prospectively and independently assessed by vaginal examination and TVS prior to a diagnostic laparoscopy and, where appropriate, radical resection and histological confirmation of endometriosis was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and positive and negative likelihood ratios (LR+ and LR-) were calculated for each test method.

RESULTS

In total, 83 (64%) women had histological confirmation of endometriosis, 52 (40%) of whom had deep infiltrating endometriosis. The prevalence of endometriosis on the uterosacral ligaments, pouch of Douglas, vagina, bladder, rectovaginal space and rectosigmoid was 23.3%, 16.3%, 8.5%, 3.1%, 6.9% and 24%. PPV, NPV, LR+ and LR- for vaginal examination were 92%, 87%, 41.56 and 0.60 for ovarian endometriosis; 43%, 84%, 2.48 and 0.63 for uterosacral ligament disease; 64%, 95%, 9.14 and 0.26 for involvement of the pouch of Douglas; 80%, 97%, 42.91 and 0.28 for vaginal endometriosis; 78%, 98%, 46.67 and 0.23 for endometriosis of the rectovaginal space; 100%, 98%, 75.60 and 0.75 for bladder involvement; 86%, 84%, 18.97 and 0.63 for rectosigmoidal endometriosis. Values for TVS were similar with regard to vaginal and rectovaginal space endometriosis, but were clearly superior to vaginal examination in cases of ovarian (87%, 99%, 24.56 and 0.04), uterosacral ligament (91%, 90%, 31.35 and 0.37) and rectosigmoidal (97%, 97%, 88.51 and 0.1) endometriosis.

CONCLUSIONS

TVS is a more useful test than is vaginal examination in detecting endometriosis in the ovaries and rectosigmoid.

Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation

OBJECTIVE

An economic evaluation of therapeutic massage, exercise, and lessons in the Alexander technique for treating persistent back pain.

DESIGN

Cost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial randomised controlled trial.

PARTICIPANTS

579 patients with chronic or recurrent low back pain recruited from primary care.

INTERVENTIONS

Normal care (control), massage, and six or 24 lessons in the Alexander technique. Half of each group were randomised to a prescription for exercise from a doctor plus behavioural counselling from a nurse.

MAIN OUTCOME MEASURES

Costs to the NHS and to participants. Comparison of costs with Roland-Morris disability score (number of activities impaired by pain), days in pain, and quality adjusted life years (QALYs). Comparison of NHS costs with QALY gain, using incremental cost effectiveness ratios and cost effectiveness acceptability curves.

RESULTS

Intervention costs ranged from pound30 for exercise prescription to pound596 for 24 lessons in Alexander technique plus exercise. Cost of health services ranged from pound50 for 24 lessons in Alexander technique to pound124 for exercise. Incremental cost effectiveness analysis of single therapies showed that exercise offered best value ( pound61 per point on disability score, pound9 per additional pain-free day, pound2847 per QALY gain). For two-stage therapy, six lessons in Alexander technique combined with exercise was the best value (additional pound64 per point on disability score, pound43 per additional pain-free day, pound5332 per QALY gain).

CONCLUSIONS

An exercise prescription and six lessons in Alexander technique alone were both more than 85% likely to be cost effective at values above pound20 000 per QALY, but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique lessons followed by exercise was the most effective and cost effective option.

Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

OBJECTIVE

To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

DESIGN

Factorial randomised trial. Setting 64 general practices in England.

PARTICIPANTS

579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription.

INTERVENTIONS

Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling.

MAIN OUTCOME MEASURES

Roland Morris disability score (number of activities impaired by pain) and number of days in pain.

RESULTS

Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage -0.58, 95% confidence interval -1.94 to 0.77, six lessons -1.40, -2.77 to -0.03, 24 lessons -3.4, -4.76 to -2.03, and exercise -1.29, -2.25 to -0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score -2.98 and -4.14, respectively). Number of days with back pain in the past four weeks were lower after lessons (compared with control median 21 days: 24 lessons -18, six lessons -10, massage -7) and quality of life improved significantly. No significant harms were reported.

CONCLUSIONS

One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons.

Systematic Review of Quality of Life following Laparoscopic and open colorectal surgery

OBJECTIVE

To compare the health-related quality of life (HRQoL) of patients following laparoscopic and open colorectal surgery.

METHODS

A systematic review was performed according to Quorum guidelines. Prospective studies comparing the HRQoL of patients after laparoscopic and open colorectal surgery were identified. The primary outcome measure was postoperative quality of life; performance status and cosmesis were secondary outcome measures.

RESULTS

23 studies were identified that satisfied the inclusion criteria; 18 assessed HRQoL, 4 performance status, and 3 cosmesis. It was not possible to perform a meta-analysis due to study heterogeneity. The studies reported outcomes for 2946 patients. The most frequent HRQoL instruments employed were SF-36, EORTC, and GIQLI. 6 studies, using a total of 12 separate measures, evaluated QoL during the first 3 post-operative months: 10 of these measures showed no significant difference, and 2 showed an improved HRQoL with laparoscopy. Twelve further studies evaluated HRQoL up to 5 years post-operatively: 9 showed no difference between the 2 groups, and 3 demonstrated a benefit for laparoscopy. Three of 4 studies assessing performance status on discharge, and all 3 studies assessing cosmesis, reported benefits with the laparoscopic approach.

CONCLUSIONS

The current evidence suggests there is no significant difference in HRQoL following laparoscopic and open colorectal surgery, although there is a lack of good quality data. There is a trend towards improved quality of life outcomes and performance status with laparoscopy in the early post-operative period. There is a need for further research, particularly assessing quality of life in the early post-operative period.

Long-term outcomes following laparoscopic supracervical hysterectomy

OBJECTIVE

Evaluation of long-term outcomes following laparoscopic supracervical hysterectomy (LSH).

DESIGN

Retrospective postal questionnaire.

SETTING

Norwegian university teaching hospital.

POPULATION

A total of 315 consecutive patients.

METHODS

A questionnaire sent to all patients who underwent a LSH during 2004 and 2005.

MAIN OUTCOME MEASURES

Persistent vaginal bleeding and pelvic pain, patient acceptability of such symptoms and patient satisfaction following LSH.

RESULTS

A total of 240 women (78%) completed the questionnaire. About 24% reported experiencing vaginal bleeding up to 3 years following their hysterectomy, although this was rated as minimal in 90% of cases, resulting in a mean bothersome score of 1.1 (SD 2.0) on a 10-point visual analogue scale (VAS). Women operated on by less experienced surgeons were more likely to report vaginal bleeding following surgery (P = 0.02). About 74% of women reported having menstrual pain prior to surgery, with a mean score of 6.8 (SD 2.1) (10-point VAS). Up to 3 years following surgery, 38% continued to experience menstrual pain, although this was significantly less intense with a mean score of 3.5 (SD 2.2) (P < 0.01). While all women reported a decrease in the amount of pain experienced following the hysterectomy, those having a hysterectomy because of endometriosis reported significantly higher levels of menstrual/cyclical pain after surgery compared with women who had a hysterectomy for other reasons (P < 0.01). Ninety per cent of women reported being satisfied with their surgery.

CONCLUSION

Although vaginal bleeding and pelvic pain are frequently observed following LSH, these symptoms are significantly reduced and patient satisfaction is high.

Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

OBJECTIVE

To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

DESIGN

Factorial randomised trial.

SETTING

64 general practices in England.

PARTICIPANTS

579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription.

INTERVENTIONS

Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling.

MAIN OUTCOME MEASURES

Roland Morris disability score (number of activities impaired by pain) and number of days in pain.

RESULTS

Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage -0.58, 95% confidence interval -1.94 to 0.77, six lessons -1.40, -2.77 to -0.03, 24 lessons -3.4, -4.76 to -2.03, and exercise -1.29, -2.25 to -0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score -2.98 and -4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons -18, six lessons -10, massage -7) and quality of life improved significantly. No significant harms were reported.

CONCLUSIONS

One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons.

TRIAL REGISTRATION

National Research Register N0028108728.

Randomised, comparative study of three primary dressings for the treatment of venous ulcers

In this article, we describe a randomised trial in which two established primary dressings - Comfeel (Coloplast, UK) and Granuflex improved formulation (Convatec, UK) - were compared to Cutinova foam (Beiersdorf Medical, UK) in the management of venous leg ulcers. Patients that met the study trial criteria were randomised to receive one of the three primary dressings. All ulcers were secondarily bandaged with Comprilan (Beiersdorf Medical, UK) short-stretch compression. The three dressings were compared in terms of their ability to promote ulcer healing (closure rate and healing rate) and reduce the prevalence and severity of ulcer-associated pain, over a 12-week period. The ease with which dressings could be used in a busy outpatient clinic setting was also considered. On enrollment, groups were well matched in terms of all of the patient and ulcer parameters studies. Six patients were withdrawn for reasons unrelated to study dressings or trial procedures. Following non-parametric analysis of the study data, the three dressings were found to be equally effective at promoting ulcer healing and alleviating ulcer-associated pain. Study personnel rated Cutinova Foam as easy, if not easier, to use than Comfeel or Granuflex. This study suggests that Cutinova Foam is as safe and effective as both Comfeel and Granuflex, in the treatment of venous leg ulcers.

Tissue viability nurses must have a united front

There are an estimated 500 tissue viability specialists practising throughout the UK, and thousands of nurses with organizational responsibility for the speciality. These nurses make key decisions for their trusts and face clinical dilemmas and managerial challenges unique to their specialty on a daily basis. However, a new Audit Commission report on ward staffing has issued a challenge for nurses, particularly clinical nurse specialists, to prove their worth (Audit Commission, 2001). The Audit Commission report states that even though many trusts now employ specialist nurses, it is not clear what their impact is, and the report questions whether nurse specialists have deskilled ward-based nurses and caused discontent.

Use of vacuum-assisted closure therapy following foot amputation

This case study highlights the use of vacuum-assisted closure (VAC) in a diabetic man following a partial transverse amputation of his foot. In this situation infection-free healing is imperative in order to salvage the limb and prevent further trauma. VAC therapy facilitates rapid granulation of wounds and reduces bacterial colonization rates. This method was adopted as a suitable therapy for treatment of a patient who suffered from a complex wound at high-risk of reinfection.

The Tielle family of dressings: overview of the product range

The Tielle family (Johnson & Johnson Medical) is a range of dressings that come in a variety of shapes and sizes, designed to fit the different types and locations of wounds that occur in practice. There are three types--Tielle, Tielle Lite and Tielle Plus--and the choice of dressing should be based on the degree of exudate that the wound is producing. This product focus aims to give an overview of the range and provides research-based evidence for application in clinical practice.

Use of the Polaroid Macro 3 SLR camera in wound assessment

Patient assessment is essential to effective care and facilitates systematic care planning. Assessment must be performed in combination with good documentation and accurate record keeping. Clinical governance, risk management and accountable practice are continuously emphasized by the UKCC (1992, 1998) and Department of Health (1998), and in the light of increasing litigation, it is imperative that planned and given care is accurately documented.

Evaluating a superabsorbent hydropolymer dressing for exuding venous leg ulcers

A new hydropolymer dressing was compared with an alginate dressing in a multicentre, prospective, controlled, randomised, stratified, open label trial of 113 patients with exuding venous leg ulcers. The study aimed to evaluate the performance of the dressings in terms of their ability to handle exudate, patient and user acceptability and cost-effectiveness. Patients were stratified according to volume of wound exudate (moderate/heavy) and randomised to the hydropolymer dressing or the alginate plus a secondary dressing. A statistically significant difference between treatment groups was observed in mean wear time, with a longer wear time observed in the hydropolymer group (3.91 days) compared with the alginate group (3.09 days, p = 0.001). In terms of patient and user acceptability, all 10 overall evaluations made by both patient and investigator were markedly in favour of the hydropolymer dressing (p < 0.001 to p = 0.020). The use of the hydropolymer dressing for patients with moderate to heavily exuding venous leg ulcers has statistically significant advantages over the alginate dressing in terms of wear time and investigator and patient acceptability. It is anticipated that this reduction in dressing frequency will translate into a cost-effective wound treatment.

An evaluation of the Parema four-layer bandage system

This article gives an overview of the treatment and causes of venous leg ulcers and focuses on a new four-layer bandage system (K-Four from Parema) which can be used in the treatment of these ulcers. The article features preliminary observations of this new system, which was used on 10 patients who had previously worn multilayer compression.

Developments in wound care for difficult to manage wounds

Research and development in wound healing has ensured that issues relating to chronic wound management remain high in the nursing agenda. Since the advent of modern wound dressings, which retain a moist wound healing environment, work has continued to progress into more advanced, interactive products which aim to alter the wound bed in order to promote a suitable environment for cell migration and growth. Rapid wound healing is advocated and necessary to reduce morbidity and mortality in patients with large chronic wounds and to reduce the financial and manpower implications of long-term wound care in the hospital or community setting. Vacuum-assisted closure, artificial skins, growth factors and larval therapy are discussed in order to give an overview of some of the emerging practices being adopted for difficult to manage wounds.

A non-comparative multi-centre clinical evaluation of a new hydropolymer adhesive dressing

This study evaluates the performance of a new hydropolymer adhesive dressing in the treatment of chronic or acute wounds, in the presence of blood and/or low levels of exudate, in 74 patients, in a five-site multi-centre non-comparative clinical trial of four weeks' duration. The primary efficacy variable was defined as the incidence of central island dressing adherence to the wound bed in the final stages of healing. The hydropolymer dressing performed extremely well with 98.4% (240 out of 244) of the dressings not adhering to the wound bed.

Prolonged fenoldopam infusions in patients with mild to moderate hypertension: pharmacodynamic and pharmacokinetic effects

Thirty-three patients with mild-to-moderate essential hypertension received either placebo or fenoldopam, a selective dopamine-1 agonist, by intravenous infusion at a fixed infusion rate ranging from 0.1 to 0.8 microg/kg/min for 48 h during a double-blind, placebo-controlled, randomized inpatient clinical trial. Blood pressure and heart rate were measured every 15 min for 24 h before, during, and 24 h after the 48-h drug infusion. Plasma concentrations of racemic fenoldopam were measured at frequent intervals during and for 24 h after fenoldopam infusion. In the 26 patients who received fenoldopam, there were dose-dependent reductions in systolic and diastolic blood pressure, which usually reached a nadir within 2 h of beginning infusion and were significant even at the lowest dose studied (-9 and -9 mm Hg for systolic and diastolic blood pressure, respectively, at 24 h for the dose of 0.04 microg/kg/min, P < .05). There were associated increases in heart rate that were greater in the first than in the last 24 h of drug infusion. Compared to the average 24-h control blood pressure, maximum mean reductions in systolic and diastolic blood pressures of 33 and 21 mm Hg, respectively, were noted in patients receiving fenoldopam at 0.8 microg/kg/min and occurred 4 and 1 h, respectively, after beginning infusion. Tolerance to the blood pressure lowering effects of the drug developed slowly during the 48 h of drug infusion; the half-life for this effect was 60 h. No serious adverse clinical effects were noted in any patient. These results demonstrate that fenoldopam is effective in reducing blood pressure of patients with mild-to-moderate hypertension at doses as low as 0.04 microg/kg/min, is well tolerated at doses up to 0.8 microg/kg/min, maintains most of its antihypertensive efficacy throughout 48 h of continuous, constant rate infusion, and produces neither prolonged pharmacodynamic effects nor rebound hypertension when discontinued. The pharmacodynamic effects of the drug are best predicted by pharmacokinetics of racemic and R-fenoldopam.

The tendering process for beds and mattresses

As increasing numbers of expensive, sophisticated bed and mattress systems become available, more trusts are negotiating contracts for supply, maintenance and training. It is important that tissue viability nurses become involved in such decision-making.

Adequacy and efficacy of lateral cervical spine radiography in alert, high-risk blunt trauma patient

OBJECTIVE

The purpose of this study was to determine the adequacy and accuracy of lateral cervical spine radiographs in the initial evaluation of alert, high-risk trauma patients evaluated at a Level I trauma center.

METHODS

Data were obtained retrospectively through review of trauma service admissions from January 1, 1994, to July 31, 1995. Included were all patients triaged to a trauma response team with age > 15 years, Glasgow Coma Scale score > 13, and blunt mechanism of injury. Lateral cervical spine radiograms were obtained routinely before secondary survey and were reviewed for technical adequacy (all seven cervical vertebrae, C7/T1 interspace). The presence of cervical symptoms (pain, tenderness, neurologic deficits) was recorded. Sensitivity and specificity were calculated for lateral cervical spine radiography and cervical symptoms in predicting the presence of cervical spine injury. Bayesian analysis, which allows for the current probability of occurrence to be factored by previously reported probabilities of occurrence, was used to determine the negative predictive probability of lateral cervical spine radiography and absence of cervical symptoms to predict the absence of injury to the cervical spine.

RESULTS

Three hundred fifty-three patients received lateral cervical spine radiograms, of which 223 (63%) were determined to be adequate for interpretation. Cervical symptoms were present in 77 patients (20%). Only 32 (42%) of this group's lateral cervical spine radiograms were adequate. Nine patients (2.4%) had acutely fractured cervical vertebrae or ligamentous disruption. Lateral cervical spine radiography showed the injury in only six of these patients. The sensitivity, specificity, and negative predictive probability for lateral cervical spine radiography were 67, 58, and 1.4%, respectively, and for absence of cervical symptoms, 89, 81, and 0.32%, respectively.

CONCLUSION

The higher accuracy and lower negative predictive probability make the absence of cervical symptoms in the alert, high-risk, blunt trauma patient a better screening test than lateral cervical spine radiography. We suggest that lateral cervical spine radiography is not needed in the initial evaluation of alert patients who have sustained blunt trauma.

Pressure-relief mattresses and patient comfort

The ideal pressure-relieving support system is comfortable, relieves pressure and prevents tissue damage. In order to ensure patient compliance with the choice of mattress, patient comfort and quality of sleep should be among the most important factors involved in the decision-making process.

Know how. Pulsating air suspension therapy

The realisation that pressure sores are caused by shearing forces and tissue distortion rather than simply by pressure, had led to the development of specialised patient support systems. The pulsating air suspension system was developed to help reduce the incidence of oedema formation. All health-care professionals using specialised bed therapy have a responsibility to understand the principles of that therapy in order to ensure appropriate patient selection, which may be aided by the development of placement criteria. The concept of pulsation therapy has been a stimulus for new thinking on the causes and treatment of pressure sores and has highlighted the need for further research on the part played by the lymphatic system and oedema on pressure sore formation, although there is already strong evidence that there is a link between tge two.

Humidification for ventilated patients

When a patient is intubated with an endotracheal tube for artificial ventilation the humidifying, warming and filtering functions of the nose and upper airways are bypassed. This article reviews the need for the provision of artificial humidification, optimal levels that should be provided and the two types of device which are available to achieve this, namely, the heat and moisture exchanging devices and the heated vaporising or nebulising humidifiers. Finally a study is presented which documents the exact level of moisture delivered to patients by the cascade water bath humidifier.

Cellular glutathione as a protective agent against 4-hydroperoxycyclophosphamide cytotoxicity in K-562 cells

Exposure of cells of the K-562 erythroleukemia cell line to 4-hydroperoxycyclophosphamide (4-HC), an analog of activated cyclophosphamide, causes a concentration-dependent inhibition of in vitro colony formation by these cells. For investigation of the role of glutathione (GSH) in the metabolism of 4-HC, GSH levels of K-562 cells were modulated by exposing the cells to buthionine sulfoximine (BSO), a specific inhibitor of GSH synthesis, and/or to GSH ethyl esters. Both the mono- and diethyl esters of GSH were synthesized in our laboratories and their identities were determined by chromatographic methods and fast-atom-bombardment mass spectrometry. An HPLC method including electrochemical detection used for thiol determination was applied for the measurement of GSH esters. Incubation of the cells with BSO depleted GSH levels to approximately 11% of control values and potentiated the cytotoxicity of 4-HC. By contrast, exposure to GSH esters approximately doubled GSH levels and protected the cells against the toxicity of 4-HC. Moreover, when cellular GSH levels were first depleted by BSO exposure and then replenished by incubation with GSH esters, the BSO-associated potentiation of 4-HC cytotoxicity was abolished. The work described herein extends the application of an HPLC method used for thiol determination to the measurement of GSH ethyl esters. In addition, it established that GSH acts as a competitive protecting agent against the in vitro toxicity of 4-HC in the K-562 cell line.

Showing where the money goes. Cost-effective care in ICU

As resource management is implemented around the country, nurses are being asked to become more cost conscious, while maintaining standards of patient care. Staff in one ICU were introduced to the effects of their care on the unit budget.