Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England

AIMS

To investigate the relationship between high diabetes-related lower limb amputation incidence and foot care services in the South-West region of England.

METHODS

The introduction of 10 key elements of foot care service provision in one area of the South-West resulted in stabilization of foot ulcer incidence and sustained reduction in amputation incidence from 2007. Services introduced included administrative support, standardized general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit. Peer reviews of the region's diabetes foot care services were undertaken to assess delivery of these service provisions and compare this with major amputation incidence in other regions with data provided by Yorkshire and Humber Public Health Observatory Hospital Episode Statistics. Recommendations were made to improve service provision. In 2015 changes in service provision and amputation incidence were reviewed.

RESULTS

Initial reviews in 2013 showed that the 3-year diabetes-related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services (P=0.0024, adjusted R² =0.51). Repeat reviews in 2015 found that two or more foot care service improvements were reported by six diabetes foot care providers, with improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012-2015 and in the year 2015 only (P ≤0.0012, adjusted R² =0.56, and P= 0.0005, R² =0.62, respectively).

CONCLUSIONS

Major diabetes-related lower limb amputation incidence is significantly inversely correlated with foot care services provision. Introduction of more effective service provision resulted in significant reductions in major amputation incidence within 2 years. Failure to improve unsatisfactory service provision resulted in continued high amputation incidence.

5 years review of periocular basal cell carcinoma and proposed follow-up protocol

AIM

(1) To investigate the recurrence of periocular basal cell carcinoma (BCC) reported as completely excised on histology. (2) To identify risks associated with recurrence. (3) To recommend a rational follow-up protocol.

METHODS

This is a cohort study by case note review of consecutive patients undergoing excision of periocular BCC between 2000 and 2006 at University Hospitals of Leicester. All lesions were excised with 3 mm clinical margin and the defect reconstructed only after the excision margin was declared clear.

RESULTS

A total of 413 episodes of surgical excision were recorded for 270 patients over the 7-year period of 2000-2006. All of them have 5 years follow-up. Mean age 73.7 (±12.5). In all, 67% were nodular BCC and 45.4% located in the lower eyelid. The main outcome measure was the recurrence rate. None of the patients with primary nodular BCC suffered recurrence. The recurrence rate for primary morphoeaform BCC following complete excision is 3.8%. In total, 8.1% of patients had several lesions simultaneously whereas 7.8% patients had BCC in multiple locations subsequently (metachronous). Three patients who had previously recurrent BCC (rBCC) treated elsewhere or not using this method had orbital/lacrimal drainage system involvement requiring exenteration.

CONCLUSION

We recommend that patients with a single, completely excised primary solid or nodular BCC can be discharged after one 6-monthly review, although they should be instructed to monitor for the development of further lesions. The incidence of recurrence for primary morphoeaform BCC is 3.8% and for rBCC is 3.6% over 5 years and these patients should stay under review for this period.

BRAF, NRAS and HRAS mutations in spitzoid tumours and their possible pathogenetic significance

BACKGROUND

The relationships between so-called spitzoid tumours have proven difficult to understand.

OBJECTIVES

To address three questions: does spitzoid tumour morphological similarity reflect molecular similarity? Does Spitz naevus progress into spitzoid melanoma? Are ambiguous spitzoid tumours genuine entities?

METHODS

BRAF, NRAS and HRAS mutations were analysed using single-strand conformational polymorphism analysis and sequencing.

RESULTS

Both Spitz naevi and spitzoid melanoma had a lower combined BRAF and NRAS mutation frequency compared with common acquired naevi (P = 0.0001) and common forms of melanoma (P = 0.0072), respectively. To look for evidence of progression from Spitz naevi to spitzoid melanoma, HRAS was analysed in 21 spitzoid melanomas, with no mutations identified. The binomial probability of this was 0.03 based on an assumption of a 15% mutation frequency in Spitz naevi with unbiased progression. Under these assumptions, HRAS mutations must be rare/absent in spitzoid melanoma. Thus, Spitz naevi seem unlikely to progress into spitzoid melanoma, implying that ambiguous spitzoid tumours cannot be intermediate degrees of progression. In addition, the data suggest that HRAS mutation is a potential marker of benign behaviour, in support of which none of three HRAS mutant spitzoid cases metastasized.

CONCLUSIONS

First, the morphological similarity of spitzoid tumours reflects an underlying molecular similarity, namely a relative lack of dependence on BRAF/NRAS mutations. Second, Spitz naevi do not appear to progress into spitzoid melanoma, and consequently ambiguous spitzoid tumours are likely to be unclassifiable Spitz naevi or spitzoid melanoma rather than genuine entities. Third, HRAS mutation may be a marker of Spitz naevus, raising the possibility that other molecular markers for discriminating Spitz naevi from spitzoid melanoma can be discovered.

Vincristine treatment revealing asymptomatic hereditary motor sensory neuropathy type 1A

A 5 year old boy developed severe weakness after receiving vincristine for treatment of acute lymphoblastic leukaemia. Although weakness improved after the discontinuation of vincristine, other symptoms suggestive of a neuropathy persisted. Neurophysiological and genetic analysis at age 8 years indicated that vincristine had induced symptoms of a hereditary sensory motor neuropathy type 1A, which had previously been asymptomatic; his genetically affected mother was also asymptomatic.

Substitution in nursing practice: clinical, management and research implications

The introduction of market forces into health care delivery systems has had a number of important influences on the roles nurses perform. There have been increasing efforts to find alternative and more cost-effective ways of delivering care. One facet of this situation has been the examination of the roles and responsibilities of registered nurses (RNs) with the view of exploring different ways of using professional skills and determining if RN services are always required. One result of this has been the increased use of unlicensed personnel. The substitution of professional nursing staff by unlicensed personnel has become a major concern for practitioner, manager and client alike. This paper reviews some of the concepts of economic substitution as well as the assumptions advanced for the use of unlicensed personnel in clinical areas as a substitute for nursing services. While there has been increased use of unlicensed staff, the evaluation of clinical outcomes has been poor. This paper reviews primarily the hospital-based evidence about the impact of using unlicensed personnel in practice, and suggests there are methodological problems with the research published to date. Findings suggest that substitute service providers generally 'do no harm'. By contrast, evidence is presented indicating the major contributions nurses make to client care when adopting advanced practice roles (acting as a substitute for other professionals).

Thyroliberin-induced changes in the fluorescence of a membrane probe in individual bovine anterior pituitary cells

1. We have investigated the use of TMA-DPH (1-[4-(trimethylammonio) phenyl]-6-phenylhexa-1,3,5-triene) as an indicator of exocytosis in individual bovine anterior pituitary cells using microfluorimetric imaging. 2. TMA-DPH was photolabile in artificial and cell membranes. In cells incubated in TMA-DPH the distribution of fluorescence depended both on the incubation time and the illumination schedule. If the dye was added while the cells were subjected to repeated cycles of 0.36 s light intermittent with 1-15 s dark, the fluorescence of the peripheral annulus and the central region of individual cells rose in parallel and reached a steady state within 200 s; the annulus was always brighter than the central region. However, using long intervening dark periods (200 s), the central region continued to incorporate dye after the annulus had reached a plateau. 3. When the cells were loaded with TMA-DPH using intermittent light with short dark periods, the dye washed out of the central region and the annulus in parallel when external dye was removed. However, if the cells had been loaded using long dark periods, the dye was washed out of the central region more slowly than from the annulus. 4. When cells were incubated in TMA-DPH in the dark for 1 min and then exposed to constant illumination in the presence of external dye, the fluorescence of the central region and the annulus both decayed in parallel to a new steady state. If the cells were incubated in TMA-DPH in the dark for 240 min the fluorescence from each region fell to a steady state but the falls were larger and were not in parallel. 5. We suggest that TMA-DPH fluorescence was derived from plasma membrane-associated and internalized dye and that the amount of fluorescence from the latter varied because TMA-DPH was photobleached. Thus, when illumination was interrupted by short dark intervals, annular fluorescence was high compared to central fluorescence because bleached dye in the plasma membrane was rapidly replaced by unbleached dye from the medium. However, long dark intervals permitted the dye to be internalized before it was bleached and fluorescence was therefore also present in central regions. 6. The total cell fluorescence, observed using 15 s dark intervals, was increased 5-40% (in single cells) in a dose-dependent fashion by addition of TRH (tripeptide thyrotrophin-releasing hormone; 1-200 nM).(ABSTRACT TRUNCATED AT 400 WORDS)

Complete heart block as a complication of varicella

A case of varicella myocarditis complicated by permanent complete heart block requiring treatment with a permanent pacemaker is presented. Antiviral therapy with Acyclovir from the moment of presentation had no effect on the course of the heart block, but may have induced recovery of myocardial contractile dysfunction.

Asymptomatic bacteriuria in healthy preterm babies

Urine was cultured from 51 healthy preterm babies. If the initial bag specimen grew more than 50 000 organisms/ml, a second bag specimen was cultured. After two positive bag specimens a suprapubic urine was cultured. Significant bacteriuria was excluded on the basis of one or two bag specimens in 90% of the babies. Suprapubic urine was sterile in a further 11 babies. Four babies with positive bag specimens were unfortunately not completely investigated: 2 had mixed growths and 2 had pure growths of 100 000 organisms/ml. As we and others consider that bacteriuria can only be diagnosed on a suprapubic sample of urine the incidence of proved infection in our series was zero. If both the babies with a pure growth of 100 000 organisms/ml had true bacteriuria, the incidence would rise to 1.3%. In view of the difficulties in obtaining clean urine samples in preterm babies and as the incidence of bacteriuria is so low, we do not recommend that healthy preterm babies be screened for bacteriuria.