National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Antisepsis of the skin before spinal surgery with povidone iodine-alcohol followed by chlorhexidine gluconate-alcohol versus povidone iodine-alcohol applied twice for the prevention of contamination of the wound by bacteria: a randomised controlled trial

AIMS

The aim of this study was to determine whether the sequential application of povidone iodine-alcohol (PVI) followed by chlorhexidine gluconate-alcohol (CHG) would reduce surgical wound contamination to a greater extent than PVI applied twice in patients undergoing spinal surgery.

PATIENTS AND METHODS

A single-centre, interventional, two arm, parallel group randomised controlled trial was undertaken, involving 407 patients who underwent elective spinal surgery. For 203 patients, the skin was disinfected before surgery using PVI (10% [w/w (1% w/w available iodine)] in 95% industrial denatured alcohol, povidone iodine; Videne Alcoholic Tincture) twice, and for 204 patients using PVI once followed by CHG (2% [w/v] chlorhexidine gluconate in 70% [v/v] isopropyl alcohol; Chloraprep with tint). The primary outcome measure was contamination of the wound determined by aerobic and anaerobic bacterial growth from samples taken after disinfection.

RESULTS

The detection of viable bacteria in any one of the samples taken after disinfection (culture-positive) was significantly lower in the group treated with both PVI and CHG than in the group treated with PVI alone (59 (29.1%) versus 85 (41.7%), p = 0.009; odds ratio 0.574; 95% confidence interval, 0.380 to 0.866).

CONCLUSIONS

Antisepsis of the skin with the sequential application of PVI and CHG more effectively reduces the contamination of a surgical wound than PVI alone. Cite this article: Bone Joint J 2017;99-B:1354-65.

Socioeconomic inequalities in neonatal intensive care admission rates

OBJECTIVE

To examine socioeconomic inequalities in neonatal intensive care (NIC) admissions relating to preterm birth, intrauterine growth restriction (IUGR), multiple births and other conditions.

METHODS

Retrospective review of all NIC admissions from 1996 to 2001 throughout a geographically defined region. Area deprivation indices were grouped into quintiles from least (1) to most (5) deprived. Admissions were classified by predefined hierarchical criteria.

RESULTS

The rate of admissions was 31.4 per 1000 births. There was a J-shaped relation with socioeconomic group (28.1 NIC admissions per 1000 in quintile 1, 34.0 in quintile 5 and below 28 in the other quintiles). The most deprived areas had a rate 19% above the regional average. The relation with socioeconomic group differed significantly according to primary reason for admission. The rates of admissions with significant prematurity (34% of all admissions) and IUGR as primary reason were highest in quintile 5 (18% and 41% above the regional average, respectively). This contrasted with the rate of admission for multiple birth which was highest in quintile 1 (45% above average). These differences provided the main explanation for the J-shaped overall curve.

CONCLUSIONS

Measures to alleviate deprivation and to improve the preterm birth and IUGR rates in deprived groups would have the greatest potential to reduce inequality in need for NIC admission. Efforts to achieve targets for reduction in infant mortality need to take account of the different effects of socioeconomic inequalities for different conditions and groups of infants.

A phase I study of nelfinavir, an FDA approved HIV protease inhibitor, in adults with refractory solid tumors

2583

Background: Preclinical studies show that HIV protease inhibitors such as nelfinavir (N) have dose- dependent, pleiotropic anti-cancer activities. However, the maximum tolerated dose (MTD) of N has not been established in humans. Methods: Pts were treated on a modified Fibonacci dose-escalation scheme with a twice daily oral dose of N starting at the FDA approved dose of 1250 mg bid on a 21-day cycle. Patients with refractory solid tumors, ECOG PS < 2, and adequate organ function were eligible. Therapy continued until MTD or disease progression. PBMCs as well as optional tumor biopsies were collected for Akt inhibition and expression of markers of ER stress (ERS). Results: 14 patients have been enrolled. Of the 11 evaluable for toxicity, there were 10 men, 10 Caucasians, and 1 African American (median age 63 years (range 24 - 77)). Tumor types included NSCLC (3), SCLC (2), thyroid (3), pancreatic (1), colorectal (1), and renal cell (1). Median number of prior systemic therapies was 2 (range, 1 - 6). There have been no grade 4 or 5 toxicities. We observed 12 grade 3 toxicities that were asymptomatic laboratory abnormalities. The most prevalent toxicities were ALT transaminitis (5 events in 8 subjects in dose level ((DL) 2, 3, 4), AST transaminitis (4 events in 8 subjects in DL 2, 4), diarrhea (8 events in 5 subjects in DL 2, 3, 4), and hyperglycemia (5 events in 5 subjects in DL 1, 2, 3). Enrollment continues at DL 4 (3125 mg twice daily). There have been no responses. Two subjects with lung cancer had stable disease for 9 weeks. Pharmacokinetic data revealed median Cmax of 2,461.5 ng/ml (DL1), 11,809 ng/ml (DL2), 11,576 ng/ml (DL3), and 11,986 ng/ml (DL4), occurring 4 hours after an oral dose. There was no relationship between the drug levels and albumin levels. Akt inhibition and increased expression of markers of ERS and apoptosis have been observed in PBMCs from week 1 in the majority of patients at every dose level, but there was no correlation with clinical response. Conclusions: N appears to be well tolerated in subjects with advanced solid tumors at 2.5 times the FDA approved dose. AUC data suggest that there may be only minimal increases in plasma drug concentrations with doses above 1875 mg twice daily.

No significant financial relationships to disclose.

Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003)

AIM

To update dietetic guidelines summarizing the systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention).

METHODS

The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to November 2002 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomised controlled trials relating to diet and secondary prevention of CVD. Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review. The quality and results of each review were discussed and summarized in a meeting of the whole group.

RESULTS

Providing evidence-based dietary information (including increasing omega-3 fat intake) to all people who have had a myocardial infarction will save more lives than concentrating dietary advice on just those in need of weight loss or lipid lowering. The practice of prioritizing dietetic time in secondary prevention to those with raised lipids is out of date since the advent of statin therapy. However, effective dietary advice for those with angina, stroke, peripheral vascular disease or heart failure is less clear.

CONCLUSION

There is good systematic review evidence that dietary advice to those with coronary heart disease can reduce mortality and morbidity as well as modify some risk factors. Dietary advice that does this most effectively should be prioritized.

Prognostic Factors in Ossiculoplasty: A Statistical Staging System

OBJECTIVE

To determine factors that predict hearing results using a standard prosthesis system.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

All patients undergoing ossiculoplasty with the Dornhoffer HAPEX partial and total ossicular replacement prostheses (PORP and TORP) from February 1995 to May 1999 who had documented postoperative follow-up and no congenital atresia or stapes fixation. A total of 185 patients (200 ears), 105 men and 80 women, were evaluated.

INTERVENTIONS

Ossiculoplasty with the Dornhoffer prostheses.

MAIN OUTCOME MEASURES

Hearing results using a four-frequency pure-tone average air-bone gap (PTA-ABG). Multivariate statistical analysis determined the effect of mucosal status, ossicular chain status, and type of reconstruction techniques on hearing.

RESULTS

The PTA-ABGs were 13.4+/-8.1 dB and 14.0+/-8.4 dB for the PORPs (n = 114) and TORPs (n = 86), respectively, which was not statistically different. When the malleus handle was present (n = 126), the PTA-ABG was 11.6+/-6.2 dB, compared with 16.9+/-10.1 dB when it was absent (n = 74), which was statistically significant (p < 0.05). Mucosal fibrosis, drainage, revision ear surgery, and type of surgical procedure had a significant detrimental impact on hearing. The type of pathologic process (perforation vs. cholesteatoma) had no significant impact on hearing results.

CONCLUSIONS

The revised staging system, the Ossiculoplasty Outcome Parameter Staging Index, more adequately predicts hearing outcome in this series of 200 cases.

Genetic variation and inferences about perceived taste intensity in mice and men

The study of genetic variation in taste produces parallels between mice and men. In mice, genetic variation across strains has been documented with psychophysical and anatomical measures as well as with recordings from whole nerves. In humans, the variation has been documented with psychophysical and anatomical measures. Whole-nerve recordings from animals and psychophysical ratings of perceived intensities from human subjects have a similar logical limitation: absolute comparisons across individuals require a standard stimulus that can be assumed equally intense to all. Comparisons across whole-nerve recordings are aided by single-fiber recordings. Comparisons across psychophysical ratings of perceived intensity have been aided by recent advances in methodology; these advances now reveal that the magnitude of genetic variation in human subjects is larger than previously suspected. In females, hormones further contribute to variation in taste. There is evidence that the ability to taste (particularly bitter) cycles with hormones in women of child-bearing age, rises to a maximum early in pregnancy and declines after menopause. Taste affects food preferences, which in turn affect dietary behavior and thus disease risks. Valid assessment of taste variation now permits measurement of the impact of taste variation on health. Advances in psychophysical methodology were essential to understanding genetic variation in taste. In turn, the association of perceived taste intensities with tongue anatomy now provides a new tool for psychophysics. The ability of a psychophysical scale to provide across-subject comparisons can be assessed through its ability to show the fungiform papillae density-taste association.

Nutrients and the surgical patient: current and potential therapeutic applications to clinical practice

Malnutrition and weight loss are associated with alterations in cellular physiology and organ function, which are of importance for the surgical patient. Pre-operative weight loss can lead to increased post-operative morbidity and mortality. This review addresses the following questions: (a) what effects can key nutrients have on the immune system, metabolism and wound healing in man, and which may be of potential benefit to the surgical patient? (b) can clinically beneficial effects be demonstrated if patients receive nutritional supplementation with one of these key nutrients? (c) what effects does nutritional supplementation with combinations of these nutrients have on clinical outcomes?

5-HT receptor knockout mice: pharmacological tools or models of psychiatric disorders

The molecular diversity of cloned serotonin receptor subtypes in the brain makes it difficult to understand the specific modulatory roles played by different receptors. In order to understand the role of the 5-HT1B receptor subtype in behavior and neuropsychiatric disorders, we have been studying genetic knockout mice lacking the 5-HT1B receptor. The 5-HT1B knockout mice show evidence of increased aggression and impulsivity, behavioral patterns that are also associated with reduced 5-HT function. They also show reduced or absent locomotor stimulation to some serotoninergic drugs, indicating that the locomotor effects of these drugs require the 5-HT1B receptor. However, in some cases, data obtained with knockout mice conflicts with the pharmacological data. The 5-HT1B receptor knockout mice show a phenotype of increased vulnerability to drugs of abuse such as cocaine. However, pharmacological studies suggest that 5-HT1B stimulation enhances the effects of cocaine, while 5-HT1B blockade can attenuate some of the effects of cocaine. Compensations that enhance dopamine function appear to be responsible for the drug-vulnerable phenotype of 5-HT1B receptor knockout mice. By studying these compensations and changes in neural function, we can learn more about the fundamental mechanisms underlying addiction. The 5-HT1B knockout mice should be considered a model for the disease state of vulnerability to drugs of abuse, rather than a direct pharmacological model of 5-HT1B receptor function.

The status of health technology assessment worldwide. Results of an international survey

Health technology assessment (HTA) has increasingly become a valuable tool to examine effectiveness, quality of care, patient outcomes, and cost-effectiveness of health care technologies. In 1994 and 1995, a survey was conducted to document the scope of worldwide HTA activities; 103 organizations from 24 countries responded. This paper summarizes the results of this international survey, including a description of each country's program, types of technologies assessed, methodologies used, and dissemination approaches. Results for Canada, the United States, and European and other countries are presented separately.

Effects of functional electrical stimulation on the joints of adolescents with spinal cord injury

Nineteen adolescent subjects with complete spinal cord injuries resulting in paraplegia or tetraplegia participated in a functional electrical stimulation (FES) program consisting of computerized, controlled exercise and/or weight bearing. The effects of stimulated exercise and standing/walking on the lower extremity joints were prospectively studied. Plain radiographs and MRIs were obtained prior to and following completion of the exercise and standing and walking stages. In addition, the joints of five subjects were studied with synovial biopsies, arthroscopy, and the analysis of serum and synovial fluid for a 550 000 dalton cartilage matrix glycoprotein (CMGP). Pre-exercise joint abnormalities secondary to the spinal cord injury improved following the stimulation program. None of the subjects developed Charcot joint changes. Upon standing with FES, one subject with poor hip coverage prior to participation developed hip subluxation which required surgical repair. No other detrimental clinical effects occurred in the lower extremity joints of subjects participating in an FES program over a 1-year period.

Examination of steroid-induced changes in LHRH gene transcription using 33P-and 35S-labeled probes specific for intron 2

We previously demonstrated that estrogen, but not progesterone, induces a increase in LHRH messenger RNA levels between 0800 and 1200 h in numerous of the rostral preoptic area/organum vasculosum of the lamina terminalis (rPOA/OVLT). To determine whether these changes are a result of increased transcription, we used in situ hybridization histochemistry to examine the temporal effects of estradiol (E2) and progesterone on cellular levels of intron-2-containing LHRH heteronuclear RNA transcripts. To make our method sufficiently sensitive to detect changes in these levels, we used 33P/35S probes to minimize both background and grain stacking over labeled cell nuclei. We found that levels of LHRH heteronuclear RNA rose between 0800 and 1000 in OVX, E2-treated rats, remained elevated at 1200 h, and declined by 1400 h. Progesterone did not affect these E2-induced changes. Our results suggest that an E2-dependent signal initiates LHRH gene transcription in neurons of the rPOA/OVLT hours before LHRH release begins and that progesterone does not affect this signal.

Haplotype analysis of MEN 2 mutations

Multiple endocrine neoplasia type 2 (MEN 2) is a dominantly inherited cancer syndrome which affects thyroid C cells, and with variable frequency, the adrenal medulla, parathyroid and enteric autonomic ganglia. The syndrome is due to germline mutation in the receptor tyrosine kinase gene, RET. We have recently shown an unexpected correlation between one particular RET mutation, cys634-->arg, and the probability of parathyroid involvement in families with MEN 2A. Here we use haplotype analysis in the families to show that this correlation is not explained by a single founder chromosome which carries both the cys634-->arg mutation and a separate allele conferring susceptibility to parathyroid abnormality, but is probably due to the cys634-->arg mutation itself. The results also indicate that new mutations to MEN 2 are not infrequent.

The feasibility and efficacy of early discharge planning initiated by the admitting department in two acute care hospitals

To determine the feasibility and efficacy of early discharge planning, initiated by admitting department personnel, a randomized, controlled trial was undertaken in 2 acute care, university-affiliated hospitals. The intervention tested was referral of patients by admitting personnel to nursing, social work, physiotherapy, occupational therapy, or dietary services for potential discharge planning. A 1-page, 65-item questionnaire was designed to identify patients for referral to the various allied health services. A copy of this was sent to the appropriate service, according to predefined criteria. The questionnaire took an average of 4 min to complete. The criteria used were highly predictive of length of stay, the most important being age, followed by living outside St. John's, admission within the previous 3 months, emergency admission, and being in need of community services. In Hospital A, the cases (n = 421) referred for early discharge planning had significantly shorter length of stay (Mantel-Cox, p = 0.03) than controls (n = 420), who were identical for all factors predictive of prolonged length of stay. The reduction in length of stay amounted to a mean of 0.8 d. In Hospital B (n = 758), the intervention was less effective because of a lower proportion of patients with factors associated with prolonged hospital stay and, perhaps, because of inadequate implementation of the program. We conclude that identification, by admitting department personnel, of patients who may benefit from early discharge planning is feasible. This process will reduce length of hospital stay, but its effectiveness is dependent on case mix variables and enthusiastic implementation of the program.

A multiple interval physical map of the pericentromeric region of human chromosome 10

Five intervals in the pericentromeric region of human chromosome 10 have been defined using a panel of somatic cell hybrids carrying portions of the chromosome. The map positions of twelve markers, consisting of four genes and eight anonymous DNA segments, have been localized by assignment to one of the five intervals. Several other markers could be placed in specific intervals by genetic linkage to assigned loci. When previously published data are incorporated, the summary map of the pericentromeric region encompasses thirty-two loci in bands 10p11.2-q11.2.

Swedes test capitalist waters in new health system reforms

While most Swedes say they're satisfied with their socialized health care system, problems ranging from long waits for surgery to a growing federal deficit have prompted health officials to inject some elements of American-style managed care and competition. Reforms include abandoning central primary care clinics in favor of allowing patients to choose a family physician; privatizing some hospitals; and separating health financing from delivery.