Simultaneous double-isotope autoradiographic measurement of local cerebral glucose metabolic rate and acid-base status in rat brain

We developed a double-isotope autoradiographic method for the simultaneous measurement of the local cerebral metabolic rate for glucose (1CMRG) and index of regional acid-base status (rABI) in single brain slices using [2-¹⁴C]deoxy-D-glucose (DG) and 5,5-dimethyl-[2-¹⁴C]oxazolidine-2,4, dione (DMO). After iv isotope administration, paper chromatography separates plasma DMO from DG activity using a methanol-methylene chloride solvent system. Initial tissue autoradiograms depict regional DMO plus DG and DG metabolite distribution. After 14 days in a well-ventilated hood, 97.5 ±0.5% of all DMO is lost from tissue sections by sublimation, and a second autoradiogram depicts DG plus DG metabolite distribution. Retention of brain lipids does not alter beta-particle self-absorption, avoiding problems associated with isotope extraction with solvents. Autoradiograms are digitized and converted to isotope-content images. The second autoradiogram is used for lCMRG computation. After subtracting the second regional isotope-content value from the first, the DMO content is obtained and used to compute rABI. Application of this method to normal animals yields expected values for lCMRG and rABI. This method is amenable to whole-slice digitization and creation of functional images of lCMRG and ABI followed by pixel-by-pixel correlations of the two variables, making this a potentially valuable tool for the investigation of the relationships between glucose metabolism and brain acid-base balance.     

Effectiveness of near-peer simulation for managing the acutely deteriorating patient among residents of an internal medicine junior residency programme

INTRODUCTIONNear-peer teaching is gaining popularity as a teaching modality, as it improves the learner’s understanding, is targeted at an appropriate level and promotes familiarisation. This study was initiated to evaluate the effectiveness of incorporating near-peer instruction into simulation-based training within a junior residency programme.METHODS42 first-year residents from an internal medicine junior residency programme were recruited. Participants underwent a simulation-based training programme conducted over five weeks. Each week involved either an emergency or acute clinical scenario. A structured questionnaire was administered prior to and after the course to compare participants’ perceived knowledge, experience and confidence in managing the clinical scenarios.RESULTSIn our study, 83% of participants agreed/strongly agreed that the scenarios were realistic. There were improvements in perceived knowledge, experience and confidence after the course. The greatest improvement was seen for experience (post-simulation: median 7.00 [interquartile range (IQR) 6.00‒8.00] vs. pre-simulation: median 5.00 [IQR 3.00–6.25]). 65% of participants were keen to help with future training.CONCLUSIONNear-peer simulation training was found to be a viable and valuable method of instruction for first-year residents for increasing experience, instilling confidence and improving perceived knowledge. Integration of such programmes within medical education curricula shows good promise of continuity, with many first-year residents inspired to organise subsequent sessions.     

Characteristics of Frequent Users of Emergency Medical Services in Singapore

Objectives: This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. Methods: All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n?=?243), with admission the primary outcome. Results: The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p?=?0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p?=?0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p?<?0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p?<?0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p?<?0.001). Many were picked up from public areas (45.5% vs. 19.6%, p?<?0.001), and had lower acuity triage scores at both EMS (p?<?0.001) and ED (p?=?0.001). They had lower admission rates (40.5% vs. 78.7%, p?<?0.001) and shorter length of stay (4.3 vs. 5.9 days, p?<?0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. Conclusion: Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission     

Outcomes of endodontically treated cracked teeth: a systematic review and meta-analysis

Clinical Oral Investigations - Systematic review analyzing the treatment outcomes of cracked teeth that received endodontic treatment is unavailable. The purpose of this study was to examine the...     

Training in mitral valve surgery need not affect early outcomes and midterm survival: a multicentre analysis

Objective: Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience. Methods: We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences. Results: Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p = 0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p = 0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p = 0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p = 0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 ± 52 vs 136 ± 50 min, p = 0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p = 0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p = 0.059). At 6 years, survival was similar (79 ± 1.4% vs 78 ± 4.0%, p = 0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 ± 58 vs 137 ± 52 min, p = 0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p > 0.99) and any mortality/morbidity (28% vs 24%, p = 0.52). Six-year survival between matched pairs was also similar (74 ± 7.2% vs 80 ± 4.4%, p = 0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and without propensity-score adjustment. Conclusions: Trainee outcomes are not inferior even when corrected for risk. This suggests that excellent operative training and supervision can be achieved in mitral valve surgery.     

Transanal irrigation improves quality of life in patients with low anterior resection syndrome

Aim Transanal irrigation (TAI) has been reported to be a cheap and effective treatment for the ‘anterior resection syndrome (ARS)’. This study aimed to evaluate its effect on the quality of life (QOL) of patients suffering from ARS. Method In a prospective study involving two colorectal centres, 14 patients (11 male; median age 68 (45–80) years) were included in the study. The median duration of ARS was 19 (9–48) months. The median number of defaecations was 8 (4–12)/day and 3 (2–5)/night. All patients were trained to perform TAI using the Peristeen? System under the guidance of a stoma nurse. Anal physiology was performed, quality of life (QOL) was estimated by the SF‐36 and Rockwood (ASCRS) questionnaires and continence by the Cleveland Incontinence Score. Results At the last follow up the median time of using TAI was 29 (15–46) months. The median volume of water used for the irrigation was 900 (500–1500) ml. There was a significant decrease in the number of defaecations during the day (baseline, 8 [4–12]; last follow up, 1 [1–2]) and at night (baseline, 3 [2–5]; last follow up, 0 [0–0]). The Cleveland Incontinence Score fell from 17 [15–20] (baseline) to 5 [4–9] (last follow up) and the mental component of the SF‐36 and all domains of the Rockwood QOL instrument improved. Conclusion Transanal irrigation is an effective treatment of anterior resection syndrome and results in a marked improvement of the continence score and QOL.