An exploratory study with an adaptive continuous intravenous furosemide regimen in neonates treated with extracorporeal membrane oxygenation

Introduction  

The objective of the present study was to explore a continuous intravenous furosemide regimen that adapts to urine output in neonates treated with extracorporeal membrane oxygenation (ECMO).     

A statistical model for estimating donor postdonation platelet counts after plateletpheresis

BACKGROUND: To avoid the need, in serial apheresis donors, either to delay plateletpheresis until a predonation platelet count is completed or to obtain a postdonation count after each procedure, a statistical model has been developed to predict the postdonation platelet count from the donor predonation platelet count, weight, and hematocrit. STUDY DESIGN AND METHODS: Predonation and postdonation platelet counts were measured in two groups of approximately 100 consecutive donors (Group A to test the model and Group B to validate it), and the postdonation counts were calculated with the model. Using stepwise multiple linear regression from donor data, estimated postdonation platelet counts were found to be comparable to the postdonation platelet counts actually measured. RESULTS: Estimated postdonation platelet counts × 10(9) per L (mean +/− SD) for each group, respectively, were Group A, 195 +/− 35, versus actual platelet counts of 195 +/− 39 (p = 0.43), and Group B, 183 +/− 36, versus actual platelet counts of 189 +/− 34 (p = 0.14). Sensitivity and specificity, respectively, were Group A, 57 and 99 percent and Group B, 62 and 99 percent. CONCLUSION: For most serial apheresis donors, application of this predictor model should preclude the need to obtain an extra postdonation platelet count.     

Nurse middle managers contributions to patient‐centred care: A ‘managerial work’ analysis

Nurse middle managers are in an ideal position to facilitate patient‐centred care. However, their contribution is underexposed in literature due to difficulties to articulate this in practice. This paper explores how nurse middle managers contribute to patient‐centred care in hospitals. A combination of time‐use analysis and ethnographic work was used to disclose their contribution to patient‐centred care at a micro level. Sixteen nurse managers were shadowed for over 560 hours in four hospitals. Some nurse middle managers seldom contribute to patient‐centred care. Others are involved in direct patient care, but this does not result in patient‐centred practices. At one hospital, the nurse middle managers did contribute to patient‐centred care. Here balancing between “organizing work” and “caring work” is seen as a precondition for their patient‐centeredness. Other important themes are feedback mechanisms; place matters; with whom to talk and how to frame the issues at stake; and behavioral style. Both “hands‐on” and “heads‐on” caring work of nurse middle managers enhances their patient‐centeredness. This study is the first of its kind to obtain insight in the often difficult to articulate “doings” of nurse middle managers with regard to patient‐centred care through combining time‐use analysis with ethnographic work.     

Failure in the application of fragility fracture prevention guidelines

Introduction

The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services.

Methods

Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX^® risk calculations were applied to patients prior to their admission with a new hip fracture.

Results

Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX^® ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice.

Conclusions

In conjunction with NICE and NOGG recommendations, FRAX^® was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.     

Urban legends series: oral candidosis

Candida species (spp) are commensal yeast that can only instigate oral infection (oral candidosis – OC) when there is an underlying predisposing condition in the host. We investigated four controversial topics on OC: (i) How can a microbiological determination of OC be made as Candida spp. are commensal yeasts and not all of them form hyphae or pseudohyphae during infection? (ii) Is median rhomboid glossitis (MRG) a manifestation of candidal infection? (iii) Can candidal infection cause palate papillary hyperplasia (PPH)? (iv) What is the best therapeutic treatment for denture‐associated erythematous stomatitis (DAES)? Results from extensive literature searches, including a systematic review, suggested the following: (i) the diagnosis of OC merely on the basis of the presence of yeasts is an oversimplification of a complex process. No convincing evidence of a single test or method better able to discriminate the transition from candidal saprophytism to pathogenicity has been reported in the literature; (ii–iii) conclusive evidence of a direct aetiopathogenic relationship between MRG and PPH and candidal infection has not been found; and (iv) only limited evidence is available for any DAES treatment, thus making it impossible to make strong therapeutic recommendations.     

Audiovisual distraction reduces pain perception during aural microsuction

Introduction

Aural microsuction is a common ear, nose and throat procedure used in the outpatient setting. Some patients, however, find it difficult to tolerate owing to discomfort, pain or noise. This study evaluated the effect of audiovisual distraction on patients’ pain perception and overall satisfaction.

Methods

A prospective study was conducted for patients attending our aural care clinic requiring aural toileting of bilateral mastoid cavities over a three-month period. All microsuction was performed by a single clinical nurse specialist. Any patients with active infection were excluded. For each patient, during microsuction of one ear, they watched the procedure on a television screen while for the other ear they did not view the procedure. All patients received the same real time explanations during microsuction of both ears. After the procedure, each patient completed a visual analogue scale (VAS) to rate the pain they experienced for each ear, with and without access to the television screen. They also documented their preference and reasons why.

Results

A total of 37 patients were included in the study. The mean pain score for patients viewing the procedure was 2.43 compared with a mean of 3.48 for patients with no television view. This difference in patients’ pain perception was statistically lower in the group who observed the procedure on the television (p=0.003), consistent with the majority of patients reporting a preference to viewing their procedure (65%).

Conclusions

Audiovisual distraction significantly lowered patients’ VAS pain scores during aural microsuction. This simple intervention can therefore reduce patients’ perceived pain and help improve acceptance of this procedure.     

Challenging boundaries: an enhanced recovery programme for radical cystectomy

Introduction

The implementation of enhanced recovery programmes (ERPs) in colorectal surgery has seen improvements in the length of inpatient stay with no increase in complications. We investigated the role of ERP in radical cystectomy at our institution.

Methods

Prospective data were collected from 26 consecutive patients prior to the introduction of the ERP and 51 patients who underwent open radical cystectomy within an ERP. Individuals in the ERP cohort did not receive bowel preparation or nasogastric drainage but received preoperative carbohydrate drinks, perioperative epidural analgesia and immediate mobilisation on day 1. Primary outcome measures included duration of intensive care unit (ICU) stay and length of hospital stay. Secondary outcome measures included the time to the passage of flatus and faeces, and time to mobilisation. Other measures that were analysed included operation time and complications.

Results

Baseline characteristics for both groups were similar. The median length of hospital stay fell from 11.5 days to 10.4 days and the mean ICU stay dropped from 2.4 days to 1.0 days (p=0.01). Time to removal of nasogastric tube, and time to passage of flatus and faeces were significantly shorter in the ERP group, as was the time to full oral diet. Clavien complication rates and 30-day mortality rates were similar in both groups. There were no readmissions.

Conclusions

ERP in radical cystectomy is safe and not associated with any increase in complications or readmissions. It is associated with reductions in ICU stay, and could also reduce length of hospital stay and duration of postoperative ileus.     

An artificial intelligence deep learning model for identification of small bowel obstruction on plain abdominal radiographs

Objectives:Small bowel obstruction is a common surgical emergency which can lead to bowel necrosis, perforation and death. Plain abdominal X-rays are frequently used as a first-line test but the availability of immediate expert radiological review is variable. The aim was to investigate the feasibility of using a deep learning model for automated identification of small bowel obstruction.Methods:A total of 990 plain abdominal radiographs were collected, 445 with normal findings and 445 demonstrating small bowel obstruction. The images were labelled using the radiology reports, subsequent CT scans, surgical operation notes and enhanced radiological review. The data were used to develop a predictive model comprising an ensemble of five convolutional neural networks trained using transfer learning.Results:The performance of the model was excellent with an area under the receiver operator curve (AUC) of 0.961, corresponding to sensitivity and specificity of 91 and 93% respectively.Conclusion:Deep learning can be used to identify small bowel obstruction on plain radiographs with a high degree of accuracy. A system such as this could be used to alert clinicians to the presence of urgent findings with the potential for expedited clinical review and improved patient outcomes.Advances in knowledge:This paper describes a novel labelling method using composite clinical follow-up and demonstrates that ensemble models can be used effectively in medical imaging tasks. It also provides evidence that deep learning methods can be used to identify small bowel obstruction with high accuracy.     

SPG7 mutational screening in spastic paraplegia patients supports a dominant effect for some mutations and a pathogenic role for p.A510V

Sánchez‐Ferrero E, Coto E, Beetz C, Gámez J, Corao A, Díaz M, Esteban J, del Castillo E, Moris G, Infante J, Menéndez M, Pascual‐Pascual SI, López de Munaín A, Garcia‐Barcina MJ, Alvarez V on behalf of the Genetics of Spastic Paraplegia study group. SPG7 mutational screening in spastic paraplegia patients supports a dominant effect for some mutations and a pathogenic role for p.A510V. Mutations in the SPG7 gene were initially reported in patients with autosomal recessive hereditary spastic paraplegia (HSP). Recent works suggested a dominant effect for some SPG7 mutations. To characterize the SPG7 mutational spectrum in a large cohort of Spanish HSP patients, we sequenced the whole SPG7 gene in a total of 285 Spastic Paraplegia patients. Large gene rearrangements were also ascertained in some patients. We found a total of 14 SPG7 mutations (12 new) in 14 patients; 2 were large deletions. All the mutation carriers had an adult onset age but only five (35%) had a complicated phenotype. We identified a single mutation in 13 patients. Familial analysis suggested a dominant inheritance for one (p.Leu78*) of these mutations. Carriers of the rare p.A510V variant were significantly more frequent in patients vs healthy controls (3% vs 1%), suggesting a pathogenic role for this SPG7 variant. We reported a high frequency of patients with only one SPG7 mutation, and a putative pathogenic role for the p.A510V variant.