Athermal nerve sparing robot-assisted radical prostatectomy: initial experience with microporous polysaccharide hemospheres as a topical hemostatic agent

Purpose

Microporous polysaccharide hemospheres (MPH) are hemostatic beads engineered from plant starch to accelerate the natural clotting cascade. The purpose of this report is to detail our initial experience with MPH as a topical hemostatic agent during robot-assisted radical prostatectomy (RARP).

Methods

We examined a single surgeon series of 30 consecutive RARP’s dividing patients into MPH or non-MPH groups. The last ten procedures utilized the MPH, which were matched 1:2 to non-MPH procedures for comparison. Nerve-sparing procedures were performed when clinically indicated and all done athermally. All demographic data, length of operation, margin status, blood loss, change in hemoglobin, and need for blood transfusion were prospectively collected and analyzed.

Results

The baseline characteristics were the same. The post-operative decrease in hemoglobin was less in the MPH group (1.8 g/dL MPH group vs. 3.2 g/dL non-MPH). One patient in each group required a blood transfusion.

Conclusions

These preliminary findings support the role for MPH as a potential hemostatic agent during athermal nerve-sparing RARP.     

Rehabilitation of spelling in a participant with a graphemic buffer impairment: The role of orthographic neighbourhood in remediating the serial position effect

Graphemic Output Buffer (GOB) disorder is defined as difficulty with the serial output of a sequence of letters in the output stage of the spelling process. In their rehabilitation study with a GOB patient, Sage and Ellis (2006 Sage, K. and Ellis, A. W. 2006. Using orthographic neighbours to treat a case of graphemic buffer disorder. Aphasiology, 20: 851–870. (doi:10.1080/02687030600738945)[Taylor & Francis Online], [Web of Science ®] , [Google Scholar]) found that improvement on treated words generalised to untreated words from the same orthographic neighbourhoods as treated items, but not to other unrelated words. GOB patients frequently show a bow-shaped accuracy curve across letter positions, where letters at the middle positions are most error-prone. It may be that consistent letters at these middle letter positions across neighbourhoods modulate this effect. Spelling was treated using an Anagram and Copy Treatment (ACT) and generalisation to three untreated sets was examined: (1) neighbours of treated words with shared middle letters (e.g., clock–block), (2) neighbours with different medial position letters (e.g., clock–click), and (3) unrelated words (e.g., clock–puppy). Improvement was found for untreated neighbours with shared middle letters. There was no effect of training on the unrelated word set, and a negative impact on untreated neighbours with changed middle letters after the treatment. We attribute these results to top-down support from learned lexical representations, which facilitate spelling of untreated neighbours with shared middle letters but impede neighbours with changed middle letters. This latter result is attributed to interference from neighbours in the trained set strengthening competing letter representations at middle positions.     

Perioperative outcomes and costs of laparoscopic versus open inguinal hernia repair

Purpose

Studies comparing laparoscopic (LIHR) vs. open inguinal hernia repair (OIHR) have shown similar recurrence rates but have disagreed on perioperative outcomes and costs. The aim of this study is to compare laparoscopic vs. open outcomes and costs.

Methods

The National Surgical Quality Improvement Program (NSQIP) was used to compare durations of surgery, anesthesia time, and length of stay (LOS). The University HealthSystem Consortium (UHC) was used to review the cost and complications between approaches. Patients were matched on demographics, year of procedure and surgical approach between datasets for statistical analysis.

Results

A sample of 5468 patients undergoing OIHR (N = 4,693) or LIHR (N = 775) was selected from UHC from 2008–2011. An identical number of patients from NSQIP were matched to those from UHC resulting in a total of 10,936 records. LIHR patients had shorter duration of wait from admission to operation (p < 0.05). Conversely, LIHR patients had longer operating time (p < 0.05), duration of anesthesia (p < 0.05), and time in the operating room (p < 0.05).Overall complication rate was higher in open (3.1 vs. 1.8 %, p < 0.05). Cost favored open over LIHR ($4360 vs $5105). The cost discrepancy mainly stemmed from LIHR supplies ($1448 vs. $340; p < 0.05) and OR services ($1380 vs. $1080; p < 0.05).

Conclusion

This study demonstrates the LOS and perioperative outcomes were superior in the LIHR group; however, the overall cost was higher due to the supplies. Advancement in technology, surgeons’ skill level and preference of supplies are all factors in decreasing the overall cost of LIHR.

     

Vancomycin administration: the impact of multidisciplinary interventions

BACKGROUND: The clinical microbiology team observed that patients were not receiving all prescribed doses of vancomycin. Ward staff was confused about ordering and interpreting vancomycin therapeutic drug monitoring (TDM) levels. AIM: To audit the incidence of vancomycin dose omission. To implement a series of interventions to improve vancomycin dose administration, and to repeat the audit process to assess these interventions. METHODS: Three prospective audits were conducted to assess the impact of vancomycin TDM on administration of vancomycin. After the first audit, a number of changes in the TDM process were undertaken. After review of the second audit, a senior pharmacist coordinated ward-based pharmacists in assisting staff to interpret levels, and TDM interpretative charts were designed for drug charts. Following the third audit, feedback to hospital management and a plan for ongoing education were undertaken. RESULTS: There was a significant reduction in the number of vancomycin doses held inappropriately in the third (10% (78/782) of prescribed doses) when compared to the first audit (16% (161/1007) of doses) (p<0.01). Of doses that were held inappropriately, there was a significant decrease in doses held for no apparent reason in audit 3 (16% (27/170) of prescribed doses) when compared to audit 1 (25% (69/282) of doses) (p<0.05). CONCLUSIONS: The interventions resulted in a 37.5% reduction in inappropriately held vancomycin doses over a one-year period; 10% of doses are still being held inappropriately. This study highlights the difficulties in identifying barriers to change and changing healthcare worker behaviour.     

The representation of unseen objects in visual neglect: effects of view and object identity

We provide evidence for long-term priming based on view-specific representations of neglected stimuli. A patient with visual neglect, M.P., was asked to search for a target presented amongst other objects on a table. Subsequently recognition memory was tested for items that were identified and for items missed in search. Items that were missed were rejected more slowly than novel items in the recognition memory task, providing evidence for implicit processing (Experiment 1). Implicit memory for missed items was both item-specific (Experiment 2) and view-specific (Experiment 3), and it was eliminated when there were intervening activities lasting about 1 hour (Experiment 4). There was also an implicit memory for distractors in the search task, which was item- but not view-specific (Experiments 2 and 3) and it lasted for at least an hour, even with other intervening activities (Experiment 4). The data suggest that the representations of neglected stimuli may differ qualitatively from those of nonneglected items, with representations of neglected objects being both view-specific and vulnerable across extended retention intervals. The results support the argument that attention is needed in order to encode object representations that are robust to view transformations and temporal decay or interference.     

Maximizing the power of comparing single cases against a control sample: an argument, a program for making comparisons, and a worked example from the Pyramids and Palm Trees Test

In neuropsychological research, it is frequently necessary to compare the performance of a single case with that of a control sample. Recently, there has been a discussion about whether existing methods are adequate in preventing Type 1 errors due to increased variability in the single-case data (Crawford, Garthwaite, Howell, & Gray, 2004; Mitchell, Mycroft, & Kay, 2004; Mycroft, Mitchell, & Kay, 2002) and about the power of any comparisons. In this paper, we propose an extension of the modified t test introduced by Crawford and Howell (1998). We provide Monte Carlo simulations that show that it is possible to increase the power of the modified t test by retesting the single case. We also make available a computer program that implements the method introduced in this paper and that can be used by neuropsychologists to test for a difference between a single case and a control group. We apply our procedure to an example of a patient examined on the "Pyramids and Palm Trees" test.     

Safety and feasibility of concomitant surgery during holmium laser enucleation of the prostate (HoLEP)

Purpose

To determine the feasibility and outcomes associated with performing simultaneous surgical procedures during holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia and concomitant urologic conditions.

Methods

A retrospective review of patients that underwent a HoLEP was performed. Patients undergoing a concomitant procedure at the time of HoLEP were selected and stratified based on complexity of the secondary procedure (simple, intermediate, and complex) and matched based on age and prostate volume to patients undergoing only a HoLEP. Baseline characteristics, preoperative, operative, and postoperative outcomes were collected.

Results

A total of 372 HoLEPs were performed. Thirty-eight (10.2 %) patients underwent concomitant procedures at the time of HoLEP. Compared to the simple and intermediate secondary surgical procedures, the matched control group that underwent a HoLEP alone did not demonstrate statistically significant differences in the preoperative, operative, or postoperative outcomes. Patients with a complex secondary surgical procedure at the time of HoLEP had statistically significant differences in operative time (221 vs. 65 min, p = 0.007), estimated blood loss (92 vs. 33 mL, p = 0.012), catheter time (8.5 vs. 1 day, p = 0.041), and length of hospitalization (2 vs. 1 day, p = 0.032) compared to the control group.

Conclusions

Obstructive voiding symptoms secondary to BPH are common in older patients and may coincide with other concomitant lower urinary tract pathology that may require surgical intervention. Rather than staging surgical interventions, it appears that definitive treatment for BPH with HoLEP is safe and efficacious in those patients that also require secondary procedures.