Radiotherapy-specific interprofessional learning through simulation

IntroductionInterprofessional learning (IPL) is a vital aspect of training in radiation oncology professions, yet is rarely delivered to those professionals who work most closely together in clinical practice. Scenario-based learning using simulation facilities provides a unique opportunity to facilitate this learning and this project aimed to determine the impact and value of this initiative.MethodsSmall groups comprising post-graduate diploma pre-registration therapeutic radiographers, medical physics trainees and radiation oncology registrars were challenged with 4 plausible and challenging radiotherapy scenarios within an academic simulation centre. Pre- and post-event completion of the “Readiness for Interprofessional Learning Scale” measured impact and a Likert-style survey gathered feedback from participants.ResultsThe session increased participants' teamwork and collaboration skills as well as strengthening professional identities. Participants reported high levels of enjoyment related to collaborative working, communication and observing other professionals deploying their technical skills and specialist knowledge.ConclusionAlthough beneficial, simulated scenarios offering equal opportunities for engagement across the professions are challenging to plan and timetabling issues between the 3 groups present significant difficulties. The safe environment and unique opportunity for these groups to learn together was particularly well received and future oncology-specific simulated scenario sessions are planned with larger cohorts.Implications for practiceSimulated scenario training can be used to improve team working across the radiotherapy interprofessional team and may have wider use in other specialist interdisciplinary team development.     

The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis

Background

A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty.

Pulmonary histiocytosis X: comparison of radiographic and CT findings

The authors retrospectively evaluated radiographs, computed tomographic (CT) scans, and results of pulmonary function tests (when available) for 17 patients with biopsy-proved pulmonary histiocytosis X. In 11 patients, high-resolution CT was used. In 12 patients, CT demonstrated cystic air spaces, usually less than 10 mm in diameter. In three of these 12, cysts were the only abnormality, but in six others, nodules (usually less than 5 mm in diameter) were also present. Two patients had only nodules and one, only emphysema. CT showed that many lesions that appeared reticular on plain radiographs were actually cysts. CT showed no central or peripheral concentration of lesions, but it did reveal that many small nodules were distributed in the centers of secondary lobules around small airways. CT findings correlated better with the diffusing capacity (rho = -0.71) than did the plain radiographic findings (rho = -0.57). Thus, CT was better than radiography at showing the morphology and distribution of lung abnormalities.     

Accuracy of fetal echocardiography

The reliability of prenatal ultrasound (US) for the detection of structural heart defects was investigated in a consecutive population of patients referred for prenatal US. Twenty-eight of 49 fetuses (57%) shown to have one or more heart defects with physical examination or autopsy were found to have congenital heart disease with prenatal US. There were 66 cardiac defects in 49 fetuses, 33 of which were entirely or partly identified (50%). Defects correctly diagnosed included hypoplasia of either ventricle, common atrioventricular canal, tetralogy of Fallot, transposition of the great vessels, and Ebstein anomaly. Defects rarely diagnosed correctly included semilunar valve stenosis, total anomalous pulmonary venous drainage, coarctation of the aorta, pulmonic atresia, atrioseptal defect, and ventricular septal defect. Many types of heart defects can be diagnosed accurately with prenatal US in a general population of patients not at high risk for congenital heart disease. Some lesions, however, were difficult to detect.     

Pathways Linking Socioeconomic Status and Postpartum Smoking Relapse

Background

Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth.

Purpose

This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy.

Methods

Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach.

Results

Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models.

Conclusions

Findings have implications for future interventions that aim to reduce postpartum relapse.     

The effect of calcium ions on the activated partial thromboplastin time of heparinized plasma

The effect of calcium chloride (CaCl2) on the activated partial thromboplastin time (aPTT) of heparinized plasma was studied. The aPTT ratio (heparinized plasma:control plasma) increased as the CaCl2 concentration to recalcify the plasma was increased from 15 to 35 mmol/L CaCl2. Platelet-poor plasma from patients receiving intravenous heparin, and in vitro heparinized plasmas from either coumarinized patients or plasma depleted of the vitamin K-dependent factors, displayed the calcium-dependent increase in the aPTT ratio. The magnitude of the calcium-dependent change in the aPTT ratio was similar for the three partial thromboplastins studied. Heparinized blood collected in 3.2% and 3.8% citrate demonstrated the calcium-dependent increase in the aPTT ratio. The authors have also studied the effect of the divalent cations (Ca+2, Mg+2, Zn+2, and Sr+2) on the anti-Factor Xa activity of heparin to determine whether the calcium-dependent increase in the aPTT was due to an increase in the anti-Factor Xa activity. The anti-Factor Xa activity of heparin was measured using chromogenic substrate S-2251, purified Factor Xa, and excess antithrombin III. The anti-Factor Xa activity of heparinized plasma increased 2.4-2.8-fold as the divalent cation concentration was increased from 0-5 mmol/L. Similar results were obtained using purified bovine Factor Xa, antithrombin III, and heparin in the absence of plasma. These results suggest that divalent cations play an important role in modulating heparin's anticoagulant activity in vitro. In addition, the CaCl2 concentration used to recalcify plasma is an important variable that modifies heparin sensitivity of the aPTT. Furthermore, divalent cations play an important role in regulating the anti-Factor Xa activity of heparin in vitro.     

Migration Patterns for Revision Total Hip Arthroplasty in the United States as Reported in the American Joint Replacement Registry

BackgroundRevision total hip arthroplasty (revTHA) is associated with higher rates of complications and greater costs than primary procedures. The aim of this study is to evaluate the effect of hospital size, teaching status, and indication for revTHA, on migration patterns in patients older than 65 years old.MethodsAll THAs and revTHAs reported to the American Joint Replacement Registry from 2012 to 2018 were included and merged with the Centers for Medicare and Medicaid Services database. Migration rate was defined as a patient’s THA and revTHA procedures that were performed at separate institutions by different surgeons. Migratory patterns were recorded based on hospital size, teaching status, and indication for revTHA. Analyses were performed by statisticians.ResultsThe number of linked procedures included was 11,906. Migration rates in revTHA due to infection were higher for small hospitals than large hospitals (46.6% vs 28.6%, P < .0001). Migration rates were higher comparing non-teaching with teaching hospitals (55% vs 34%, P < .0001). This difference was significant for periprosthetic fractures (70.6% vs 37.2%, P = .005), instability (56.5% vs 35.5%, P = .04), and mechanical complications (88.9% vs 34.7%, P < .05). Most patients migrated to medium or large hospitals rather than small hospitals (89% vs 11%, P < .0001) and to teaching rather than non-teaching institutions (82% vs 18%, P < .0001).ConclusionHospital size and teaching status significantly affected migration patterns for revTHA. Migration rates were significantly higher in small non-teaching hospitals in revTHA due to infection, periprosthetic fracture, instability, and mechanical complications. Over 80% of patients migrated to larger teaching hospitals.     

Mental disorders in female prisoners

OBJECTIVE: The objective of the study was to investigate the rates of mental disorder among women in prison in Victoria, and to compare with community rates. DESIGN: A midnight census of all women in prison in Victoria was undertaken. Respondents were interviewed with a version of the Composite International Diagnostic Interview (CIDI), an adapted version of the Personality Diagnostic Questionnaire (PDQ-4+) and a demographics questionnaire. MAIN OUTCOME MEASURES: Twelve-month prevalence rates of ICD-10 mental disorders including depressive disorders, anxiety disorders and drug-related disorders were examined. Prevalence of personality disorders was also investigated. RESULTS: Eighty-four per cent of the female prisoners interviewed met the criteria for a mental disorder (including substance harmful use/dependence) in the year prior to interview. This rate was reduced to 66% when drug-related disorders were excluded. Forty-three per cent of subjects were identified as cases on a personality disorder screener. For all disorders, (except obsessive-compulsive disorder and alcohol harmful use) women in prison had a significantly greater likelihood of having met the 12-month diagnostic criteria when compared to women in the community. The most prevalent disorders among the female prisoners were: drug use disorder (57%), major depression (44%), Posttraumatic stress disorder (36%), and personality disorders. Almost a quarter (24%) of respondents were identified as a 'case' on the psychosis screen. CONCLUSIONS: In the present study female prisoners had significantly higher rates of the mental disorders investigated (with the exceptions of OCD and alcohol harmful use) when compared with women in the community. The pattern of disorder found among female prisoners is consistent with the abuse literature, suggesting that histories of abuse among the prison population may account for part of the discrepancy. These results highlight the need for improved assessment and treatment resources to meet the demands of this population.     

The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient

Background

Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.

Methods

Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.

Conclusions

The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.