Introduction of a Day-Case Laparoscopic Cholecystectomy Service in the UK: A Critical Analysis of Factors Influencing Same-Day Discharge and Contact with Primary Care Providers

INTRODUCTION

The objective of this study was to determine the safety and acceptability of the implementation of a day-case laparoscopic cholecystectomy (LC) service in a large UK teaching hospital, and analyse factors influencing contact with primary care providers. Wide-spread introduction of day-case LC in the UK is a major target of healthcare providers. However, few centres have reported their experience. In the US, out-patient surgery for LC has been reported, though many groups have utilised 24-h observation units to facilitate discharge. Concerns remain amongst surgeons regarding the feasibility and acceptability of the introduction of day-case LC in the UK.

PATIENTS AND METHODS

Comprehensive care and operative data were prospectively collected on the first 106 consecutive day-case procedures in our hospital. Postoperative recovery was monitored by telephone questionnaire on days 2, 5 and 14, including complications, satisfaction and general practitioner consultation.

RESULTS

A total of 106 patients were admitted for day-case LC, of whom 84% were discharged on the day of surgery. Patient satisfaction rate was 94% in both the successful day-case and the admitted patients. Mean operation time was 62 min, with an average total stay on the day-care unit of 426 min. Training-grade surgeons performed 31% of operations. Both the re-admission rate after surgery and rate of conversion to open surgery were 2%. Advice from primary healthcare providers was sought by 33% of patients within the first 14 postoperative days.

CONCLUSIONS

Introduction of day-case LC in the UK is feasible and acceptable to patients. The potential burden to primary care providers needs further study.     

Mechanical properties of oxygenated red blood cells in sickle cell (HbSS) disease

Little data exist for the mechanical properties of individual irreversible or reversible sickle cells (ISC and RSC, respectively), nor is the process of ISC formation well understood. For oxygenated ISC and density-fractionated RSC, we have used micropipette techniques to measure cell surface area (SA) and volume (V), membrane shear elastic modulus (mu), time constant for viscoelastic shape recovery (tc), and hence to calculate membrane surface viscosity (eta = mu X tc). Volume loss associated with increasing cell density was accompanied by a proportionately smaller surface area decrease; SA/V ratio thus increased for denser cells, with ISC having the highest values. Membrane area loss by fragmentation must thus be accompanied by an accelerated decrease in cell volume. ISC had relatively rigid membranes (mu 130% above normal controls) and tc close to normal values, so that their effective membrane viscosity was more than double control. RSC had viscoelastic properties close to control, but showed wider variation between sickle cell donors and within samples. Measurements on density-separated RSC showed that, on average, mu was nearly constant, but that tc was longer for the densest cells, with their eta approaching ISC levels. A small subpopulation of RSC were found that had mu close to ISC values. Hypotonically swollen ISC (with internal hemoglobin concentration decreased to normal levels) retained their increased membrane stiffness but had markedly decreased tc, so that their eta approached normal values. The results show that elevated hemoglobin concentration influences the viscoelastic behavior of ISC and RSC, but that an irreversible change in membrane elasticity also occurs for ISC. These data suggest that ISC formation occurs via a two- stage process: (1) accelerated volume loss leading to increased cytoplasmic and effective membrane viscosity; (2) a sharp rise in membrane rigidity, presumably linked to membrane structural alteration.     

Frequency of human immunodeficiency virus (HIV) infection among contemporary anti-HIV-1 and anti-HIV-1/2 supplemental test- indeterminate blood donors. The Retrovirus Epidemiology Donor Study

Background: Follow-up studies from the mid-1980s showed that 1 to 5 percent of blood donors testing reactive in anti-human immunodeficiency virus type 1 (HIV-1) enzyme immunoassay (EIA) and testing indeterminate in Western blot were infected with HIV-1 and were in the process of seroconverting. The present study was conducted to establish the rate of HIV infection among contemporary anti-HIV-1/HIV type 2 (HIV-2) EIA- reactive, Western blot-indeterminate donors. Study Design and Methods: Donations (n = 607) with indeterminate HIV supplemental test results were identified by screening 3,021,342 donations given from November 1990 through August 1993 at five participating blood centers. Consenting donors were enrolled and samples taken 4 to 8 weeks after donation. Follow-up sera were tested by EIA and Western blot for anti- HIV-1 seroconversion and by type-specific peptide assays for antibodies to HIV-2 and HIV-1 subtype O. Peripheral blood mononuclear cells and/or plasma from the follow-up samples were tested for HIV-1 DNA and/or RNA by polymerase chain reaction. The rate of HIV-1 infection among Western blot-indeterminate donors was also estimated by multiplying the incidence rate of HIV-1 seroconversion in this donor population by the estimated duration of the EIA-reactive and Western blot-indeterminate window during seroconversion (8.5 days). Results: Supplemental test- indeterminate donors (n = 355) enrolled a median of 38 days after donation; 265 (75%) of these donors were identified as indeterminate after an anti-HIV-1/2 EIA-reactive donation. Enrolled and non-enrolled donors had similar distributions of demographic characteristics and band patterns. Follow-up samples from all 355 donors tested negative for HIV-1 in polymerase chain reaction. Follow-up sera tested Western blot-negative in 54 cases (15%) and Western blot-indeterminate in 299 (84%). Two follow-up sera (0.6%) were interpreted, according to manufacturer's package insert criteria, as Western blot positive with p24 and gp41 bands and/or gp120/160 bands; however, paired testing of index and follow-up sera from these two cases showed identical Western blot and EIA reactivity, and polymerase chain reaction was negative for HIV RNA and DNA, which ruled out HIV infection. The absence of HIV infection in 355 Western blot-indeterminate donors was consistent with our incidence-based model analysis, which yielded an estimate of one HIV-1 infection for every 215 Western blot-indeterminate donations (95% CI, 1/39-1/8333). Conclusion: Contemporary blood donors classified as indeterminate in supplemental HIV testing are infrequently infected with HIV. Donors whose follow-up samples test negative in anti-HIV-1/2 EIAs and negative or persistently indeterminate in Western blots should be considered eligible for reinstatement.     

Bilateral paediatric cataract surgery - outcomes of 298 children from Kinshasa,the Democratic Republic of the Congo

IntroductionThe leading cause of childhood blindness globally is paediatric cataract. Bilateral cataract surgery can help to improve visual performance and to diminish the burden of childhood blindness.ObjectiveTo report in a retrospective observational cohort study the long-term outcomes of 298 children who had bilateral cataract surgery with IOL implantation from 2001–2016 in Kinshasa.MethodsA standardized surgical treatment of paediatric cataract was practiced on 298 children. Patient''s follow-up, complications, and visual outcomes were recorded and analysed.ResultsThe mean age was 5.7 ± 4.3 years and males were predominant (64.9%). Most of children were living mainly in urban poorest areas (96.3%). Strabismus, nystagmus and microcornea were encountered in 20.1%, 25.1% and 8.7% of children, respectively. Using WHO criteria most of patients were classified as blind preoperatively and 81.9% of them had improved visual outcomes after surgery. Main reasons for reduced vision during follow-up were secondary cataract (5.7%), IOL decentration (1.2%), retinal detachment (1.2%), and secondary glaucoma (1.5%).ConclusionIn spite of the post conflict challenges, elimination of cataract blindness in children remains a priority. Children present at a late age for surgery and long term follow-up is poor. There is need for program strengthening in these areas.     

Facing the unacceptable: the emotional response to infertility

The emotional response to infertility, a major circumstantial loss, is frequently likened to bereavement. It is described as circumstantial because it does not happen to everyone, unlike a necessary loss, such as being weaned both nutritionally and emotionally. Another circumstantial loss is the death of someone, particularly if one has close emotional ties to this person. It is not surprising to find that a conceptual framework, developed to understand mourning a death, is used to make sense of the reaction to infertility; but this framework alone is not sufficient. The understanding of stigmatization and learned helplessness also assist helping the infertile to come to terms with their loss. It is suggested that the pronatalist tendency of British society results in denial of the stressful nature of infertility which compounds the difficulty in the loss being recognized and makes it exceptionally difficult to grieve.      

贺普丁治疗慢性乙型肝炎的成本-效果分析

该研究运用中国上海慢性乙型肝炎与肝硬化病人的年总成本和直接医疗成本以及葛兰素史克公司NUCB 3009，NUCB 3010，NUCA3010临床研究中的血清转换率与肝硬化转归率，分析了贺普丁治疗1年后的四种成本节约模型。结果显示：模型Ⅰ采用贺普丁治疗所有慢性乙型肝炎病人一年后，每一病人节省的卫生保健成本可抵消46．3％贺普丁年治疗成本；模型Ⅱ采用贺普丁治疗ALT水平高于2倍正常值的慢性乙型肝炎病人，每一病人节省的卫生保健成本可抵消90．8％贺普丁年治疗成本；模型Ⅲ采用贺普丁治疗ALT水平高于2倍正常值的慢性乙型肝炎，每一病人节省的卫生保健成本可抵消62．2％贺普丁年直接医疗成本；模型Ⅳ采用贺普丁治疗亚州ALT水平高于2倍正常值的慢性乙型肝炎病人，除可抵消贺普丁年治疗成本外，每一病人还可净节省426．9元卫生保健成本。由此可见，贺普丁治疗慢性乙型肝炎1年后初步看出成本节省倾向。     

Platelet serotonin transporter in coeliac disease

Abstract We investigated a peripheral serotonergic marker, i.e. platelet tritiated imipramine (³H-IMI) binding sites, which are part of the 5-HT transporter complex similar to that present in the brain, in 20 patients affected by coeliac disease (CD), as compared with 20 healthy controls. Platelet membranes and ³H-IMI binding were carried out according to a standardized protocol. The results showed that coeliac patients had significantly lower H-IMI binding sites than controls. This finding would suggest the presence of a dysfunction at the level of the 5-HT transporter that might underline the psychic disturbances frequently observed in coeliac patients.     

前庭神经切断术中内镜技术的应用

目的　探讨经乙状窦后径路行前庭神经切断术 (vestibularneurotomy ,VNT)控制梅尼埃病眩晕症状中 ,辅助应用内镜微创技术的方法及其减轻术中脑组织压迫和减少术后并发症发生率的价值和意义。方法　临床观察乙状窦后径路常规VNT( 12例 )与辅助应用内镜技术VNT( 9例 )的 2组手术患者手术前后症状控制效果、面神经功能及其听觉和前庭生理功能变化结果。结果　常规VNT组患者术后有 2例发生脑水肿 ,需行脱水、降压等处理 ;平均听阈上升>15dB者 2例 ;平衡功能代偿所需时间平均为 ( 2 9.0 0± 9.60 )天。辅助应用内镜的VNT组术后平均听阈上升 >15dB者 2例 ;平衡功能代偿所需时间平均为 ( 2 8.5 6± 7.91)天。 2组术后均未出现面瘫等并发症 ;术后 2年内再发作眩晕 ,常规手术组有 2例 (分别发作 1次和 4次 ) ,内镜手术组有 1例 (发作 2次 )。结论　经乙状窦后径路行VNT是目前普遍采用的一种较为方便、安全的控制或消除梅尼埃病患者眩晕症状手术方法 ,同时能保存听觉功能和面神经完整性 ;手术中辅助应用内镜技术 ,使该手术操作成为微创和安全 ,可有效地减轻对脑组织的压迫和减少术后脑水肿发生 ,未出任何由此而导致的并发症