Emergency surgery preoperative delays: realities, economic impacts and gains of a second emergency operating theatre.

INTRODUCTION: Time-to-theatre (TTT) is a key performance indicator of theatre efficiency and delayed TTT incurs significant costs and poor clinical outcomes. An increasing Irish population in conjunction with an ageing population puts increasing pressure on emergency surgical services across Ireland. We examined our institution's experience with introducing a second emergency theatre and semi-elective theatre lists for acute surgical patients. METHODS: A retrospective review of electronic, prospectively maintained databases was performed between 1 February 2018 and 31 January 2020. A cost analysis was conducted to assess the economic impact of delayed TTT. The cost-saving benefit of introducing a second emergency theatre and semi-elective Kaizen lists was then calculated and compared with 2012-2014 figures from our institution. RESULTS: In total, 6,679 procedures were performed. Overall mean TTT was 16h, 10h shorter than before the introduction of a second emergency theatre and Kaizen theatre lists (p < 0.001). Patients aged >65 years, who are historically a significantly disadvantaged group, had a shorter TTT following the introduction of a second emergency theatre. The economic advantage of a second emergency theatre resulted in a cost saving of €3,674,538 over 24 months. CONCLUSION: Investment in emergency surgical services resulted in more efficient access to emergency theatres. There was a reduction in out-of-hours operating across all specialties and across the more at-risk groups such as those over the age of 65, who had an overall reduction in TTT. This had significant financial benefits and likely reduced the clinical risk associated with delayed TTT and out-of-hours operating.

Characterising energy transfer upconversion in Nd-doped vanadates at elevated temperatures.

The Energy Transfer Upconversion (ETU) macroparameter is measured for Nd-doped GdVO4 and YVO4 samples at temperatures ranging from Room Temperature (RT) to 450K, by means of a simple and automated z-scan technique. Furthermore, the ground state absorption cross section into the 2H9/2 +4F5/2 energy levels is characterised for both crystals over the same range of temperatures. The 808 nm π-polarisation absorption cross section is found to decrease from (58.6 ± 0.2) pm2 to (30.9 ± 0.6) pm2 for Nd:YVO4 and (54.0 ± 0.3) pm2 to (25.7 ± 0.5) pm2 for Nd:GdVO4, from RT to 450K. Over the same range the ETU coefficient decreases from (3.2 ± 0.7) 10-16cm3/s to (1.8 ± 0.4 10-16cm3/s and (5.0 ± 0.5) 10-16cm3/s to (3.4±0.2) 10-16cm3/s for 0.6 at. % and 1 at. % Nd:YVO4 respectively, and (3.3 ± 0.5) 10-16cm3/s to (0.8 ± 0.2) 10-16cm3/s and (5.5 ± 0.5) 10-16cm3/s to (3.1 ± 0.3) 10-16cm3/s for 0.5 at.% and 1.1 at.% Nd:GdVO4.

Arthrodesis of Little Finger Distal Interphalangeal Joint in Flexion to Regain Sporting Ability.

BACKGROUND: Finger injuries are common in the sport of hurling. Injury to the little finger distal interphalangeal joint (DIPJ) often occurs when a high dropping ball impacts on the outstretched finger. The little finger contributes to approximately 15% of grip strength. Injury therefore results in reduced grip strength and may impair the ability of players to grip or catch a ball. METHODS: Six elite hurlers with post-traumatic arthritis of their non-dominant little finger DIPJ underwent arthrodesis in 30 degrees of flexion. Kirchner wires were inserted for up to 8 weeks to achieve fusion of the joint. Patients were evaluated after recovery using a dynamometer to assess grip strength, the DASH questionnaire and a sport specific questionnaire. RESULTS: All arthrodeses achieved bony union without complication. All patients reported a resolution of their pain and recovery in their ability to catch & retain a ball. Measurements of grip strengths were comparable between hands. DASH scores improved by up to 47 points. All scores were less than 5 at final follow-up. CONCLUSIONS: Grip strength decreases when fingers are immobilized in full extension. In sports that require catching or gripping a ball or a bat, arthrodesis of the DIP joint in flexion can improve grip strength and hand function. Fusion in 30 degrees of flexion for hurlers results in restoration of function and resolution of pain. Little finger DIPJ arthrodesis is a valid method of treating posttraumatic arthritis in ball and bat sports.

Amplification of a radially polarised beam in an Yb:YAG thin-slab.

The use of an Yb:YAG thin-slab architecture for amplification of a radially polarised beam at 1030 nm is investigated and shown to be a promising route for power scaling. The detrimental impact of the Gouy phase shift on radial polarisation purity is considered and a simple scheme for effective phase shift management to restore polarisation purity is presented. Preliminary experiments based on a double-pass amplifier configuration yielded an output beam with a high radial polarisation extinction ratio of 15 dB and no degradation in polarisation purity despite the non- axial symmetry of amplifier gain medium. At 50 W of launched pump power a small-signal gain of 7.5 dB was obtained for a 25 mW input, whilst 4.4 dB gain was obtained for a 1.45 W input. The prospects for further power scaling are discussed.

Influence of complications following immediate breast reconstruction on breast cancer recurrence rates.

BACKGROUND: The rate of immediate breast reconstruction is rising. Postoperative infections are more frequent in patients who undergo reconstruction. The inflammatory response to a postoperative infection can increase the risk of tumour recurrence in other forms of cancer through the release of proinflammatory mediators. The aim of this study was to assess the relationship between complications and breast cancer recurrence in patients undergoing immediate reconstruction. METHODS: This was a review of a prospectively maintained database of all patients who had immediate breast reconstruction between 2004 and 2009 at Galway University Hospital, a tertiary breast cancer referral centre serving the west of Ireland. All patients had a minimum follow-up of 5 years. Outcomes assessed included the development of wound complications and breast cancer recurrence. The data were evaluated by univariable and multivariable Cox regression analysis. RESULTS: A total of 229 patients who underwent immediate reconstruction were identified. The overall 5-year recurrence-free survival rate was 85·6 per cent. Fifty-three patients (23·1 per cent) had wound complications, of whom 44 (19·2 per cent) developed a wound infection. There was a significantly greater risk of developing systemic recurrence among patients who experienced a postoperative wound complication compared with those without a complication (hazard ratio 4·94, 95 per cent c.i. 2·72 to 8·95; P < 0·001). This remained significant after adjusting for Nottingham Prognostic Index group in the multivariable analysis. The 5-year recurrence-free survival rate for patients who had a wound complication was 64 per cent, compared with 89·2 per cent in patients without a complication (P < 0·001). CONCLUSION: This study has demonstrated that wound complications after immediate breast reconstructive surgery have significant implications for patients with breast cancer. Strategies are required to minimize the risk of postoperative wound complications in patients with breast cancer undergoing immediate reconstruction.

Clinical and economic benefit of general practitioner integration to a symptomatic breast service.

BACKGROUND: Integration of general practitioners (GPs) into a tertiary care team is a model used internationally to assist with provision of patient care. Symptomatic breast clinics have seen significant increases in attendances and consequential staffing issues. We wished to analyze the integration of GPs into a tertiary breast care team and establish whether their inclusion is a cost-effective approach. METHODS: A prospectively maintained database was used to identify 1614 new and 1453 review patients seen in the clinic between September and December 2013. The triple assessment clinical, radiological, and biopsy scores of patients assessed by GPs were compared to those assessed by registrars and to the overall number of patients seen. A cost analysis was performed based on the hourly rates of GPs and registrars. RESULTS: 1614 new patients seen over the 4-month period. GPs reviewed a mean of 153.6 new patients and registrars reviewed a mean of 97.8. Registrars reviewed patients who were allocated higher 'S' scores, with 46 % of patients allocated an S4 and 21 % of patients allocated an S5 score. GPs reviewed a mean of 115.6 return patients and registrars reviewed a mean of 110.1 return patients. The weekly cost of employing 3 GPs for 15 h was €835. This compares favorably to the cost of employing a full-time registrar. CONCLUSION: This study demonstrates that GPs can play a substantial role in the provision of a symptomatic breast service. In addition, the incorporation of GPs in this setting can prove cost-effective.

Increased risk environment for emergency general surgery in the context of regionalization and specialization.

BACKGROUND: The pressures on tertiary hospitals with increased volume and complexity related to regionalization and specialization has impacted upon availability of operating theatres with consequent displacement of emergencies to high risk out of hours settings. METHODS: A retrospective review of an electronic emergency theatre list prospectively maintained database was performed over a two year period. Data gathered included type of operation performed, Time to Theatre (TTT), operation start time and length of stay (LOS). RESULTS: Of 7041 emergency operations 25% were performed out of hours. 2949 patient had general surgical emergency procedures with 910 (30%) performed out of hours. 53% of all emergency laparotomies and 54% of appendicectomies were out of hours. 57% of cases operated on out of hours had been awaiting surgery during the day. Mean TTT was shorter for those admitted at the weekend compared to those admitted during the week (15.6 vs 24.9 h) (p < 0.0001). CONCLUSION: The majority of major emergency surgery is performed out of hours in a way unfavorable to good clinical outcomes. It is of concern that more than half of the most life threating procedures involving laparotomy, take place out of hours. Regionalization needs to be accompanied by infrastructure planning to accommodate emergency surgery.

Incidental discovery of a long standing arteriovenous fistula after thrombectomy for acute lower limb ischaemia.

INTRODUCTION: Arteriovenous fistula (AVF) is the abnormal connection between an artery and vein. Congenital AVF of the popliteal artery is very rare. PRESENTATION OF CASE: 89 year old lady presented with right acute lower limb ischaemia. She had unilateral chronic venous hypertensive change in the right leg. Femoral embolectomy was performed. Backflow was achieved. Arteriotomy was closed. The patient's leg continued to deteriorate. She returned to theatre. On-table angiogram showed an occluded SFA. Thrombectomy was completed. SFA was patent but no blood flowed into the distal popliteal artery. A second on table angiogram revealed AVF between popliteal artery and vein. Dissection to the posterior aspect of the knee revealed the fistula. The vein was arterialized and enlarged. The AVF was ligated. Normal distal blood flow was achieved. Retrospectively we measured the leg lengths. Right leg was 3cm longer than the left. The right leg circumference was 7cm greater than the left. She reported chronic venous change from a young age. She did not report any history of trauma to the limb. DISCUSSION: Popliteal artery to popliteal vein fistula is a rare. Trauma is the most common cause of popliteal AVF. Should the condition develop before closure of the epiphyses, there may be an increase in leg measurements. CONCLUSION: We postulate that this case of AV fistula may be congenital due to discrepancy in leg measurements and unilateral chronic venous hypertensive change. Rarely persistent remnants of the embryonic sciatic artery can lead to arteriovenous anastomoses, which may be a possible aetiology.

Emergency surgery pre-operative delays - realities and economic impacts.

BACKGROUND: A key principle of acute surgical service provision is the establishment of a distinct patient flow process and an emergency theatre. Time-to-theatre (TTT) is a key performance indicator of theatre efficiency. The combined impacts of an aging population, increasing demands and complexity associated with centralisation of emergency and oncology services has placed pressure on emergency theatre access. We examined our institution's experience with running a designated emergency theatre for acute surgical patients. METHODS: A retrospective review of an electronic prospectively maintained database was performed between 1/1/12 and 31/12/13. A cost analysis was conducted to assess the economic impact of delayed TTT, with every 24hr delay incurring the cost of an additional overnight bed. Delays and the economic effects were assessed only after the first 24 h as an in-patient had elapsed. RESULTS: In total, 7041 procedures were performed. Overall mean TTT was 26 h, 2 min. There were significant differences between different age groups, with those aged under 16 year and over 65 having mean TTT at 6 h, 34 min (95% C.I. 0.51-2.15, p < 0.001) and 23 h, 41 min (95% C.I. 19.6-23.9, p < 0.001) respectively. 2421 (34%) waited greater than 24 h for emergency procedures. The >65 years age group had a mean TTT of 23 h, 41 min which was significantly longer than the overall mean TTT Vascular and urological emergencies are significantly disadvantaged in competition with other services for a shared emergency theatre. The economic impact of delayed TTT was calculated at €7,116,000, or €9880/day of additional costs generated from delayed TTT over a 24 month period. CONCLUSION: One third of patients waited longer than 24 h for emergency surgery, with the elderly disproportionately represented in this group. Aside from the clinical risks of delayed and out of hours surgery, such practices incur significant additional costs. New strategies must be devised to ensure efficient access to emergency theatres, investment in such services is likely to be financially and clinically beneficial.

Compact, highly efficient ytterbium doped bismuthate glass waveguide laser.

Laser slope efficiencies close to the quantum defect limit and in excess of 78% have been obtained from an ultrafast laser inscribed buried channel waveguide fabricated in a ytterbium-doped bismuthate glass. The simultaneous achievement of low propagation losses and preservation of the fluorescence properties of ytterbium ions is the basis of the outstanding laser performance.

Strain field manipulation in ultrafast laser inscribed BiB3O6 optical waveguides for nonlinear applications.

A novel technique was used to control the spatial overlap of the orthogonal linearly polarized waveguide modes in ultrafast laser inscribed BiB(3)O(6) waveguides. We report that the strain fields induced by the expansion of material in the laser focus can be considered independently in the design of "type II" waveguides guiding orthogonal linearly polarized light. The waveguide with the optimal mode overlap was used for type I birefringently phase-matched second-harmonic generation of a continuous wave laser source at 1047 nm.

Ultrafast laser inscription of near-infrared waveguides in polycrystalline ZnSe.

We report the successful fabrication of a low-loss near-IR waveguide in polycrystalline ZnSe using ultrafast laser inscription. The waveguide, which was inscribed using the multiscan fabrication technique, supported a well-confined mode at 1.55 µm. Propagation losses were characterized at 1.55 µm using the Fabry-Perot technique and found to be 1.07 dB · cm(-1) ± 0.03 dB · cm(-1).

Shaping ultrafast laser inscribed optical waveguides using a deformable mirror.

We use a two-dimensional deformable mirror to shape the spatial profile of an ultrafast laser beam that is then used to inscribe structures in a soda-lime silica glass slide. By doing so we demonstrate that it is possible to control the asymmetry of the cross section of ultrafast laser inscribed optical waveguides via the curvature of the deformable mirror. When tested using 1.55 mum light, the optimum waveguide exhibited coupling losses of approximately 0.2 dB/facet to Corning SMF-28 single mode fiber and propagation losses of approximately 1.5 dB.cm(-1). This technique promises the possibility of combining rapid processing speeds with the ability to vary the waveguide cross section along its length.

The molecular cloning of the complementary deoxyribonucleic acid for bovine vitamin D-dependent calcium-binding protein: structure of the full-length protein and evidence for homologies with other calcium-binding proteins of the troponin-C superfamily of proteins.

We have cloned the cDNA for bovine intestinal vitamin D-dependent calcium-binding protein and, based on the sequence of the DNA, have deduced the structure of the full-length protein. The sequence of the cDNA clone predicts a protein comprised of 78 amino acids with a mol wt of 8788. The mRNA for the protein in bovine duodenum is about 500-600 bases in length. The protein sequence of bovine intestinal calcium-binding protein is 87% homologous with the sequence of porcine intestinal vitamin D-dependent calcium-binding protein and 81% homologous with the sequence of rat intestinal vitamin D-dependent calcium-binding protein. Hydrophilicity plots of the proteins noted above show that despite differences in amino acid sequence the proteins have similar patterns. In addition, the predicted secondary structure of the proteins is similar. Bovine intestinal calcium-binding protein shows 48.6% homology with the alpha-chain and 38.2% homology with the beta-chain of bovine S-100 protein and a similar high degree of homology with the beta-chain of human S-100 protein. The protein also demonstrates 36-43% homology with parvalbumin alpha and beta from various species and with troponin-C. There is some homology with the 28K vitamin D-dependent calcium-binding proteins. Vitamin D-dependent bovine intestinal calcium-binding protein is closely related to other mammalian intestinal calcium-binding proteins and to the S-100 proteins, parvalbumins, and troponin-C.

Simian virus 40 morphogenetic pathway. An analysis of assembly-defective tsB201 DNA protein complexes.

Under restrictive conditions, the 220 S SV40 virions are not assembled in tsB201-infected cells. Instead, a new class of SV40 DNA-containing particles is isolated in addition to the 75 S chromatin. This new class of nucleoprotein complex sediments heterogeneously between 100 to 160 S with a peak at 130 S. Under an electron microscope, these complexes appear predominantly as SV40 chromatin associated with a shell-like protein cluster. These structures resemble the wild type assembly intermediates previously observed by Coca-Prados and Hsu (Coca-Prados, N., and Hsu, M.-T. (1979) J. Virol. 31, 199-208). Like the wild type assembly intermediates, the tsB201 DNA-protein complexes are unstable in high salt. In CsCl, they yield a protein species with a density characteristic of empty shells. In 1 M NaCl, they release heterogeneous 55-110 S protein polymers which consist of the capsid proteins VP1, VP2, and VP3. Our results indicate that the tsB201 nucleoproteins consist of capsid proteins, with varying extents of polymerization, held to chromatin by electrostatic bonds. The accumulation of these nucleoproteins is consistent with a simian virus 40 morphogenetic pathway wherein the capsid proteins are added gradually to the 75 S chromatin.