Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand.

BACKGROUND: Decisions to admit high-risk postoperative patients to critical care may be affected by resource availability. We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe additional 'high-acuity' beds capable of managing high-risk patients outside the ICU/HDU environment. METHODS: We used a modified Delphi consensus method to design a survey that was disseminated via investigator networks in the UK, Australia, and NZ. Hospital- and ward-level data were collected, including bed numbers, tertiary services offered, presence of an emergency department, ward staffing levels, and the availability of critical care facilities. RESULTS: We received responses from 257 UK (response rate: 97.7%), 35 Australian (response rate: 32.7%), and 17 NZ (response rate: 94.4%) hospitals (total 309). Of these hospitals, 91.6% reported on-site ICU or HDU facilities. UK hospitals reported fewer critical care beds per 100 hospital beds (median=2.7) compared with Australia (median=3.7) and NZ (median=3.5). Additionally, 31.1% of hospitals reported having high-acuity beds to which high-risk patients were admitted for postoperative management, in addition to standard ICU/HDU facilities. The estimated numbers of critical care beds per 100 000 population were 9.3, 14.1, and 9.1 in the UK, Australia, and NZ, respectively. The estimated per capita high-acuity bed capacities per 100 000 population were 1.2, 3.8, and 6.4 in the UK, Australia, and NZ, respectively. CONCLUSIONS: Postoperative critical care resources differ in the UK, Australia, and NZ. High-acuity beds may have developed to augment the capacity to deliver postoperative critical care.

SNAP-2 EPICCS: the second Sprint National Anaesthesia Project-EPIdemiology of Critical Care after Surgery: protocol for an international observational cohort study.

INTRODUCTION: The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties. METHODS AND ANALYSIS: One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome. ETHICS AND DISSEMINATION: The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences.

The biomechanical characteristics of wearing FitFlop™ sandals highlight significant alterations in gait pattern: a comparative study.

BACKGROUND: The net contribution of all muscles that act about a joint can be represented as an internal joint moment profile. This approach may be advantageous when studying footwear-induced perturbations during walking since the contribution of the smaller deeper muscles that cross the ankle joint cannot be evaluated with surface electromyography. Therefore, the present study aimed to advance the understanding of FitFlop™ footwear interaction by investigating lower extremity joint moment, and kinematic and centre of pressure profiles during gait. METHODS: 28 healthy participants performed 5 walking trials in 3 conditions: a FitFlop™ sandal, a conventional sandal and an athletic trainer. Three-dimensional ankle joint, and sagittal plane knee and hip joint moments, as well as corresponding kinematics and centre of pressure trajectories were evaluated. FINDINGS: FitFlop™ differed significantly to both the conventional sandal and athletic trainer in: average anterior position of centre of pressure trajectory (P<0.0001) and peak hip extensor moment (P=0.001) during early stance; average medial position of centre of pressure trajectory during late stance; peak ankle dorsiflexion and corresponding range of motion; peak plantarflexor moment and total negative work performed at the ankle (all P<0.0001). INTERPRETATION: The present findings demonstrate that FitFlop™ footwear significantly alters the gait pattern of wearers. An anterior displacement of the centre of pressure trajectory during early stance is the primary response to the destabilising effect of the mid-sole technology, and this leads to reductions in sagittal plane ankle joint range of motion and corresponding kinetics. Future investigations should consider the clinical implications of these findings.

Vaginismus in peri- and postmenopausal women: a pragmatic approach for general practitioners and gynaecologists.

Vaginismus is generally described as an involuntary contraction of the vaginal musculature, which usually results in the failure of penetration. Despite a lack of consensus as to the exact definition, prevalence rates vary between 4.2% and 42%. It is commonly diagnosed at both gynaecological and psychosexual clinics. The majority of studies and treatment options concentrate on the premenopausal age group. It is accepted that even within this age group, the diagnosis is often incorrect as symptoms can be confused with dyspareunia and other sexual pain disorders. There is no literature discussing vaginismus in the postmenopausal patient, despite evidence that an active sex life is important to the majority of women, irrespective of age. It is known that the majority of women do not report difficulties in their sex life and it may be that the older patient is more embarrassed at disclosing any such difficulties. This review aims to highlight the possible causes of vaginismus in this older age group and to aid the clinician in asking the appropriate questions, performing the appropriate examination and suggesting possible treatment options.

The relationship of nightmare frequency and nightmare distress to well-being.

Nightmares can be defined as very disturbing dreams, the events or emotions of which cause the dreamer to wake up. In contrast, unpleasant dreams can be defined in terms of a negative emotional rating of a dream, irrespective of whether or not the emotions or events of the dream woke the dreamer. This study addresses whether frequency of unpleasant dreams is a better index of low well-being than is frequency of nightmares. A total of 147 participants reported their nightmare frequency retrospectively and then kept a log of all dreams, including nightmares, for 2 weeks, and rated each dream for pleasantness/unpleasantness. Anxiety, depression, neuroticism, and acute stress were found to be associated with nightmare distress (ND) (the trait-like general level of distress in waking-life caused by having nightmares) and prospective frequency of unpleasant dreams, and less so with the mean emotional tone of all dreams, or retrospective or prospective nightmare frequency. Correlations between low well-being and retrospective nightmare frequency became insignificant when trait ND was controlled for, but correlations with prospective unpleasant dream frequency were maintained. The reporting of nightmares may thus be confounded and modulated by trait ND: such confounding does not occur for the reporting of unpleasant dreams in general. Thus there may be attributional components to deciding that one has been awoken by a dream, which can affect estimated nightmare frequency and its relationship with well-being. Underestimation of nightmare frequency by the retrospective questionnaire compared with logs was found to be a function of mean dream unpleasantness and ND.