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.

The application of human reliability analysis to carpal tunnel decompression.

INTRODUCTION: Many surgical procedures are prone to human error, particularly in the learning phase of skills acquisition. Task standardisation has been suggested as an approach to reducing errors, but it fails to account for the human factors associated with learning. Human reliability analysis (HRA) is a structured approach to assess human error during surgery. This study used HRA methodologies to examine skills acquisition associated with carpal tunnel decompression. METHODS: The individual steps or subtasks required to complete a carpal tunnel decompression were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was carried out by consensus of subject matter experts. This identified the potential human errors at each subgoal, the level of risk associated with each task and how these potential errors could be prevented. RESULTS: Carpal tunnel decompression was broken down into 46 subtasks, of which 21 (45%) were medium risk and 25 (55%) were low risk. Of the 46 subtasks, 4 (9%) were assigned high probability and 18 (39%) were assigned medium probability. High probability errors (>1/50 cases) included selecting incorrect tourniquet size, failure to infiltrate local anaesthetic in a proximal-to-distal direction and completion of the World Health Organization (WHO) surgical sign-out. Three (6%) of the subtasks were assigned high criticality, which included failure to aspirate before anaesthetic injection, whereas 21 (45%) were assigned medium criticality. Remedial strategies for each potential error were devised. CONCLUSIONS: The use of HRA techniques provides surgeons with a platform to identify critical steps that are prone to error. This approach may improve surgical training and enhance patient safety.

Development, validation and implementation of a quantitative food frequency questionnaire to assess habitual vitamin D intake.

BACKGROUND: A well-designed, validated quantitative food frequency questionnaire (FFQ) could offer an efficient and cost-effective method for assessing habitual vitamin D intake. The present study aimed to describe the development, validation and implementation of a vitamin D FFQ. METHODS: National food consumption survey data obtained from Irish adults (18-64 years) were used to identify foods that contribute 95% of vitamin D intake. A winter-based validation study was carried out for the resulting FFQ in 120 females, including 98 women [mean (SD) 65.0 (7.3) years] and 22 girls [12.2 (0.8) years], using a 14-day diet history (DH) as a comparator. Serum 25(OH)D concentrations were analysed. Validity coefficients were calculated using the method of triads. Cross-classification and Bland-Altman analysis were also performed. RESULTS: Median (interquartile range) vitamin D intakes (including the contribution from nutritional supplements) were 5.4 (3.7) and 3.7 (5.9) µg day(-1) from the FFQ and DH, respectively and intakes of vitamin D from food sources were 3.6 (3.1) and 2.4 (2.2) µg day(-1) . The FFQ and DH classified 86% and 87% of individuals into the same and adjacent thirds of wintertime serum 25(OH)D status, respectively. There was a strong association (r = 0.71, P < 0.0001) and no significant systematic or proportional bias observed for the difference between estimates from the FFQ and DH. The validity coefficient for the FFQ was 0.92 (95% confidence interval = 0.80-0.97). Repeatability analysis (n = 56) performed 6-12 months later showed no significant difference in estimates of vitamin D between administrations. CONCLUSIONS: The data obtained in the present study indicate high validity and good reproducibility of a short, interviewer-administered FFQ for vitamin D.

Relationships between vitamin D status and cardio-metabolic risk factors in young European adults.

BACKGROUND/AIMS: To explore associations between vitamin D and cardiovascular disease risk factors in young European adults. METHODS: This was a cross-sectional analysis of serum 25-hydroxyvitamin D [s25(OH)D], intact parathyroid hormone (iPTH) and biomarkers of cardiovascular disease risk in 195 healthy 20- to 40-year-olds (109 women) with a BMI between 27.5 and 32.5 from Iceland (64° N; n = 82), Ireland (51° N; n = 37) and Spain (42° N; n = 76) during mid-late winter. RESULTS: The median s25(OH)D was 52.8 nmol/l (IQR 38.1-69.9) or 21.1 ng/ml (IQR 15.2-28.0) with a latitude-dependent gradient (p ≤ 0.0001): Iceland, 41.7 nmol/l (IQR 32.7-54.2) or 16.7 ng/ml (IQR 13.1-21.7); Ireland, 52.9 nmol/l (IQR 35.3-68.6) or 21.2 ng/ml (IQR 14.1-27.4), and Spain, 67.1 nmol/l (IQR 47.1-87.1) or 26.8 ng/ml (IQR 18.8-34.8). Eleven percent of Icelandic participants had s25(OH)D concentrations <25 nmol/l (10 ng/ml) and 66% of Icelandic, 43% of Irish, and 30% of Spanish volunteers had concentrations <50 nmol/l (20 ng/ml), respectively. Overall, 17% met 3 or more of the NCEP/ATP III criteria for cardio-metabolic syndrome (MetS). Participants in the lowest third of s25(OH)D [≤ 42.5 nmol/l (17 ng/ml)] were more likely to have MetS (OR 2.49, p = 0.045) and elevated TAG (OR 3.46, p = 0.019). Individuals with iPTH concentrations in the lowest third [2.34 pmol/l (22.2 pg/ml)] were more likely to have elevated fasting TAG (OR 4.17, p = 0.039), insulin (OR 3.15, p = 0.029) and HOMA-IR (OR 2.15, p = 0.031), and they were less likely to have elevated IL-6 (OR 0.24, p = 0.003). CONCLUSION: There were interactions between s25(OH)D, iPTH and cardio-metabolic risk factors which, given the increasing prevalence of overweight and obesity and a low vitamin D status among adults, require randomised controlled vitamin D intervention studies in overweight persons.

Measurement, reconstruction, and flow-field computation of the human pharynx with application to sleep apnea.

Repetitive closure of the upper airway characterizes obstructive sleep apnea. It disrupts sleep causing excessive daytime drowsiness and is linked to hypertension and cardiovascular disease. Previous studies simulating the underlying fluid mechanics are based upon geometries, time-averaged over the respiratory cycle, obtained usually via MRI or CT scans. Here, we generate an anatomically correct geometry from data captured in vivo by an endoscopic optical technique. This allows quantitative real-time imaging of the internal cross section with minimal invasiveness. The steady inhalation flow field is computed using a k-ω shear-stress transport (SST) turbulence model. Simulations reveal flow mechanisms that produce low-pressure regions on the sidewalls of the pharynx and on the soft palate within the pharyngeal section of minimum area. Soft-palate displacement and side-wall deformations further reduce the pressures in these regions, thus creating forces that would tend to narrow the airway. These phenomena suggest a mechanism for airway closure in the lateral direction as clinically observed. Correlations between pressure and airway deformation indicate that quantitative prediction of the low-pressure regions for an individual are possible. The present predictions warrant and can guide clinical investigation to confirm the phenomenology and its quantification, while the overall approach represents an advancement toward patient-specific modeling.

Pressure wave propagation in fluid-filled co-axial elastic tubes. Part 1: Basic theory.

Our work is motivated by ideas about the pathogenesis of syringomyelia. This is a serious disease characterized by the appearance of longitudinal cavities within the spinal cord. Its causes are unknown, but pressure propagation is probably implicated. We have developed an inviscid theory for the propagation of pressure waves in co-axial, fluid-filled, elastic tubes. This is intended as a simple model of the intraspinal cerebrospinal-fluid system. Our approach is based on the classic theory for the propagation of longitudinal waves in single, fluid-filled, elastic tubes. We show that for small-amplitude waves the governing equations reduce to the classic wave equation. The wave speed is found to be a strong function of the ratio of the tubes' cross-sectional areas. It is found that the leading edge of a transmural pressure pulse tends to generate compressive waves with converging wave fronts. Consequently, the leading edge of the pressure pulse steepens to form a shock-like elastic jump. A weakly nonlinear theory is developed for such an elastic jump.

Pressure wave propagation in fluid-filled co-axial elastic tubes. Part 2: Mechanisms for the pathogenesis of syringomyelia.

Our aim in this paper is to use a simple theoretical model of the intraspinal cerebrospinal-fluid system to investigate mechanisms proposed for the pathogenesis of syringomyelia. The model is based on an inviscid theory for the propagation of pressure waves in co-axial, fluid-filled, elastic tubes. According to this model, the leading edge of a pressure pulse tends to steepen and form an elastic jump, as it propagates up the intraspinal cerebrospinal-fluid system. We show that when an elastic jump is incident on a stenosis of the spinal subarachnoid space, it reflects to form a transient, localized region of high pressure within the spinal cord that for a cough-induced pulse is estimated to be 50 to 70 mm Hg or more above the normal level in the spinal subarachnoid space. We propose this as a new mechanism whereby pressure pulses created by coughing or sneezing can generate syrinxes. We also use the same analysis to investigate Williams' suck mechanism. Our results do not support his concept, nor, in cases where the stenosis is severe, the differential-pressure-propagation mechanism recently proposed by Greitz et al. Our analysis does provide some support for the piston mechanism recently proposed by Oldfield et al. and Heiss et al. For instance, it shows clearly how the spinal cord is compressed by the formation of elastic jumps over part of the cardiac cycle. What appears to be absent for this piston mechanism is any means whereby the elastic jumps can be focused (e.g., by reflecting from a stenosis) to form a transient, localized region of high pressure within the spinal cord. Thus it would seem to offer a mechanism for syrinx progression, but not for its formation.

Treatment of urinary incontinence among caregiver-dependent adults.

It is estimated that approximately 50% of residents in long-term care settings suffer from urinary incontinence. Developing and implementing a continence program in long-term care settings is one of the most challenging aspects of continence care. Careful assessment of residents will allow interventions to be targeted to those most likely to benefit. The combination of nursing measures and targeting the behavioral interventions to those most likely to benefit increases the likelihood that the program will produce clinically significant reductions in UI.

Arranging a clinical practicum in a health care facility.

Staff development educators and administrators collaborate frequently to establish clinical experiences for student nurses. This article outlines key elements to consider and a time line for planning practicums. Some tools are offered to assist in the process. Arranging a clinical practicum in a health care facility requires flexibility, negotiation, and attention to detail for both the school and the facility. A mutually beneficial affiliation flourishes in such a facilitative environment.