Measuring quality of recovery-15 after day case surgery.

BACKGROUND: 'Quality of recovery' scores are patient-reported outcome measures evaluating recovery after surgery and anaesthesia. However, they are not widely used in the clinical or research setting. The Quality of Recovery-15 (QoR-15) is a recently developed, psychometrically tested and validated questionnaire. METHODS: We conducted a prospective study of all adult patients undergoing orthopaedic day case surgery over a period of six months (June 2013-November 2013). Patients completed the QoR-15 score preoperatively, and then were asked to repeat the score by telephone at 24 h, 48 h and seven days after surgery. RESULTS: 633 patients from a possible 714 (89%) completed the preoperative questionnaire and data from 437 patients who completed scores at all four time points were analysed. Most patients returned to their preoperative score by 48 h, and had exceeded it by seven days. Construct validity was supported by a negative correlation with duration of surgery and total inpatient opioid use. There was also excellent internal consistency (Cronbach's alpha 0.80-0.83). CONCLUSION: The QoR-15 is a clinically acceptable and feasible patient-centred outcome measure after day case surgery. The score demonstrated good validity, reliability and responsiveness. However, measurement of the QoR-15 score on the day of surgery may not provide a true baseline value. We suggest one follow-up call at 48 h would enable an adequate patient-centred assessment of postoperative recovery after day case orthopaedic surgery.

Atrial and ventricular tachyarrhythmias in military personnel.

Although rare, sudden cardiac death does occur in British military personnel. In the majority of cases, the cause is considered to be a malignant ventricular tachyarrhythmia, which can be precipitated by a number of underlying pathologies. Conversely, a tachyarrhythmia may have a more benign and treatable cause, yet the initial clinical symptoms may be similar, making differentiation difficult. This is an overview of the mechanisms underlying the initiation and propagation of arrhythmias and the various pathological conditions that predispose to arrhythmia genesis, classified according to which parts of the heart are involved: atrial tachyarrhythmias, atrial and ventricular, as well as those affecting the ventricles alone. It encompasses atrial tachycardia, atrial flutter, supraventricular tachycardias and ventricular tachycardias, including the more commonly encountered inherited primary electrical diseases, also known as the channelopathies. The clinical features, investigation and management strategies are outlined. The occupational impact-in serving military personnel and potential recruits-is described, with explanations relating to the different conditions and their specific implication on continued military service.

Deep vein thrombosis and pulmonary embolism in the military patient.

OBJECTIVES: Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, is a common, potentially lethal condition and a cause of long-term morbidity and functional limitation. This paper is a clinical review focused on military epidemiology, evidence-based recommendations for prevention, diagnosis and management of VTE and occupational considerations in a military population. METHODS: A literature review was conducted through Pubmed and Embase for systematic reviews, meta-analyses and clinical trials relating to VTE. Guidelines from the National Institute for Health and Care Excellence, British Thoracic Society and the American College of Chest Physicians were reviewed and recommendations considered. RESULTS: Acute morbidity from VTE can range from limb pain and swelling to life-threatening cardiovascular compromise. Long-term sequelae include postthrombotic syndrome, chronic thrombosis and pulmonary hypertension. Diagnosis should follow a validated pathway depending on the patient's prerest probability. The management of the condition should vary with attention to risk stratification. DISCUSSION: Prompt initiation of anticoagulation reduces symptoms, rates of recurrent VTE and death but treatment must be balanced against the risk of major haemorrhage. Military operations expose personnel to a unique combination of risk factors for VTE and operating in austere environments can increase the challenge of diagnosis, prognostication and management. Furthermore, there are implications for troop attrition, operational readiness and return to work.

Atrial fibrillation in the military patient: a review.

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia, and increases an individual's risk of morbidity and mortality from cardiovascular and thromboembolic events. In this article, we review the pathophysiology and clinical presentations of AF and describe appropriate investigations and management likely to be appropriate for a military population, in line with current National Institute for Health and Care Excellence and European Society of Cardiology guidelines. The implications for the individual's Medical Employment Standard in the UK Armed Forces, with specific reference to specific military occupational activities such as aviation, diving and driving occupationally, are also reviewed.

Thromboelastography (TEG®) compared with total platelet count in thrombocytopenia haematological malignancy patients with bleeding: a pilot observational study.

BACKGROUND: There has been no reported use of Thromboelastography(®) (TEG(®) ) in assessing thrombocytopenic haematological malignancy (HM) patients experiencing bleeding. OBJECTIVES: To assess whether there are differences in TEG(®) variables in thrombocytopenic HM patients experiencing clinically significant bleeding compared with those not experiencing bleeding. METHODS: Thirty adult patients with HM and a total platelet count (TPC) of ≤ 30 × 10(9) L(-1) were observed for greater than or equal to grade two World Health Organisation (WHO) bleeding episodes for 72 h. They had TPC, TEG(®) parameters [maximal amplitude (MA), reaction time (R-time), alpha (α-angle) and functional fibrinogen (FF) levels], activated partial thromboplastin time (APTT) and prothrombin time (PT) measured at inclusion, 24 and 48 h. RESULTS: Five patients had nine significant bleeding episodes. Patients bleeding (n) were all more hypocoaguable when measured by TEG(®) than patients not bleeding at inclusion n = 4 (MA: 16.9 vs 31.8 mm, P < 0.01; R-time: 10.1 vs 7.5 min, P = 0.02; α-angle: 18.8 vs 28.4, P < 0.01; FF: 182.4 vs 204 mg dL(-1), P < 0.01), at 24 h n = 3 (MA 18 vs 29.4 mm, P = 0.02; R-time: 9.4 vs 7.4 mins, P = 0.02; α-angle: 21.6 vs 26.5, P = 0.04 and FF: 168 vs 201 mg dL(-1) P = 0.01) and at 48 h n = 2 (MA: 29.7 vs 23.0, P = 0.02; R-time: 8.1 vs 6.7 mins, P = 0.05; α-angle: 22.6 vs 26.5, P = 0.04; FF: 170 vs 208 mg dL(-1), P = 0.01). There were no significant differences in TPC, APTT or PT between patients that bled and those that did not at each time point. CONCLUSIONS: Thrombocytopenic HM patients experiencing bleeding are hypocoaguable on TEG(®).