Analysis of a 5-year, evidenced-based, rational blood utilisation project in a South African regional hospital.

BACKGROUND: Blood products are a lifesaving but limited resource, particularly in resource-limited settings. Evidence-based transfusion criteria tailored to local hospitals have shown great promise in reducing costs, minimising shortages, and ameliorating the morbidity and mortality associated with liberal blood product usage. We implemented the "Saving Blood, Saving Lives" project to: promote responsible blood product use and reduce blood product ordering inefficiencies and expenditure. METHODS: A comprehensive change management programme, preceded by 3 months of clinical department consultation and training, was implemented. A new evidence-based protocol for blood product utilisation was developed, together with an accountability form. This form was used in monthly audit meetings to refine policies, identify new problems, improve communication, and to drive hospital staff accountability and training. The primary measure of the programme's success was the change in the number of red cell concentrate units ordered. RESULTS: Project implementation required minimal time and no additional budget or staff. Annual red cell concentrate usage reduced from 7211 units in year one to 4077 units in year 5 (p < 0.001). Similar reductions were seen in freeze-dried plasma and platelet usage, as well as administrative costs. Total project saving, adjusted to baseline admission numbers, amounted to over R46 million ($2.5 million). CONCLUSIONS: As a change management programme centred the "Saving Blood, Saving Lives" project, was able to significantly reduce blood product-related administration and expenditure by implementing evidence-based transfusion criteria. The programme is simple, replicable and cost effective, making it ideally suited for use in resource-constrained environments.

Efficacy of Various Low Temperature and Exposure Time Combinations for Thaumatotibia leucotreta (Meyrick) (Lepidoptera: Tortricidae) Larvae.

A systems approach was developed as an alternative to a standalone quarantine disinfestation treatment for Thaumatotibia leucotreta in citrus fruit exported from South Africa. The systems approach consists of three measures: pre and postharvest controls and measurements, postpacking inspection, and postharvest exposure to low temperatures. Different cold treatment conditions with a range of efficacy levels can be used for this last measure. A series of trials reported here evaluated the efficacy of seven temperatures ranging from 0 to 5°C for durations from 14 d to 26 d. Mortality of the most cold-tolerant larval stages of T. leucotreta was determined. Temperatures of 0, 1, 2, and 3°C for 16, 19, 20, and 24 d respectively, induced 100% mortality of the tested populations. Probit 9 level treatment efficacy was achieved at 0 and 1°C for 16 and 19 d respectively. Mortalities higher than 90% were obtained with temperatures of 4, 4.5, and 5°C, after exposure for the longer durations. We demonstrated a significant difference in cold-induced insecticidal efficacy between 1, 2, 3, and 4°C. There was no significant difference in insecticidal efficacy between 4 and 4.5°C, but both of these temperatures were more efficacious than 5°C. The results of this study are valuable to support the use of cold treatment conditions with lower risk of fruit chilling injury in an effective systems approach, where the cold treatment efficacy can be augmented with other components of the systems approach.

Evidence of negative pressure therapy for anastomotic leak: a systematic review.

BACKGROUND: Anastomotic leak (AL) is a devastating complication. Several new treatment options are available, endoluminal negative pressure therapy is one. The aims of this systematic review are; to report success rates and stoma closure rates following endoluminal negative pressure therapy in colorectal AL patients. METHODS: A systematic review of MEDLINE, PubMed, Cochrane and Embase databases from inception to June 2018. Search limits were; English language, humans, sample >5 and >18 years. Search terms were Endospong* OR Endo-spong* OR Endo spong* OR Endoluminal negative pressure OR Endoluninal vac* OR Vacuum assisted OR negative pressure. Combined with colon OR rectum OR colorect* AND anastomotic leak OR leak*. RESULTS: Twenty articles met inclusion criteria. There were 334 patients. Reported success rates ranged from 60% to 100%. However, success definition varied considerably. The most widely used definition was endoscopic assessment of residual cavity size, but this also varied from 0.5 cm to 3 cm. Stoma closure rates were only reported in 11 studies and ranged from 31% to 100%. Complication rates were reported in 13 studies (65%). The most common was on-going sepsis. CONCLUSIONS: Included studies suggest that 60-100% of ALs heal with endoluminal negative pressure therapy. However, results from this review need to be interpreted with caution because of the variable definition of success. A more objective assessment of success may be stoma closure but this is only reported in 60% of studies. Further studies are needed to assess the benefit of negative pressure therapy in anastomotic leaks.

An Improved Systems Approach as a Phytosanitary Measure for Thaumatotibia leucotreta (Lepidoptera: Tortricidae) in Export Citrus Fruit From South Africa.

A systems approach was previously developed for mitigating phytosanitary risk of Thaumatotibia leucotreta (Meyrick) in citrus fruit exported from South Africa, as an alternative to a standalone cold disinfestation treatment. The present study first tested the original systems approach by applying it on a semicommercial scale in 10 Nova mandarin orchards. Fruit were inspected at points in the production, packing, and simulated shipping process, to assess performance of the systems approach. Additional data were obtained from 17 Valencia orange orchards and six packinghouses. In the second part of this study, the systems approach was accordingly revised and improved, consisting of three measures: 1) preharvest controls and measurements and postpicking sampling, inspection, and packinghouse procedures; 2) postpacking sampling and inspection; and 3) shipping conditions. The model quantifying the effectiveness of the systems approach was improved by correcting errors in the original version, updating parameter values and adding a component that provides for comparison with the risk mitigation provided by a standalone disinfestation treatment. Consequently, the maximum potential proportion of fruit that may be infested with live T. leucotreta after application of the improved systems approach is no greater than the proportion of fruit that may be infested after application of a Probit 9 efficacy postharvest disinfestation treatment to fruit with a 2% pretreatment infestation. The probability of a mating pair surviving is also determined. The model enables a priori determination of the required threshold levels for any of the three measures, based on quantification of the other two measures.

Review of emotional intelligence in health care: an introduction to emotional intelligence for surgeons.

BACKGROUND: The aim of this review is to explain the components of emotional intelligence (EI) and explore the benefits within today's health care system with an emphasis on surgery. EI is a person's ability to understand their own emotions and those of the individuals they interact with. Higher individual EI has multiple proposed benefits, such as reducing stress, burnout and increasing work satisfaction. The business world recognizes EI as beneficial in terms of performance and outcomes. Could surgeons benefit from being more cognisant of EI and methods of assessing and improving EI to reap the aforementioned benefits? METHODS: A search of Embase, Cochrane and Medline databases using the following search terms; emotional intelligen*, surg*, medic* yielded 95 articles. After review of all the literature 39 remaining articles and five text books were included. RESULTS: To perform optimally, surgeons must be aware of their own emotions and others. EI differs from IQ and can be taught, learnt and improved upon. EI is measured via validated self-reporting questionnaires and 'multi-rater' assessments. High EI is positively associated with leadership skills in surgeons, non-technical skills, reduction in surgeon stress, burnout and increased job satisfaction, all of which translate to better patient relationships and care. Future implications of EI have been postulated as a measure of performance, a selection tool for training positions and a marker of burnout. EI should be an explicit part of contemporary surgical education and training.

Point-of-care viscoelastic assay devices (rotational thromboelastometry and thromboelastography): a primer for surgeons.

BACKGROUND: Bleeding is a common occurrence in surgery. Point-of-care testing with viscoelastic (VE) assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) has become more common place. TEG and ROTEM have the potential to guide management of coagulopathy. Many healthcare professionals still rely upon standard laboratory tests (SLTs) to manage a bleeding patient. It was our aim to investigate the literature surrounding management of the surgically bleeding patient via VE assays. METHODS: Literature review of Embase, MEDLINE, PubMed and the Cochrane Library using 'TEG, ROTEM and surgery' search terms was conducted. RESULTS: Through the literature search and reference lists reviewed by both authors, a total of 62 articles have been evaluated, 35 of these have been included in this review. CONCLUSION: VE assays are used most commonly during orthotopic liver transplantation, trauma, postpartum haemorrhage and cardiac surgery. Although the evidence is not overwhelming, we have identified recurrent themes where VE assays seem to be beneficial. VE assay use, especially when incorporated into an algorithm, appears to reduce blood product administration which in turn reduces cost and potential adverse events. They are quicker than SLTs and they can detect hyperfibrinolysis, the hallmark of coagulopathy, via in vivo clot analyses which SLTs are unable to do. Ultimately more randomized controlled trials are required.

Presentation of secondary parasitic infection 37 years after primary infection.

Echinococcus granulosus (EG) is a neglected pathology that causes cystic echinococcosis and primarily affects the liver and lung. EG infects ~6 million worldwide and mortality is quoted as 2-4% per 100 000 inhabitants. The increase in human traffic from endemic regions demands clinician's awareness. Dogs are the most common definitive host for the EG tapeworm. Human infection requires ingestion of fecal parasitic eggs. Primary infection causes cysts to appear in affected organs, rupture of which leads to secondary infection. Ultrasound remains the mainstay of diagnosis. Treatment can be either; chemotherapeutic, radiological, surgical or a combination depending on the organ affected.

Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature.

BACKGROUND: Chlorhexidine (CHL) has antiseptic and disinfectant properties used to prevent hospital-acquired infections. CHL-induced anaphylaxis is poorly reported in surgical literature despite government warnings and growing recognition. The aim of this review is to increase awareness of CHL-induced anaphylaxis in the surgical population. METHODS: Literature review of Embase, Medline, PubMed and the Cochrane library using 'anaphylaxis (and) chlorhexidine' search terms. RESULTS: Thirty-six articles were published on surgical patients suffering anaphylaxis to CHL. Within these, seven patients had two proven separate anaphylactic reactions and one had three separate proven anaphylactic reactions. The most commonly affected speciality was urology. The majority occurred during elective procedures. A history of atopy was surprisingly uncommon as was bronchospasm. Six patients required active chest compressions and 39.71% of patients had their surgical procedure abandoned. Unplanned intensive care admissions occurred in 27.94%. DISCUSSION: In order to reduce abandoned procedures, unplanned intensive care unit admissions, morbidity and mortality associated with CHL-induced anaphylaxis we recommend the following: rationalization of CHL-containing products, greater vigilance regarding subtle symptoms of CHL allergy, appropriate investigation of these symptoms and a greater awareness of CHL-containing products. Lastly, we outline the appropriate investigations and highlight the need for meticulous documentation in those who are CHL allergic.

Inverted Meckel's diverticulum causing intussusception in a Crohn's patient.

Cases of inverted intraluminal Meckel's diverticulum (MD) containing a lipoma, pancreatic and gastric ectopic tissue resulting in intussusception are extremely rare. We have been unable to locate any such presentation in a Crohn's patient; here, we discuss one such case. MD is the most common congenital malformation of the human gastrointestinal tract. Its paediatric preponderance may result in its oversight in the adult population as a cause for symptoms. Intestinal obstruction is the most common adult presentation in non-inverted MD, whereas haemorrhage and anaemia are the most frequent presenting complaint with an 'inverted' MD. Adult intussusception due to an inverted MD is exceptionally rare with a poorly understood pathophysiology and life-threatening consequences. There is no gold standard diagnostic test for an inverted MD causing an intussusception, rather clinicians should utilize many modalities including angiography, ultrasound and computed tomography. Treatment of an inverted adult MD causing intussusception is surgical resection.

A cross-sectional pilot study to investigate patient attitudes and perception regarding the use of real time digital recording of urological procedures for research and teaching purposes.

Little conclusive evidence exists regarding the best way to educate and evaluate skill acquisition of advanced surgical trainees, despite it being recognised as one of the most important aspects of training. Many laparoscopic trainers have been produced with complex engineering at great cost, but, there seems to be a reluctance to use the most precious entity available to us; the patient. We thus propose the use of real time digital recording of urological procedures for research and teaching purposes. This study was prompted by the lack of literature regarding such issues. A 19 question questionnaire was circulated at a single urology out-patient department (Essex, England) over a 6 month period to evaluate attitudes and perceptions of urological patients on potentially having their procedure digitally recorded for educational and research purposes. 11 patients declined, 187 questionnaires were included in the final analysis. Male patients are more willing to consent than female patients. Older patients resulted to have a higher propensity in being recorded for medical teaching. Greater than 50% believe being recorded is intrusive but the majority do not think privacy is an issue. Lastly, the vast majority require a formal debrief post operatively. Our results show that a percentage of the public are potentially willing to be digitally recorded but many financial and social barriers exist. We have also highlighted areas of possible future research, namely the reluctance behind young urology patients to consent and questions regarding how best to educate possible study participants to ensure proper informed consent is gained.

A Differential Diagnosis of Haematuria following a Motor Vehicle Collision: Nutcracker Syndrome.

A young female presented to the emergency department following a motor vehicle collision. She complained of left flank pain and was found to have haematuria. After investigation no trauma related injuries were identified. However, an incidental finding of nutcracker phenomenon/syndrome was made. Nutcracker phenomenon is a rare cause of haematuria resulting from nontraumatic compression of the left renal vein between the superior mesenteric artery and the aorta. It affects females more than males and its presentation can range from asymptomatic to debilitating haematuria, pelvic congestion in females, varicosities in males, and pain. No validated diagnostic criteria exist and treatment is usually surgical in those with debilitating symptoms or refractory anaemia.

A mystifying mass.

A 57-year-old male was referred by his general practitioner (GP) to hospital with right upper quadrant pain and a palpable mass (10 × 9 cm). He had been assessed by his GP several weeks earlier and represented as initial treatment failed. On his second presentation a mass was evident and thought to represent cholecystitis by the referring GP. However, the correct and prompt use of appropriate radiological imaging enabled swift diagnosis and management of atypical acute appendicitis through microbial specific therapy. Atypical appendicitis delays diagnosis and treatment which represents greater levels of appendiceal ischaemia and heightened perforation risk. This case study highlights the non-surgical management of acute atypical appendicitis and also reinforces the use of appropriate imaging modalities.