The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set.

BACKGROUND: Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. METHODS: Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. RESULTS: Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15-0.23), higher ASA scores (OR 0.19, 95% CI 0.15-0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58-0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48-0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34-0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). CONCLUSIONS: The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy.

Daycase hernia surgery: a missed training opportunity.

INTRODUCTION: Traditionally uncomplicated elective hernia operations were performed by surgical trainees; allowing them to develop key competencies and skills transferable to emergency hernia surgery. Daycase surgical units (DCU) are increasingly accommodating operations that traditionally contributed to operating lists in general elective theatres. We aim to assess whether DCU could help improve training in hernia surgery. SUBJECTS AND METHODS: Operative Room Information System (ORMIS) data was collected retrospectively to identify hernia operations performed at a large NHS hospital between January 2007 and 2012. Data collected included operating surgeon(s), procedure performed and procedure time (PT). Hospital coding records were used to collect data related to patient length of stay (LOS), complications, readmissions and deaths within 30 days of procedure. RESULTS: 4668 hernia operations were performed; 3063 in DCU. 91.5% (n = 2803) were open and 8.5% (n = 260) laparoscopic repairs. Trainees assisted in 24.6% (n = 752) and led 7.8% (n = 238) of cases. Overall, the mean PT for consultant led open hernia operations was 37.44 min (95% CI 36.75-38.12) and 43.07 min (95% CI 40.99-45.16) for trainees (p < 0.05). Subgroup analysis of all hernia operations performed showed no significant difference in PT between consultants and trainees when performing open bilateral inguinal, femoral, epigastric, incisional and laparoscopic hernia operations. There were no differences in LOS, readmissions and death rates within 30 days of the operation. CONCLUSIONS: DCU are an underutilised opportunity for trainees to acquire experience of hernia operations. When given the opportunity to lead hernia operations in DCU, trainees have similar PT and complication rates to consultants in many instances. Trainees should be encouraged to assist and lead hernia cases in DCU under adequate supervision to ensure appropriate competency is achieved and high standards are maintained.

Internal hernias: a brief review.

Hernias are very familiar to a core surgical trainee in the setting of clinics and the surgical assessment unit. By definition, a hernia is an abnormal protrusion of a viscus from one compartment to another. In clinic, they are visible lumps, exhibiting a cough reflex often with a well definable history making them readily identifiable. In the acute setting, they are the third commonest cause of small bowel obstruction in the developed world. Ventral and inguinal hernias account for the majority of these with only a small proportion due to internal hernias. This article aims to educate the core surgical trainee on the anatomy and distinguishing clinical features of these rare but important types of internal abdominal hernias.

Measuring T2 and T1, and imaging T2 without spin echoes.

During adiabatic excitation, the nuclear magnetization in the transverse plane is subject to T(2) (spin-spin) relaxation, depending on the pulse length τ. Here, this property is exploited in a method of measuring T(2) using the ratio of NMR signals acquired with short and long-duration self-refocusing adiabatic pulses, without spin-echoes. This Dual-τ method is implemented with B(1)-insensitive rotation (BIR-4) pulses. It is validated theoretically with Bloch equation simulations independent of flip-angle, and experimentally in phantoms. Dual-τT(2) measurements are most accurate at short T(2) where results agree with standard spin-echo measures to within 10% for T(2) ≤ 100 ms. Dual-τ MRI performed with a long 0° BIR-4 pre-pulse provides quantitative T(2) imaging of phantoms and the human foot while preserving desired contrast and functional properties of the rest of the MRI sequence. A single 0° BIR-4 pre-pulse can provide T(2) contrast-weighted MRI and serve as a "T(2)-prep" sequence with a lower B(1) requirement than prior approaches. Finally, a Tri-τ experiment is introduced in which both τ and flip-angle are varied, enabling measurement of T(2), T(1) and signal intensity in just three acquisitions if flip-angles are well-characterized. These new methods can potentially save time and simplify relaxation measurements and/or contrast-weighted NMR and MRI.

Glutathione and related enzymes in fascioliasis before and after treatment with bithionol.

The present work is an update evaluation of the glutathione status in patients with established fascioliasis before and after treatment with bithionol. Blood glutathione (GSH), erythrocyte glutathione S-transferase (GST) and serum gamma-glutamyl transferase (GGT) activities were studied. After treatment, the variations observed in these parameters were restored to the corresponding normal control values confirming the toxic features resulting from fascioliasis and suggesting no adverse effect of bithionol on the parameters studied. We recommend the use of serum GGT, blood GSH and erythrocyte GST for the early detection of therapeutic response in fascioliasis.

Biological availability of sulfamethoxypyridazine and sulfisomidine polymers.

Dissolution rates and apparent solubilities of forms I, II and III of Sulfamethoxypyridazine (1) and forms I and II of sulfisomidine (2) were determined in water at 37 degrees C. The ratios of apparent solubilities of I:II:III for 1 forms and I:II for 2 forms were 1:1.18:1.25 and 1:1.32 respectively. Upon long contact of 2 with water the ratio of II:I decreased. This has been attributed to gradual transformation of 2 from form II to I. Gastrointestinal absorption of form III of 1, in human volunteers, was studied in comparison with the more stable form I. The same study was carried out on forms I and II of 2. Data were correlated and expressed in availability rate constants (K1), applying the one compartment open: model. This and other parameters show that form III of 1 is 1.4 times as much absorbed as form I, and that the availability of the metastable form II of 2 is 1.2 times as much absorbed as the stable form I.