Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study.

BACKGROUND: A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs. METHODS: Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. RESULTS: Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category. CONCLUSION: The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

The relationship between pre-operative hypertension and intra-operative haemodynamic changes known to be associated with postoperative morbidity.

Hypertension is not consistently associated with postoperative cardiovascular morbidity and is therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with peri-operative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, non-cardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of < 55 mmHg occurred in 59 (18.2%) patients, of which 25 (42.4%) were hypertensive. Intra-operative tachycardia (heart rate> 100 beats.min-1 ) occurred in 126 (38.9%) patients, of whom 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data, therefore, support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient's blood pressure is < 180/110 mmHg.

Using therapeutic mammoplasty to extend the role of breast-conserving surgery in women with larger or ptotic breasts.

INTRODUCTION: The equivalence of breast-conserving surgery followed by postoperative radiotherapy against mastectomy is now firmly established in patients with early breast cancer. The results of surgery in large-breasted women can be poor, with radiation-induced fibrosis, chronic pain and poor cosmesis contributing to long-term psychological and physical morbidity. Therapeutic mammoplasty offers an alternative management strategy to both enhance the role of breast-conserving surgery and provide better outcomes. METHODS: A retrospective note review was undertaken of all patients undergoing therapeutic mammoplasty for breast malignancy between 2007 and 2011. All cases were performed using a Wise pattern-reduction technique. Histology and pathological outcomes were assessed. Postoperative outcomes reviewed included wound infection, seroma and need for further intervention. RESULTS: During the study period, 20 patients underwent therapeutic mammoplasty with a mean follow-up duration of 36 months. The mean weight of the lumpectomy specimen was 330g. The average cancer size was 34mm, with a mean margin clearance of 7mm. There was one episode of wound infection and three of delayed wound healing at the T-junction. One patient required a mastectomy for involved margins. There were no recurrences at the most recent follow-up visit. CONCLUSIONS: Therapeutic mammoplasty offers a tailored approach to women with larger breasts and early breast cancers with good cosmetic results and oncological outcomes.

Ultrasonic dissection versus electrocautery in mastectomy for breast cancer - a meta-analysis.

BACKGROUND: Electrocautery has advanced the practice of mastectomy but significant morbidity, such as seroma and blood loss, remains a concern. This has led to newer forms of dissection being introduced including the ultrasonic dissection devices, which are thought to reduce tissue damage. The aim of this systematic review was to compare the outcomes after mastectomy using novel ultrasonic dissection or standard electrocautery in published trials. METHODS: Medline, Embase, trial registries, conference proceedings and reference lists were searched for comparative trials of ultrasonic dissection versus electrocautery for mastectomy. The primary outcomes were total postoperative drainage, seroma development and intra-operative blood loss. Secondary outcomes were operative time and wound complications. Odds ratios were calculated for categorical outcomes and standardised mean differences for continuous outcomes. RESULTS: Six trials were included in the analysis of 287 mastectomies. There was no effect in total postoperative drainage (pooled analysis weight mean difference: -0.21 (95% CI: -0.70-0.29); p = 0.41) or seroma development (pooled analysis odds ratio: 0.77 (95% CIs 0.43-1.37); p = 0.37). Intra-operative blood was slightly less for ultrasonic dissection compared to standard electrocautery (pooled analysis weight mean difference: -1.04 (95% CI: -2.00 to -0.08); p = 0.03). Ultrasonic dissection and standard electrocautery had similar outcomes with regard to operative time and wound complications. CONCLUSION: Ultrasonic dissection and standard electrocautery appear to deliver similar results in the mastectomy setting. Further cost-effectiveness analysis may guide surgeon selection in the use of new technologies for mastectomy.

Cyclooxygenase-2 and chemoprevention of breast cancer.

This article discusses the role of cyclooxygenase-2 (COX-2) in the aetiology and progression of breast cancer. Renewed interest in chemoprevention using non-steroidal antiinflammatory drugs (NSAIDS) has come from observations that regular NSAID use is associated with a reduced incidence of some cancers including that of the breast. There is an increasing body of evidence supporting a role for COX-2 in breast cancer development and progression via effects on angiogenesis and apoptosis as well as via effects on intratumoural aromatase. New selective inhibitors of COX-2 are currently licensed for use in the treatment of arthritis and more recently in the chemoprevention of familial adenomatous polyposis (FAP). Large clinical chemoprevention studies with COX-2 inhibitors are already underway in colorectal cancer. Their role in breast cancer prevention and treatment has yet to be fully characterised, but merits further investigation.

Polychlorinated biphenyls and organochlorine pesticides in EELS (Anguilla anguilla L.) from Welsh rivers.

Organochlorine concentrations in the muscle tissues of eels at 41 freshwater sites across Wales were surveyed in 1993. Positive but weak relationships were detected between eel age or length and the concentration of some organochlorines. Isomers of HCH were below detection at most sites. Dieldrin was widespread at 10-100 microg kt(-1) wet weight, despite its ban in sheep dip in 1989. Total DDT residue concentrations averaged 73 microg kg(-1). Total PCB burdens expressed as Arochlor 1260, were > 50 microg kg(-1) at 76% of sites and > 100 microg kg(-1) at 46% of sites. The range of concentrations was comparable with other UK data. Rural sites had relatively low levels of PCBs, highest contamination occurring in the lower reaches of industrialised catchments. The inferences for environmental effects are discussed.

Semantic generalization investigated using second-order conditioned visual afterimages.

A series of experiments is reported during which three subjects were initially classically conditioned to produce visual percepts to a sound only, second-order conditioned to transfer that response to an animal name, and finally taught a "foreign language". The results suggest that semantic generalization occurs whether the semantic relationships are formed either before or after the conditioned response is established.

An effective paradigm for conditioning visual perception in human subjects.

Repeated pairing of an auditory conditioned stimulus with a weak visual unconditioned stimulus produced extended image sequences and visual responses conditioned to the tone alone. The experiment is set into the context of Pavlov's view of Helmholtz's "unconscious inference" thus providing experimental evidence linking the higher mental process of perception with classical conditioning.

Study of hydrolysis of amido-substituted gamma-butyrolactones by pH-stat titration and ultraviolet spectroscopic analyses.

pH-Stat titration and ultraviolet absorption spectroscopy have been used to study the rates of ring-opening in a series of gamma-butyrolactones and their analogues. The half-lives for the lactones can be related to Hammett inductive and steric parameters.