Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery.

BACKGROUND: Despite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions. METHODS: An ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ). RESULTS: We included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ±â€¯24.1 vs 46.1 ±â€¯37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ±â€¯8.7 vs 15.1 ±â€¯10.3 MMEQ, P <0.001), lower peak pain scores (7 [5-9] vs 8 [7-9], P=0.007) and a shorter hospital length of stay (2.5 ±â€¯0.5 vs 2.9 ±â€¯1.2 days, P <0.001) were found after the introduction of the ERAS protocol. CONCLUSIONS: Implementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

Prospective study of skin surgery in smokers vs. nonsmokers.

BACKGROUND: Smoking may increase complications following minor surgery leading many clinicians to urge patients to refrain from smoking before and after surgery. OBJECTIVE: To study the association between smoking and complications following skin surgery. METHODS: In a 5-year prospective observational study 7224 lesions were excised on 4197 patients. Patients were not instructed regarding smoking. All complications were recorded. RESULTS: A total of 439 smokers (10.5%) underwent 646 procedures (9%), 3758 nonsmokers (89.5%) underwent 6578 procedures (91%). Smokers were younger (55 +/- 16 years) than nonsmokers (66 +/- 17 years) (P < 0.001). Infection incidence was not significantly different, 1.9% (12/646) in smokers compared with 2.2% (146/6578) in nonsmokers (P = 0.55). There were two bleeds with smokers (0.3%) vs. 50 in nonsmokers (0.8%) (P = 0.2). The incidence of wound dehiscence in nonsmokers (three) was not different from nonsmokers (21) (P = 0.54). However, the incidence of scar contour distortion in smokers (three) was greater than in nonsmokers (two) (odds ratio 15.3; 95% confidence interval 2.5-92). Total complication incidence was similar, 3.6% in smokers vs. 4.0% in nonsmokers (P = 0.58). Out of 2371 flaps there were 14 (0.6%) cases of end-flap necrosis but smokers were not at increased risk. The case-control analysis compared each smoker with two nonsmokers matched for age, sex, postal code and outdoor occupational exposure. This again demonstrated no difference in infection, scar complication, bleed, dehiscence, end-flap necrosis or total complication incidence. CONCLUSIONS: Smokers and nonsmokers suffer skin surgery complications similarly. The increased risk of contour distortion identified was difficult to interpret. Advice to cease smoking in the short term to improve outcomes with skin cancer surgery is not supported by these data.

Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy.

BACKGROUND: The aim was to identify risk factors for postoperative bleeding following skin cancer surgery. METHODS: This was a prospective study of 5950 skin lesions excised in 2394 patients. No patient stopped taking aspirin or warfarin unless the international normalized ratio (INR) exceeded 3.0. RESULTS: The rate of postoperative bleeding was 0.7 per cent overall and 2.5 per cent in the 320 patients taking warfarin. The rate of bleeding was 1.0 per cent for skin flap repairs, 0.4 per cent for simple excision and closure, and 5.0 per cent for skin grafts. Diabetic patients and smokers were not at increased risk of bleeding. There were four independent factors for bleeding: age 67 years or older (odds ratio (OR) 4.7 (95 per cent confidence interval 1.8 to 12.2); P = 0.002), warfarin therapy (OR 2.9 (1.4 to 6.3); P = 0.006), surgery on or around the ear (OR 2.6 (1.2 to 5.7); P = 0.012) and closure with a skin flap or graft (OR 2.7 (1.4 to 5.3); P = 0.004). Aspirin therapy was not an independent risk factor for bleeding. CONCLUSION: Most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin. There was no case for discontinuing aspirin before skin surgery, but the INR should be monitored in patients taking warfarin.

Randomized clinical trial of the effect of applying ointment to surgical wounds before occlusive dressing.

BACKGROUND: A blinded randomized clinical trial was undertaken to evaluate the effect of applying ointment to a wound before occlusive dressing, in comparison with no ointment or sterile paraffin. METHODS: Some 778 patients with 1801 surgical wounds following excision of skin lesions were enrolled in the trial. No ointment was placed on 510 sutured wounds of 247 patients, paraffin ointment was put on 729 wounds (269 patients) and mupirocin ointment on 562 wounds (262 patients). Wound infection, scar, haemorrhage, dehiscence and other complications were assessed at suture removal. At 6-9 months after surgery, patients were surveyed to assess the wounds, with a response rate of 74.0 per cent. RESULTS: There were no significant differences in outcome for all endpoints evaluated. The infection rate was 1.4 per cent with no ointment, 1.6 per cent for paraffin and 2.3 per cent for mupirocin (P = 0.490). Total complication rates were 3.5, 4.7 and 4.8 per cent for no ointment, paraffin and mupirocin respectively (P = 0.590). Some 10.9, 10.3 and 8.2 per cent of patients respectively had a neutral or negative perception of their wounds at 6-9 months after surgery (P = 0.650). There was no difference in postoperative pain, degree of inconvenience or overall level of satisfaction with treatment. CONCLUSION: Putting ointment on a surgical wound before occlusive dressing does not benefit the patient. In view of the risk of antibiotic resistance, mupirocin ointment is not indicated for clean surgical wounds.

An effective, cosmetically acceptable, novel hydro-gel emollient for the management of dry skin conditions.

BACKGROUND: A novel hydro-gel emollient (Doublebase) has been developed with improved moisturizing effects. OBJECTIVE: To test this novel hydro-gel for its moisturizing effect, for its potential to cause skin irritancy/allergy and for its clinical effectiveness and acceptability in dry skin conditions. METHODS/RESULTS: Skin hydration (corneometry) and trans-epidermal water loss (TEWL) studies with a single application in 18 volunteers confirmed its efficacy (p < 0.0001) and showed that it was superior to Ultrabase and Diprobase (p < 0.001). Skin hydration studies with multiple applications in 12 volunteers also showed that it was superior to Ultrabase and Diprobase (p < 0.0001). Irritation tests in 74 eczema-prone patients resulted in only one mild reaction, and allergy tests in 99 healthy volunteers elicited no positive reactions. The clinical acceptability and effectiveness of Doublebase was demonstrated in an open study of 78 patients with dry skin conditions. CONCLUSION: Doublebase may be considered a suitable preparation that can be used effectively by most patients with dry skin conditions.

Probable colchicine-induced neutropenia not related to intentional overdose.

OBJECTIVE: To report a case of neutropenia caused by colchicine not associated with intentional overdose or with preceding severe gastrointestinal symptoms. CASE SUMMARY: A 68-year-old white man was admitted to the hospital with intractable pain from an acute attack of gout. The patient was treated with standard doses of oral colchicine for several days. He experienced mild loose stools, but no severe diarrhea or nausea during treatment. The patient then developed severe neutropenia, with an absolute neutrophil count of 240 cells/mm3. His white blood cell count returned to normal after discontinuing colchicine and administering filgrastim. DISCUSSION: Although colchicine is commonly associated with neutropenia in cases of intentional or accidental overdose, the patient developed this adverse effect after being treated with doses commonly used for the acute treatment of gout. In addition, this patient had taken low-dose colchicine for many years without experiencing hematologic adverse effects. CONCLUSIONS: Colchicine is often an attractive alternative to nonsteroidal antiinflammatory agents for the treatment of gout, especially in patients at risk for renal impairment or gastropathy. Our case illustrates that colchicine treatment can cause hematologic adverse effects; the clinician should monitor cell counts in patients receiving this agent, especially at the higher doses used for acute treatment of gout.

Evaluating the efficacy of vaccine storage in the general practice setting.

OBJECTIVES: To describe the implementation of guidelines for vaccine storage in general practice, and their effectiveness in achieving optimum vaccine storage temperatures in fridges. DESIGN: Repeated cross-sectional surveys over time--phase 1 1996/97, phase 2 1998/99, phase 3 1999/2000. SETTING: Central Coast, New South Wales. PARTICIPANTS: Phase 1--all general practices on the Central Coast. Phases 2 and 3--samples of practices. INTERVENTIONS: Each practice was surveyed about how they stored vaccines. A datalogger recorded fridge temperatures over six days. Individual feedback and advice were given. MAIN OUTCOME MEASURES: Proportion of: 1. fridges maintaining a temperature in the 2-8 degrees C range; 2. fridges freezing; 3. practices with one person responsible for vaccine storage; 4. bridge temperature checked daily; 5. fridges storing no items other than vaccines; 6. bridges with thermometers; and 7. associations between storage practices and fridge temperatures. RESULTS: In phase 1, 102 fridges, and in phase 3, a random sample of 36 practices was surveyed. The findings for phase 1 and phase 3 respectively were: 31% and 50% of fridges were in the 2-8 degrees C range; 36% and 25% were <0 degrees C; one person was responsible in 52% and 53% of cases; 20% and 38% reported daily checks; 74% and 94% of fridges had no extraneous items and 53% and 86% of fridges had thermometers. No statistically significant associations were found between vaccine storage practices and bridge temperatures. CONCLUSIONS: Despite improvements in vaccine storage practices, a quarter of fridges were freezing, thereby compromising the potency of many of the immunisation schedule vaccines.

Novel kainic acid analogues. Effects on cyclic GMP content of adult rat cerebellar slices.

On the basis of previous electrophysiological studies, it has been proposed that there are three main classes of excitatory amino acid receptor in the mammalian central nervous system, which are activated preferentially by kainic acid, quisqualic acid and N-methyl-D-aspartate respectively. Although the pharmacology of the N-methyl-D-aspartate receptor has been investigated extensively, potent and selective ligands which act at the kainate or quisqualate sites are lacking. In this study, we report that a number of novel kainate analogues possess either agonist or antagonist activity in a system which permits investigation of receptor-mediated coupled responses, viz. the ability of excitatory amino acids to elevate cyclic GMP concentrations in incubated cerebellar slices prepared from the adult rat. The data reported here provide some clues as to the likely structural requirements for developing effective kainate antagonists.

Kainic acid derivatives with anticonvulsant activity.

beta-Kainic acid, and the glycine and amino-methylphosphonate derivatives of alpha- and beta-kainic acid, have been injected intracerebroventricularly in DBA/2 mice, that show sound-induced seizure responses. An anticonvulsant effect is observed with marked protection against the tonic and clonic phases of the seizure response. ED50 values against clonus are (in mumol): beta-kainic acid, 0.09; beta-kainylglycine, 0.11; alpha-kainylglycine, 0.28; alpha-kainylaminomethylphosphonate, 0.31; beta-kainylaminomethylphosphonate, greater than 1.5. In addition a direct convulsant effect occurs after the alpha-kainyl derivatives.

Ultrastructural localisation of fibronectin in mouse kidney.

The ultrastructural localisation of fibronectin in mouse kidney was investigated by indirect immunoperoxidase cytochemistry. In glomeruli, fibronectin was found predominantly in matrix between endothelial and mesangial cells. Smaller quantities were demonstrable in peripheral capillary walls both subendothelially and around visceral epithelial cell foot processes. It was present between parietal epithelial cells and Bowman's capsule and at the base of tubular epithelial cells outlining the inner aspect of tubular basement membranes.

Interstitial nephritis.

The clinical and pathological findings are reviewed in ten cases where renal biopsy showed abnormalities predominantly within the interstitium. In six the nephritis was considered to be drug-induced; in two the aetiology was slightly obscure but the most likely diagnosis was considered to be sarcoidosis. Of the remaining two cases one was chronic pyelonephritis and the other polyarteritis nodosa. The diagnosis and pathogenesis of the renal lesions are discussed and attention is drawn to the importance of distinguishing primary interstitial changes from those found in association with glomerular disease.

Distribution of fibronectin in normal and diseased human kidneys.

The distribution of fibronectin in 42 renal biopsies was investigated using an indirect immunoperoxidase technique on paraffin sections of formalin-fixed material. Biopsies were obtained from normal human kidneys and from patients with a variety of glomerular disorders. In normal glomeruli, fibronectin was present in Bowman's capsule, in the mesangium, and outlining peripheral capillary loops. A significant increase in fibronectin was observed in most types of glomerulopathy with a distribution closely related to the histopathological diagnosis. Fibronectin was diminished or absent in segmental scars, old diabetic nodules, and hyalinised glomeruli.

Immunoperoxidase localisation of fibronectin in glomeruli of formalin fixed paraffin processed renal tissue.

An indirect immunoperoxidase technique was used to demonstrate fibronectin in sections of routine formalin fixed paraffin embedded renal tissue. Previous exposure of the sections to a solution of pepsin (4 mg/ml) in 0.01 N HCl for 2 h at 37 degrees C was essential in order to demonstrate antigenicity of fibronectin previously masked by fixation and embedding procedures.

Indoprofen and naproxen in the treatment of rheumatoid arthritis: a clinical trial.

Thirty-six patients suffering from rheumatoid arthritis took part in a double-blind crossover trial, in which they received either indoprofen 800 mg/day, naproxen 500 mg/day, or a matching placebo. Indoprofen was shown to be significantly superior as an analgesic and in improving grip strength and the patients preferred it. Adverse effects were comparable, although indigestion was seen slightly more often during indoprofen treatment. Indoprofen is therefore at least as effective as existing anti-inflammatory drugs in rheumatoid arthritis and seems to be better tolerated.

The great toe as a clinical problem in rheumatoid arthritis.

Two hundred consecutive in-patients with rheumatoid arthritis were examined for pain or deformity of the feet, and of the great toe in particular. Some abnormality occured in 196 feet and the deformities observed are presented. The symptoms that arise from these deformities are mainly derived from ill-fitting shoes, and the need for suitable foot-wear is emphasized. Two hitherto un-named entities are described namely Hallux tortus and chisel toe, since they give rise to their own shoe-fitting problems.