The effect of the transition to Electronic Patient Records on adherence to venous thromboembolism prophylaxis guidelines in general surgical patients.

INTRODUCTION AND OBJECTIVES: Surgical patients are at risk of hospital-acquired venous thromboembolisms (VTEs), and preventative measures such as thromboembolism deterrent stockings (TEDs) and low molecular weight heparin (LMWH) are proven to be beneficial. The National Quality Requirement in the NHS Standard Contract 2017/19 in England mandates that 95% of inpatients undergo VTE risk assessments. As hospitals transition to Electronic Patient Records (EPR), it is important to observe the impact on vital safety indicators such as VTE risk. The aim of this study is to observe the effect of implementing EPR in a tertiary centre on adherence to national guidelines, including VTE assessment rates and prophylaxis administration in surgical patients. MATERIALS AND METHODS: Using consecutive sampling, all acute surgical admissions at the hospital from 26/02/2018 to 18/03/2018 (n=154) pre-EPR and 31/10/2018 to 25/11/2018 (n=151) post-EPR were observed for VTE risk assessment, 24-h re-assessment, prophylaxis prescriptions, administration, and patient compliance. Data was compared using a two-tailed Z-test. RESULTS: Pre-EPR, 96% of patients had completed VTE assessments, which increased after EPR implementation to 97% (p=0.39). LWMH prescription rates decreased from 82% to 77% following EPR (p=0.14). Moreover, TED prescriptions decreased from 84% to 64% post-EPR (p<0.01). Administration rates of prophylaxis generally improved post-EPR. The 24-h re-assessment rate decreased from 62% to 54% of patients (p=0.08). CONCLUSION: The study demonstrated that EPR is non-inferior to paper records. Transitioning to an EPR system did not interfere with the completion of VTE risk assessments, hence did not negatively impact the ability to achieve national targets.

The effects of microstructure, Nb content and secondary Ruddlesden-Popper phase on thermoelectric properties in perovskite CaMn1-x Nb x O3 (x = 0-0.10) thin films.

CaMn1-x Nb x O3 (x = 0, 0.5, 0.6, 0.7 and 0.10) thin films have been grown by a two-step sputtering/annealing method. First, rock-salt-structured (Ca,Mn1-x ,Nb x )O thin films were deposited on 11̄00 sapphire using reactive RF magnetron co-sputtering from elemental targets of Ca, Mn and Nb. The CaMn1-x Nb x O3 films were then obtained by thermally induced phase transformation from rock-salt-structured (Ca,Mn1-x Nb x )O to orthorhombic during post-deposition annealing at 700 °C for 3 h in oxygen flow. The X-ray diffraction patterns of pure CaMnO3 showed mixed orientation, while Nb-containing films were epitaxially grown in [101] out of-plane-direction. Scanning transmission electron microscopy showed a Ruddlesden-Popper (R-P) secondary phase in the films, which results in reduction of the electrical and thermal conductivity of CaMn1-x Nb x O3. The electrical resistivity and Seebeck coefficient of the pure CaMnO3 film were measured to 2.7 Ω cm and -270 µV K-1 at room temperature, respectively. The electrical resistivity and Seebeck coefficient were reduced by alloying with Nb and was measured to 0.09 Ω cm and -145 µV K-1 for x = 0.05. Yielding a power factor of 21.5 µW K-2 m-1 near room temperature, nearly eight times higher than for pure CaMnO3 (2.8 µW K-2 m-1). The power factors for alloyed samples are low compared to other studies on phase-pure material. This is due to high electrical resistivity originating from the secondary R-P phase. The thermal conductivity of the CaMn1-x Nb x O3 films is low for all samples and is the lowest for x = 0.07 and 0.10, determined to 1.6 W m-1 K-1. The low thermal conductivity is attributed to grain boundary scattering and the secondary R-P phase.

Synthesis and characterization of single-phase epitaxial Cr2N thin films by reactive magnetron sputtering.

Cr2N is commonly found as a minority phase or inclusion in stainless steel, CrN-based hard coatings, etc. However, studies on phase-pure material for characterization of fundamental properties are limited. Here, Cr2N thin films were deposited by reactive magnetron sputtering onto (0001) sapphire substrates. X-ray diffraction and pole figure texture analysis show Cr2N (0001) epitaxial growth. Scanning electron microscopy imaging shows a smooth surface, while transmission electron microscopy and X-ray reflectivity show a uniform and dense film with a density of 6.6 g cm-3, which is comparable to theoretical bulk values. Annealing the films in air at 400 °C for 96 h shows little signs of oxidation. Nano-indentation shows an elastic-plastic behavior with H = 18.9 GPa and E r = 265 GPa. The moderate thermal conductivity is 12 W m-1 K-1, and the electrical resistivity is 70 µΩ cm. This combination of properties means that Cr2N may be of interest in applications such as protective coatings, diffusion barriers, capping layers and contact materials.

A DNA methylation site within the KLF13 gene is associated with orexigenic processes based on neural responses and ghrelin levels.

We investigated five methylation markers recently linked to body mass index, for their role in the neuropathology of obesity. In neuroimaging experiments, our analysis involving 23 participants showed that methylation levels for the cg07814318 site, which lies within the KLF13 gene, correlated with brain activity in the claustrum, putamen, cingulate gyrus and frontal gyri, some of which have been previously associated to food signaling, obesity or reward. Methylation levels at cg07814318 also positively correlated with ghrelin levels. Moreover, expression of KLF13 was augmented in the brains of obese and starved mice. Our results suggest the cg07814318 site could be involved in orexigenic processes, and also implicate KLF13 in obesity. Our findings are the first to associate methylation levels in blood with brain activity in obesity-related regions, and further support previous findings between ghrelin, brain activity and genetic differences.

The effect of implant design and bone density on maximum torque and holding power for femoral neck fracture devices.

BACKGROUND AND AIMS: Displacement of internally fixed femoral neck fractures due to implant migration is a common problem. This in vitro study was performed to compare maximum torque and holding power for five different implants. MATERIAL AND METHODS: Synthetic porous material with low, medium or high density was used to simulate cancellous bone. The tested implants included three conventional screws (AO, Olmed, Hansson), one screw with threads and a barb (Hybrid), and a pin with a hook (LIH). RESULTS: The Hansson screw provided higher maximum torque in low and medium density blocks when compared with the other implants (p < 0.0001) followed by LIH, Hybrid, Olmed, and AO. For high-density blocks there was no significant difference between Hansson and Hybrid screws, both with significantly higher torque than the other implants. The maximal pullout in low-density blocks differed significantly between all five implants with the Hansson screw providing the highest holding power. For medium and high-density blocks the conventional screws had significantly higher pullout resistance compared with the Hybrid and LIH. CONCLUSION: The in vitro model used seemed to provide reproducible and clinically relevant results. There was a good correlation between material density and holding power for all implants. Screws inserted without predrilling provided higher maximal torque while maximal pull out load seemed less affected by predrilling being used or not.

Long-term cardiac mortality following radiation therapy for Hodgkin's disease: analysis with the relative seriality model.

PURPOSE: (a) To assess the increased risk of death due to ischemic heart disease (IHD) in a group of patients treated for Hodgkin's disease (HD) with radiation therapy (RT) as the primary treatment. (b) To quantify the dose response of IHD using a biophysical model. MATERIALS AND METHODS: Patient material consisted of 157 patients diagnosed for HD between 1972 and 1985 who received RT as the primary treatment at Radiumhemmet, Karolinska Hospital. The general population formed the control group. The RT treatments were reconstructed based on the individual treatment data and simulator films. Individual clinical and dosimetrical data were analyzed with the relative seriality model. The material was also analyzed grouping the material according to dose-volume constraints. RESULTS: Of the 157 patients, 13 (8.3%) died due to IHD. The standardized mortality ratio (SMR) was 5.0 (95% CI, 2.7-8.6). Analysis of dose-volume histograms (DVH) showed an increasing risk with increasing dose to a larger volume fraction. The observed individual clinical complication data could not be modeled unambiguously. The group analysis resulted in the dose-response parameters: D(50)=71 Gy, gamma=0.96 and s=1.0. CONCLUSIONS: A significantly increased risk of death due to IHD following RT for HD was found. The risk was found to increase with higher dose and larger volume fraction irradiated.

Radiation pneumonitis after breast cancer irradiation: analysis of the complication probability using the relative seriality model.

BACKGROUND: Toxicity of the respiratory system is quite common after radiotherapy of thoracic tumors; breast cancer patients represent one of the groups for which there is also a long expected survival. The quantification of lung tissue response to irradiation is important in designing treatments associated with a minimum of complications and maximum tumor control. METHODS: The study population consisted of 68 patients who received irradiation for breast cancer at Stage II. Radiation pneumonitis was retrospectively assessed on the basis of clinical symptoms and radiological findings. For each patient, a measure of the exposure (i.e., the lung dose-volume histogram [DVH]) and a measure of the outcome was available. Based on these data, a maximum likelihood fitting to the relative seriality model was performed. The uncertainties of the model parameters were calculated and their impact on the dose-response curve was studied. The optimum parameter set was then applied to 5 other patient groups treated for breast cancer, and the normal tissue complication probability (NTCP) was calculated. Each group was individuated by the radiotherapy treatment technique used; the dose distribution in the lung was described by a mean DVH and the incidence of radiation pneumonitis in each group was known. Lung radiosensitivity was assumed to be homogeneous through all of the calculations. RESULTS: The relative seriality model could describe the dataset. The volume effect was found to be relevant in the description of radiation pneumonitis. Age was found to be associated with increased risk of radiation pneumonitis. Two distinct dose-response curves were obtained by splitting the group according to age. The impact of the parameter uncertainties on the dose-response curve was quite large. The parameter set determined could be used predictively on 3 of the 5 patient groups. CONCLUSION: The complication data could be modeled with the relative seriality model. However, further independent datasets, classified according to the same endpoint, must be analyzed before introducing NTCP modeling in clinical practice.

Role of endogenous pro-enkephalin A-derived peptides in human T cell proliferation and monocyte IL-6 production.

In this paper, we describe that met-enkephalin and/or enkephalin-containing intermediary peptides of the prohormone pro-enkephalin A are produced and secreted by human peripheral blood T cells and monocytes. The peptides are produced after stimulation with the mitogenic monoclonal antibodies anti-CD2.1/2.2 and anti-CD28. In monocytes, enkephalin synthesis was induced by stimulation with lipopolysaccharide. We demonstrate here that these immune cell-derived enkephalins play an important regulatory role in the immune response. By using an anti-sense oligonucleotide strategy we could block the production of enkephalins. Blockade of the production of met-enkephalin and enkephalin-containing intermediary peptides resulted in enhancement of the proliferative T cell response and inhibition of monocyte IL-6 secretion. In vitro reconstitution of the anti-sense treated cultures with synthetic met-enkephalin or the delta-type specific opioid receptor agonist deltorphin could reverse inhibition of monocyte IL-6 production, suggesting that endogenous enkephalins act via membrane opioid receptors. In contrast, addition of met-enkephalin or deltorphin to the anti-sense treated T cell cultures did not have any effect on T cell proliferation.

Bile acid malabsorption after intestinal bypass surgery for obesity. A comparison between jejunoileal shunt and biliointestinal bypass.

Seventeen patients were operated on with intestinal shunts for morbid obesity, in eight a biliointestinal bypass (BI) was constructed and in the rest a conventional jejunoileal (JI)-shunt. The reduction in weight was similar in both groups, and so was malabsorption of fat, but the BI-group had significantly less bowel motions with less watery diarrhoea. Bile acid malabsorption was measured both chemically by estimating the total amount of faecal bile acids excreted, as well as indirectly by using a 75Se-labelled synthetic bile acid (SeHCAT). Both techniques revealed a substantial loss of bile acid after both types of operation, but patients with BI bypass surgery had significantly lower elimination time of the bile acid than those with JI-shunts. There was a significant negative correlation between SeHCAT retention and total faecal bile acids. However, some patients with low SeHCAT retention had normal or even reduced output of faecal bile acids. Estimation of faecal bile acids may display false negative results when the bile acid pool is decreased. The SeHCAT-test seems to be a better technique for measuring bile acid losses. The study suggests that BI bypass surgery for obesity seems to be advantageous over the JI shunt in reducing the postoperative loss of bile acids and choleretic diarrhoea, without influencing the weight loss.

Biliointestinal bypass.

To eliminate the blind loop in conventional jejunoileal bypass (JIB) and to maintain enteroheptic circulation of bile, thus hoping to diminish important side-effects of JIB, biliontestinal bypass was introduced in 1975, entailing anastomosis of the blind jejunal loop to a functioning gallbladder. Twenty-two patients with a mean weight of 126 kg (91-154 kg) have had primary bilio-intestinal bypass and another four secondary anastomosis of the gallbladder due to side-effects of the previous JIB. A mean weight reduction of 50 kg was achieved in the 20 patients observed for 24 months, without any serious side-effects, corresponding to a reduction of overweight from 89 per cent preoperative to 14 per cent in a subsample of seven patients followed for five years. Without affecting body weight in the four patients subjected to secondary operation, it ameliorated the side-effects of JIB during observation of more than 6 months. Follow-up with i.v. cholangiography and Tc99 HIDA scintigram conclusively revealed open anastomoses in nine of ten patients adequately judged by the scan and no evidence of gallstones on 15 cholangiograms performed so far. Renal calculi were found in three patients, mainly in the first postoperative year but urine oxalate was in the normal range after more than years of follow-up. It is concluded that jejunoileal bypass combined with cholecystojejunostomy in patients with functioning gallbladders is a safe and relatively simple method for treating morbid obesity in selected cases.