An opportunity in op-notes.

Operative notes in surgical practice are a vital source of information and communication between healthcare professionals as well as being a legal document. Errors and omissions can have serious effects on patient care and lead to confusion. We audited our compliance within trauma and orthopaedics at a busy district general hospital in South East England with the standard set by the Royal College of Surgeons (England) before and after the introduction of an operation note template. We achieved significant improvements in compliance across almost all of the standard's domains and recommend widespread implementation of similar templates nationally.

Acute kidney injury in ELBW infants (<  750 grams) and its associated risk factors.

BACKGROUND: The advancement of neonatology over the past 20 years has allowed a greater number of ELBW infants to survive. However, these advancements have contributed to the increased incidence of acute kidney injury (AKI) seen in this population. Understanding the risk factors for AKI in this population of ELBW infants is imperative for the successful survival of these infants since the morbidity and mortality rates from this disease are increasing. OBJECTIVES: 1) to determine the prevalence of AKI in ELBW (<  750 grams). 2) to compare the mortality rate of ELBW infants (<  750 grams) with and without AKI; and 3) to identify the associated risk factors of AKI in ELBW infants (<  750 grams). METHODS: A retrospective chart review of all infants with AKI as defined by AKIN criterias, admitted to the NICU between 1998 and 2008 was conducted. Case-controls were matched for BW, gestational age and date of birth, (SPSS v17.0 software, using Student's t test, X2 test, and Mann-Whitney U test were used for statistical analysis. CONCLUSION: The prevalence rate of ELBW infants (<  750 grams) with AKI admitted at CHMCA NICU from 1998 to 2008 was 26% . The mortality rate of ELBW infants (<  750 grams) with AKI was 54% , compared to 20% in those ELBW infants who did not have AKI. The associated risk factors of AKI in the ELBW infants (<  750 grams) were as follows: presence of maternal placental abruption/bleeding, grade III or IV IVH, PDA, positive culture/s, NEC, use of steroid, nephrotoxic drugs, and longer use of the ventilator and TPN.

Injuries to the tibiofibular syndesmosis.

The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.

Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738). INTERVENTIONS: NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g. RESULTS: Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997. CONCLUSION: We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.

Economic implications of neonatal intensive care unit collaborative quality improvement.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Data on treatment costs were collected for infants with birth weight 501 to 1500 g for the period of January 1, 1994 to December 31, 1997. Data on resources expended by hospitals to conduct this project were collected in a survey for the period January 1, 1995 to December 31, 1996. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Nine other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (N = 2993) and the 9 comparison NICUs (N = 2203); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (N = 663) and the 9 comparison NICUs (N = 1007). INTERVENTIONS: NICUs formed multidisciplinary teams which worked together to undertake a collaborative quality improvement effort between January 1995 and December 1996. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: Treatment cost per infant is the primary economic outcome measure. In addition, the resources spent by hospitals in undertaking the collaborative quality improvement effort were determined. RESULTS: Between 1994 and 1996, the median treatment cost per infant with birth weight 501 to 1500 g at the 6 project NICUs in the infection group decreased from $57 606 to $46 674 (a statistical decline); at the 4 chronic lung disease hospitals, for infants with birth weights 501 to 1000 g, it decreased from $85 959 to $77 250. Treatment costs at hospitals in the control group rose over the same period. There was heterogeneity in the effects among the NICUs in both project groups. Cost savings were maintained in the year following the intervention. On average, hospitals spent $68 206 in resources to undertake the collaborative quality improvement effort between 1995 and 1996. Two thirds of these costs were incurred in the first year, with the remaining third in the second year. The average savings per hospital in patient care costs for very low birth weight infants in the infection group was $2.3 million in the post-intervention year (1996). There was considerable heterogeneity in the cost savings across hospitals associated with participation in the collaborative quality improvement project. CONCLUSION: Cost savings may be achieved as a result of collaborative quality improvement efforts and when they occur, they appear to be sustainable, at least in the short run. In high-cost patient populations, such as infants with very low birth weights, cost savings can quickly offset institutional expenditures for quality improvement efforts.

A theoretical model of infant incubator dynamics.

A spatially lumped mathematical model was developed and used for a computer simulation of the neonate-incubator system for parametric analysis of the factors that influence neonatal thermo-regulation. The simulation examined the effects of the following parameters: (1) size of the infant; (2) respiratory rate; (3) metabolic rate; (4) heart rate; (5) thermal properties of the mattress; (6) specific heat capacity of the incubator wall; (7) air flow rate; (8) heater control mechanisms.

Teaching intubation skills using newly deceased infants.

This prospective study was designed to (1) test the hypothesis that the majority of families of newly dead infants in a tertiary neonatal intensive care unit would consent to their infants' being intubated for teaching purposes, (2) determine factors related to family consent, and (3) determine the effects of participation on resident physicians and respiratory therapists. Family consent for intubation was requested following 44 (80%) of the 55 deaths that occurred during the 10-month study period. Of these requests, 32 (73%) were granted. Proportionately more white than black families consented and consent was positively related to autopsy permission. Fifty-three (75%) of 71 trainees completed a mailed questionnaire after their first intubation experience. Although each respondent found the experience helpful, many reported mixed feelings categorized as doubt about participating, apprehension and discomfort, respect for the body, appreciation for the opportunity, a sense of achievement, and feelings of comfort knowing that consent had been obtained. These findings confirm our initial hypothesis and suggest that (1) newly dead infants can be a valuable resource for teaching intubation skills, and (2) others considering a similar approach need to be aware of and sensitive to trainees' feelings.

Fetal intestinal transplant model for mucosal immune responses.

A rat fetal intestinal transplant model was developed for long-term study of intestinal immune responses. For the model, fetal small intestine is transplanted into the dorsal subcutaneous tissue of syngeneic adults and allowed to mature, providing an accessible site, isolated from the intestinal stream. We previously demonstrated normal histologic maturation of the transplant. Specific antibody-producing cells appeared in the lamina propria of both transplant and native in situ intestine following intraluminal immunization of the transplant with cholera toxin, and conversely, in transplants after immunization of in situ intestine. An enterointestinal lymphocyte migratory pathway (originating in intestine and migrating to another region of the intestine) was thus demonstrated unequivocally. We found a bacterial flora in the transplant, and showed normal villus morphology in scanning electron microscopy. Less than 200 pg, i.e., a 10(-7) fraction, of 2 mg macromolecular lipopolysaccharide placed in the transplant lumen was absorbed per plasma lipopolysaccharide half-life. Immunization of the transplant with cholera toxin resulted in specific IgA and IgG antibody in the transplant lumen and in bile, and specific IgG, but not IgA, antibody in serum. A second dose of antigen gave an anamnestic rise in intra-transplant antibody. Intestinal immune tolerance was also demonstrated: sheep red blood cells (SRBC) administered into the transplant for 7 days suppressed splenic IgM plaque forming responses to subsequent intraperitoneal challenge with SRBC. These studies further demonstrate that the fetal intestinal transplant behaves immunologically like native intestine, and therefore provides a useful model for investigation of the intestinal immune system.

Occult blood in stools and necrotizing enterocolitis. Is there a relationship?

A prospective study was undertaken to determine the incidence of occult hematochezia in enterally fed low-birth-weight neonates (less than 1800 g at birth). The relationship of this occult hematochezia to the development of necrotizing enterocolitis (NEC) was then analyzed. Daily stool specimens from 95 neonates were tested for occult blood during the first six weeks of life. Fifty-four (58%) of the 95 neonates had one or more blood-positive stools. Six neonates (6.3%) developed NEC. Necrotizing enterocolitis occurred in only two of the 54 neonates with one or more blood-positive stools vs four of the 41 neonates with blood-negative stools only. Presence of occult blood in the stools did not correlate with development of NEC.

A trial of metaproterenol by metered-dose inhaler and two spacers in preschool asthmatics.

Because most young children have difficulty in coordination for correct use of metered-dose inhalers (MDI), a trial of two spacer devices attached to MDIs was performed. In 13 children with asthma, aged 2-5 years old, a collapsible bag (Inspir-Ease) and a tube spacer (Aerochamber) were tested in a double-blind crossover trial with metaproterenol (1,300 micrograms). Respiratory resistance was measured by the forced oscillation method. Thirty minutes after metaproterenol administration there was a significant decrease in resistance with both spacers, while no significant change occurred after placebo administration. There was no difference in degree of bronchodilation between the two spacers. It is concluded that metaproterenol can be safely and effectively administered to preschool asthmatics by an MDI with spacer devices.

Fetal intestinal transplants in syngeneic rats: a developmental model of intestinal immunity.

We conducted a longitudinal study of the development of lymphoid tissue in fetal small intestine transplanted to a subcutaneous site in adult syngeneic Fischer strain rats. Fetal jejunoileal segments obtained between 18 and 21 days of gestation were transplanted to a dorsal subcutaneous site on syngeneic adult rats. Three weeks later, intestinal segments greater than 2.5 cm in length were found in 70% of recipients. Each week for 6 wk post-transplantation, a full-thickness biopsy was obtained for histologic and immunohistologic examination. At the time of transplantation, fetal rat intestine did not display Peyer's patches, intraepithelial lymphocytes, lymphoid follicles, or IgA-containing plasma cells. These lymphoid structures reached adult levels by 4 wk after transplantation, and the sequence of development of the lymphoid structures in the transplants appeared to match the postnatal development of normal small intestine. After immunizing the in situ intestine or the transplanted fetal intestine with cholera toxin, the number of cells producing specific antibodies to the immunogen increased significantly in intestinal transplants and in situ intestine. In contrast, few if any cells synthesizing antibodies to cholera toxin developed in the transplants after i.p. immunization. This study suggests that fetal intestinal transplants behave as part of the mucosal immune system. This model may provide useful approaches to studying the development of mucosal immunity.

Suppressor-cytotoxic T-lymphocyte panniculitis.

A 3 1/2-year-old girl had fever and nonsuppurative panniculitis. Biopsies revealed lobular lymphocytic panniculitis. An extensive evaluation of the patient for infectious and other systemic diseases yielded negative results. Although the number of peripheral T lymphocytes was normal, suppressor-cytotoxic (OKT8) lymphocytes predominated in the subcutis of the lesions. Suppressor-cytotoxic T-lymphocyte panniculitis may represent a unique type of panniculitis.