Evolution of sentinel lymph node biopsy for breast cancer patients in a rural setting: 10 years' experience.

Sentinel lymph node (SLN) biopsy is the standard axillary staging procedure of early breast cancer. Superparamagnetic iron oxide (SPIO) nanoparticles have been found to be comparable to, while overcoming many of the limitations associated with, the current standard of care for SLN biopsies (dual localisation with radioisotope and patent blue dye). Here, SPIO dual localisation (Sienna+® and blue dye) is compared to blue dye alone for SLN biopsies in a rural centre where radioisotope techniques are not readily available. Sienna+® dual localisation is shown to be more likely to detect nodes (detection rate of 99% compared to 90% when using blue dye alone), and detect more nodes, than blue dye alone. The use of Magseed, a magnetic tracer, was not found to influence node detection. The results from this work show that Sienna+® dual localisation is superior to blue dye alone for detecting SLN, suggesting that it is an excellent alternative to dual localisation of radioisotope and blue dye for small centres lacking easy access to a nuclear medicine department.

Impact of public-private partnership on a regional colonoscopy service.

BACKGROUND: A public-private partnership for endoscopy was introduced in Geelong where there was no capacity for public hospital endoscopy lists to expand. This paper presents the impact of this partnership on colonoscopy services. METHODS: Data were collated from prospectively maintained databases. Wait-times to outpatient appointments, colonoscopy and follow-up were analysed between July 2015 and June 2017 allowing for a 12-month period of analysis before and after the initiation of the contract. Data are presented as medians (interquartile range). RESULTS: A total of 1300 colonoscopies were done between July 2015 and June 2016 compared to 2114 colonoscopies (P < 0.01) after the initiation of the public-private contract; 1073 (51%) colonoscopies were done on private contract. Prior to public-private contract, 41% patients waited more than 120 days from first presentation to healthcare services to diagnostic colonoscopy, this decreased to 19% after. Improvements were seen in both the waiting time for outpatient consultation (reduced from 92 days (39-136) prior to July 2016 to 73 days (32-122); P < 0.01) after) and the time taken from consultation to colonoscopy (from 125 days (70-207) to 36 days (21-159); P < 0.01) for category 1 patients. CONCLUSION: Wait-times for both specialist outpatient assessment and colonoscopy have been significantly reduced through the introduction of a unique public-private partnership in the Greater Geelong area, resulting in more timely access for public patients and improved compliance with new guidelines.

Hospital-wide implementation of an electronic-workflow solution aiming to make surgical practice improvement easy.

BACKGROUND: In measuring quality of health-care delivery, digital infrastructure is essential. The aim at this tertiary centre was to create a hospital-wide workflow system that collected data prospectively as part of daily practice. METHODS: In moving towards an electronic health record, a hospital-wide integrated workflow system was introduced in 2013, which electronically managed the perioperative patient journey while simultaneously facilitating surgical audit. Analysis of its implementation was carried out presenting early outcomes using general surgery as an example. RESULTS: Theatre-bookings (44 953) were made with compliance approaching 90% for all services. Of 7179 general surgical operations over 24 months, 5785 (80%) had an operation note created using the new system. Cumulative summation of uptake of synoptic operative reporting (SOR) for laparoscopic cholecystectomy (LC) was 81% with documentation being superior in terms of antibiotic use and steps to safe cholecystectomy (P < 0.001). A LC SOR took 4 min to complete (interquartile ranges 2-5 min, n = 425) and was immediately available on the day of surgery compared to narrative operative reports taking 2 days (interquartile ranges 1-5 days, n = 174) (P < 0.001). From July 2014 to November 2015, 557 (10%) complications were recorded for 5749 general surgical operations with 99% of complications being reviewed. CONCLUSION: The rapid and sustained uptake of both theatre-bookings and SOR likely reflect high end-user satisfaction with the system. Service metrics indicate a significant improvement in the time of delivery. The ability to seamlessly complete the audit cycle at an individual, department and hospital level has been achieved.

Twelve years' experience of sentinel lymph node biopsy for melanoma at a rural New Zealand hospital.

AIM: To document the false-negative sentinel lymph node biopsy (SLNB) rate for melanoma patients at a rural NZ hospital and the likelihood of further nodal involvement on completion lymph node dissection (CLND). METHODS: All patients undergoing SLNB for melanoma at this centre were identified from the study period. Basic demographics along with histological data of both the primary lesion and SLNB were collated. Local and regional recurrences were recorded as was mortality. RESULTS: Between January 2000 and July 2012, 95 patients underwent SLNB for melanoma. Ten patients (11%) underwent CLND after positive SLNB. A further two patients had a median of two additional nodes involved (range 1-3). After a median follow-up period of 65 months (range 47-112), 6 patients suffered nodal recurrence where previously a negative SLNB had been harvested, giving a false-negative rate of 38%. Recurrence occurred a median of 16 months after WLE and SLNB. CONCLUSION: A high false negative-negative rate was observed in this study. For those with a positive SLNB, a further 20% have further nodal involvement on CLND.

Index cholecystectomy: a continuing challenge for a provincial hospital.

AIMS: To review the management of acute gallstone disease at a provincial New Zealand centre and compare to current national/international practice. METHODS: All patients presenting to Nelson Hospital with acute gallstone-related pathology were identified from the study period. The first presentation within the audit period was defined as the index admission. Length of stay and interventions were recorded. Waiting lists were compared. RESULTS: Between January 2004 to December 2010, 390 patients were admitted with acute gallstone-related pathology to Nelson Hospital. The index cholecystectomy rate was 17% (57/329) after exclusion of 61 ineligible patients; 158/329 patients subsequently underwent elective cholecystectomy, with patients waiting a median time of 97 days (range 7-1922). There were 132 Emergency Department visits (median one (range 0-8)), and 59 readmissions with acute gallstone-related pathology for those waiting for cholecystectomy. Of the 37 admitted with gallstone pancreatitis, 11 underwent cholecystectomy within 2 weeks of index admission. Waiting lists remained unchanged over time. CONCLUSIONS: Nelson Hospital has a low rate of index cholecystectomy. High numbers of patients represent to the emergency department or are readmitted whilst waiting for definitive surgery. Patients presenting with gallstone pancreatitis fail to receive treatment in accordance with international management guidelines.

Index cholecystectomy for management of acute gallstone disease: a change of practice at a major New Zealand metropolitan centre.

OBJECTIVES: This study aimed to examine the effects of a change in practice in index cholecystectomy on waiting lists at a New Zealand metropolitan hospital. METHODS: Patients presenting with gallstone disease from January 2004 to October 2010 were identified. Data on acute and elective cholecystectomies were collated and analysed for length of stay. Waiting lists for cholecystectomy were compared. RESULTS: During the study period, 3999 patients were admitted with acute gallbladder disease. The median number of admissions decreased from 49 to 40 per month (P < 0.01). The median number of index cholecystectomies increased from three to 22 per month (P < 0.01). Total monthly bed days for all cholecystectomies decreased from 175 days to 124 days (P < 0.01), but only median postoperative bed days for acute cholecystectomy showed a similar trend, decreasing from 4 days to 3 days (P < 0.01). The number of patients on the waiting list decreased from 334 in January 2004 to 132 in January 2006 as a result of government-imposed cuts. The number of patients wait-listed for elective cholecystectomy remained unchanged. CONCLUSIONS: An increasing number of index cholecystectomies have been performed at this centre. An effect on waiting list numbers is yet to be shown, but the wait list has not ballooned to previous numbers, although the number of patients joining the wait list remains unchanged. Monthly bed days have decreased for all patients with acute gallstone disease, probably in response to a combination of the changes implemented.

Regulation of the calcium release channel from skeletal muscle by suramin and the disulfonated stilbene derivatives DIDS, DBDS, and DNDS.

Activation of skeletal muscle ryanodine receptors (RyRs) by suramin and disulfonic stilbene derivatives (Diisothiocyanostilbene-2',2'-disulfonic acid (DIDS), 4,4'-dibenzamidostilbene-2,2'-disulfonic acid (DBDS),and 4,4'-dinitrostilbene-2,2'-disulfonic acid (DNDS)) was investigated using planar bilayers. One reversible and two nonreversible mechanisms were identified. K(a) for reversible activation (approximately 100 micro M) depended on cytoplasmic [Ca(2+)] and the bilayer composition. Replacement of neutral lipids by negative phosphatidylserine increased K(a) fourfold, suggesting that reversible binding sites are near the bilayer surface. Suramin and the stilbene derivatives adsorbed to neutral bilayers with maximal mole fractions between 1-8% and with affinities approximately 100 micro M but did not adsorb to negative lipids. DIDS activated RyRs by two nonreversible mechanisms, distinguishable by their disparate DIDS binding rates (10(5) and 60 M(-1) s(-1)) and actions. Both mechanisms activated RyRs via several jumps in open probability, indicating several DIDS binding events. The fast and slow mechanisms are independent of each other, the reversible mechanism and ATP binding. The fast mechanism confers DIDS sensitivity approximately 1000-fold greater than previously reported, increases Ca(2+) activation and increases K(i) for Ca(2+)/Mg(2+) inhibition 10-fold. The slow mechanism activates RyRs in the absence of Ca(2+) and ATP, increases ATP activation without altering K(a), and slightly increases activity at pH < 6.5. These findings explain how different types of DIDS activation are observed under different conditions.

Calsequestrin is an inhibitor of skeletal muscle ryanodine receptor calcium release channels.

We provide novel evidence that the sarcoplasmic reticulum calcium binding protein, calsequestrin, inhibits native ryanodine receptor calcium release channel activity. Calsequestrin dissociation from junctional face membrane was achieved by increasing luminal (trans) ionic strength from 250 to 500 mM with CsCl or by exposing the luminal side of ryanodine receptors to high [Ca(2+)] (13 mM) and dissociation was confirmed with sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting. Calsequestrin dissociation caused a 10-fold increase in the duration of ryanodine receptor channel opening in lipid bilayers. Adding calsequestrin back to the luminal side of the channel after dissociation reversed this increased activity. In addition, an anticalsequestrin antibody added to the luminal solution reduced ryanodine receptor activity before, but not after, calsequestrin dissociation. A population of ryanodine receptors (approximately 35%) may have initially lacked calsequestrin, because their activity was high and was unaffected by increasing ionic strength or by anticalsequestrin antibody: their activity fell when purified calsequestrin was added and they then responded to antibody. In contrast to native ryanodine receptors, purified channels, depleted of triadin and calsequestrin, were not inhibited by calsequestrin. We suggest that calsequestrin reduces ryanodine receptor activity by binding to a coprotein, possibly to the luminal domain of triadin.