Assessment of the validity of the English National Health Service Adult In-Patient Survey for use within individual specialties.

BACKGROUND: Healthcare improvement requires rigorous measurement. Patient experience is a key healthcare outcome and target for improvement. Its measurement requires psychometrically validated questionnaires. In England, the Adult In-Patient Survey (AIPS), which is validated for use across the entire acute inpatient population, is administered to unselected patients after discharge from National Health Service acute Trusts. The AIPS is reported at an organisational level, but subhospital level data are needed for local quality improvement; it is currently uncertain whether the AIPS retains validity in local specialty subgroups. METHODS: We analysed the results of AIPS for 2010 (n=56 931 returns) by specialty (medicine, surgery, orthopaedics, renal medicine, neurosurgery, obstetrics-gynaecology and oncology) to determine whether validity is retained at a suborganisational level. RESULTS: Criterion validity and internal consistency of AIPS were retained for most specialty subgroups. When small local samples were excluded, the results for Trust level specialty groups were similar over a 2-year period, indicating test stability. For oncology there was poor internal consistency in the 'doctors' domain and criterion validity, expressed as the relationship elements of experience and overall rating of care, was less than for other specialties. CONCLUSIONS: The AIPS is suitable for use within many specialties, but our findings question some elements of validity for oncology inpatients. We recommend that future surveys are administered and reported by specialty, to inform local improvement and permit comparison of specialty units.

Radiographic imaging features of thoracic complications after pneumonectomy in oncologic patients.

PURPOSE: The morbidity and mortality for pneumonectomy in patients has been reported to be as high as 24%. To determine if a subset of patients undergoing pneumonectomy for a malignancy would have similar complication rates and appearances, we performed a review of the radiographic findings of patients at our institution. METHOD: A retrospective review of a thoracic surgery database was performed at our institution for patients who underwent pneumonectomy between January 2001 and April 2004. All images were reviewed on the institutional patient archive communication system, by two experienced, fellowship trained, thoracic radiologists. RESULTS: There were 144 patients (112 men and 32 women) with a mean age of 52 years (range 21-83 years). Of the 144 patients, thoracic complications were present in 52 (36%) patients consisting of pneumonia in 19 (13%), empyema/pleural space infection in 9 (6%), adult respiratory distress syndrome (ARDS) in 8 (6%), bronchopleural fistula in 7 (5%), gortex graft failure/organ herniation in 4 (3%), chylothorax/chyle leak in 2 (1%), pulmonary embolus in 2 (1%), pulmonary hemorrhage in 1 (<1%). CONCLUSION: In oncologic patients, post-pneumonectomy complications occur in over a third of patients and can be life threatening. The presentations are similar to other pneumonectomy patients and are often radiographically detectable. Therefore it is important for radiologist to be aware of the radiographic manifestations of these complications so that appropriate immediate treatment is instituted.

An inverting circumferential suture for flexor tenorraphy.

Zone two flexor tendon repair remains challenging with significant outcome variation using recognised techniques. Tendon adhesion formation results in poor outcomes and rehabilitation regimes aim to limit this. Some repairs augment strength, but increasing bulk mitigates against movement. This novel epitendinous technique causes tendon inversion with potential gliding benefits and improved outcomes. 60 porcine tendons were randomised to a 2-stranded modified Kessler or a 4-stranded Adelaide repair, then sudivided into three different circumferential technique groups: locked running, Silfverskiold, or a new inverting repair. Tendon load to failure (LTF), 2 mm gap formation, bulking effect and method of failure were analysed during digital tensiometry. Four-stranded repairs demonstrated better LTF than 2-stranded techniques. The inverting epitendinous and Silfverskiold repairs showed higher LTF characteristics than the locked running suture, and better tissue holding capacity. The inverting repair has similar properties to commonly used suturing methods and the conformation creates a smooth inverted repair.

A new barbed device for repair of flexor tendons.

We split 100 porcine flexor tendons into five groups of 20 tendons for repair. Three groups were repaired using the Pennington modified Kessler technique, the cruciate or the Savage technique, one using one new device per tendon and the other with two new devices per tendon. Half of the tendons received supplemental circumferential Silfverskiöld type B cross-stitch. The repairs were loaded to failure and a record made of their bulk, the force required to produce a 3 mm gap, the maximum force applied before failure and the stiffness. When only one device was used repairs were equivalent to the Pennington modified Kessler for all parameters except the force to produce a 3 mm gap when supplemented with a circumferential repair, which was equivalent to the cruciate. When two devices were used the repair strength was equivalent to the cruciate repair, and when the two-device repair was supplemented with a circumferential suture the force to produce a 3 mm gap was equivalent to that of the Savage six-strand technique.

Opinions and acceptability of common weight-loss practices.

A disconnect between research findings and public beliefs may lead to further dieting failures for consumers. Participants (N=300) were surveyed to determine their weight loss practices, opinions of weight loss methods, and rated the acceptability of popular and empirically validated weight loss programs. Dieting, the intention to diet, and the use of popular diets and diet aids were prevalent. There was a tendency for participants to view weight as more of a problem for society than themselves. The Behavioral Program was rated as most acceptable and Surgical Treatment least acceptable. However, participants were more likely to try a popular diet or supplement. It is vital for researchers and clinicians to improve communication with the public about efficacious weight loss programs.

The optimum length of the Silfverskiöld circumferential cross stitch.

Three groups of six porcine deep flexor tendons were repaired with a locking loop modified Kessler core suture using 4-0 braided polyester. Silfverskiöld repairs were performed using 6-0 monofilament nylon taking bites 2, 4 and 6 mm from the cut end of the tendon. The repairs were tested to failure and record made of bulking, mode of failure, force to produce a 3 mm gap and the ultimate strength. Data were analysed using one-way ANOVA, with analysis of mode of failure using the Chi-squared test. The 4 mm repairs were significantly stronger than the 2 mm for all parameters but there was no difference between the 4 mm and 6 mm repairs. We feel that optimal repair strength is provided using bites 4 mm from the cut tendon ends. Taking bites further from the cut end has no significant benefits and carries the theoretical risk of increasing the work of flexion.

Cyclical ischaemic preconditioning modulates the adaptive immune response in human limb ischaemia-reperfusion injury.

BACKGROUND: Reperfusion injury (RI) has significant local and systemic consequences. Ischaemic preconditioning (IPC) modulates RI and the innate immune response. This study examined whether IPC attenuates RI-mediated changes in lymphocyte populations and function following elective surgery. METHODS: Twenty-five patients sustaining 1 h of tourniquet ischaemia during cruciate ligament reconstruction were randomized before surgery to three 5-min ischaemia cycles separated by 5 min of reperfusion, or to a control group. Systemic levels of interleukin (IL) 4 and interferon (IFN) gamma, and surface expression of CD45ro/ra, CD62L and CD95 were measured. T cells were examined systemically and in stimulated serum co-culture to determine CD4/CD8 and Th1/Th2 shifts through intracellular cytokine production. RESULTS: CD4 CD45ro cell numbers increased after RI without IPC, whereas CD8 cells expressing CD45ro and CD95 increased with IPC. Preconditioned serum in co-culture attenuated increases in CD4 and decreases in CD8 numbers, a process prevented by inhibition of antigen activation. Following RI, systemic IL-2 levels were significantly lower after IPC, whereas co-culture with post-RI serum increased proinflammatory intracellular cytokine production. CONCLUSION: IPC modulated T cell responses in limb RI through reduced activation and proinflammatory cytokine production by CD4 cells, while preventing CD4/CD8 derangement. IPC prevented lymphocyte-directed immune dysfunction.

An assessment of skin preparation in upper limb surgery.

Postoperative wound infections remain a major source of upper limb morbidity. The effectiveness of peri-operative human upper limb preparation was determined using a clear fluid antiseptic and an iodine-based solution over 60 and 90 seconds. Less area was missed using iodine over both times and increasing clear solution preparation time from 60 to 90 seconds improved coverage. Surgical experience had little outcome relevance and a 90-second preparation time with either solution was insufficient, with fingers being the sites most commonly missed.

Radiological features of synovial cell sarcoma.

Synovial cell sarcoma is an uncommon soft-tissue malignant tumour. These tumours have common radiological features with a variety of both benign and malignant lesions. However, there is a variety of imaging findings that can suggest a pre-biopsy diagnosis of synovial cell sarcoma. This pictorial review aims to describe the imaging features of synovial sarcoma in a series of cases with various age ranges and tumour locations. In addition, the pathology, staging, prognosis and management of synovial sarcoma is briefly discussed.

Radiological imaging features of non-uterine leiomyosarcoma.

Leiomyosarcomas are unusual soft-tissue tumours that occur in the retroperitoneum, peripheral soft tissues, gastrointestinal and genito-urinary tracts, vessels and (rarely) in bone. The aim of this pictonal review is to delineate the more specific radiological features that would suggest a radiological diagnosis of leiomyosarcoma prior to biopsy.

A biomechanical analysis of multistrand repairs with the Silfverskiold peripheral cross-stitch.

We compared the bulking and tensile strength of the Pennington modified Kessler, Cruciate and the Savage repairs in an ex vivo model. A total of 60 porcine tendons were randomised to three groups, half repaired using a core suture alone and the remainder employing a core and peripheral technique. The tendons were distracted to failure. The force required to produce a 3 mm gap, the ultimate strength, the mode of failure and bulking for each repair were assessed. We found that there was a significant increase in strength without an increase in bulk as the number of strands increased. The Cruciate repair was significantly more likely to fail by suture pullout than the Pennington modified Kessler or Savage repairs. We advise the use of the Savage repair, especially in the thumb, and a Cruciate when a Savage is not possible. The Pennington modified Kessler repair should be reserved for multiple tendon injuries.

Analysis of close proximity quenching of phosphorescent metalloporphyrin labels in oligonucleotide structures.

Quenching of phosphorescent platinum(II) and palladium(II) coproporphyrin (MeCP) labelled oligonucleotides was investigated. Strong hybridization-specific quenching was observed in duplex DNA structures with a variety of quenchers and with two identical porphyrin labels when in close proximity. Classical resonance energy transfer mechanism was ruled out, since quenching did not correlate with spectral overlaps and lifetime changes were insignificant. Quenching of MeCP by the free quenchers in solution revealed that porphyrin-porphyrin quenching is predominantly static while other dyes quench dynamically. The results suggest that the quenching in DNA duplex proceeds via direct contact.

Differences for gender, weight and exercise in body image disturbance and eating disorder symptoms.

OBJECTIVE: Differences for gender, weight, exercise frequency and type for eating disorder symptoms and body image disturbance were examined. Further understanding of male body image disturbance was the primary goal. METHOD: Males (n=200) and females (n=233) completed measures to assess eating disorder symptoms and multiple components of body image disturbance. Measures were modified to be more appropriate for males. RESULTS: Females endorsed higher levels of eating and body concerns. Males were divided between a desire to maintain, increase or decrease their size. Higher weight and exercise frequency was associated with increased body image concern and eating disorder symptoms, particularly for males. Exercise frequency was also linked to higher self-esteem for males. Males who used muscle-enhancing supplements indicated increased social pressures and concern for appearance, and a desire to increase their size. DISCUSSION: The findings support that weight and exercise frequency affect eating disorder symptoms and body image disturbance. Males appear to exhibit body image disturbance, which is related to their current weight status. Results support the call for further development of measures that more adequately address male concerns.

The imaging features of gastrointestinal stromal tumours.

Gastrointestinal stromal tumours (GISTs) are a rare group of mesenchymal neoplasms that occur predominantly in the gastrointestinal tract. Previously GISTs were classified as smooth muscle tumours referred to as leiomyomas, leiomyosacromas or leiomyoblastomas. However, with the advent of immunohistochemistry, GISTs are now defined by the identification of cKit positivity. This is now used to select patients with metastatic disease who may respond to chemotherapeutic agents such as the tyrosine kinase inhibitor, STI-571. In this pictorial essay we have attemped to describe the range of imaging findings of GISTs that can suggest a pre-biopsy diagnosis.

Retrospective analysis of evidence base for tests used in diagnosis and monitoring of disease in respiratory medicine.

OBJECTIVES: To determine how many common clinical tests used in a respiratory medicine outpatient clinic are based on high quality evidence. DESIGN: Retrospective review of case notes. Record of first three tests for each patient. Diagnostic tests, tests used to assess existing condition, explicit trials of therapy were included. Literature search for supporting evidence and grading of best evidence for each test. SETTING: Inner city university teaching hospital in the United Kingdom. PARTICIPANTS: All new outpatients referred to a single respiratory medicine team over a period of three months. MAIN OUTCOME MEASURES: Proportion of tests supported by level 1a-1c evidence (scale developed by Centre for Evidence Based Medicine). RESULTS: Only half the tests that were used to make or exclude a diagnosis and a fifth of the tests used to assess a known condition were supported by level 1a-1c evidence. There was no evidence to support trials of therapy. CONCLUSIONS: A large proportion of clinical tests in respiratory medicine are not supported by level 1a-1c evidence. None of the therapeutic trials that were used were supported by evidence.

Platelet dynamics following allergen challenge in allergic asthmatics.

BACKGROUND: There is evidence that platelet activation occurs in allergic inflammation and asthma, but little is known about the role platelets play in airway inflammation associated with asthma. OBJECTIVES: In the present study, we have investigated the kinetics of platelet activation following allergen provocation of allergic asthmatics to determine the dynamics of platelet activation relative to changes in lung function and changes in airway inflammation. METHODS: Changes in platelet count and haematocrit from baseline were measured during the early asthmatic response (EAR), late asthmatic response (LAR; or at corresponding time points) and at 24 h were compared between allergen- and saline-challenged groups. A subgroup of allergen-challenged asthmatics, a group of 7 challenged asthmatics and 7 controls were bronchoscoped, and BAL fluid was collected and analysed for levels of histamine and eosinophil cationic protein. RESULTS: There was a fall in circulating platelet count, but not haematocrit after allergen challenge when compared with saline during the LAR or at 24 h. At 24 h FEV(1) had returned to within 20% of baseline in all subjects, although the thrombocytopaenia and airway inflammation persisted. CONCLUSIONS: Our results suggest that persistent thrombocytopaenia accompanies allergen exposure and persists beyond changes in airway obstruction at a time when airway inflammation is present. Our results provide further evidence that platelets may be involved in allergic disease.

Risk factors for post-carotid endarterectomy hematoma formation.

PURPOSE: To identify risk factors for post-carotid endarterectomy (CEA) hematoma formation and establish the incidence of this complication at The Ottawa Hospital - Civic Campus (TOH-CC). METHODS: A chart review of all patients who underwent CEA at TOH-CC from January 1, 1996 to December 31, 1997 was completed. Identified cases of post-CEA wound hematoma were entered into a case-control study using age and sex-matched controls from within the cohort. These matched pairs were assessed for 31 potential risk factors including demographic details, co-existing medical conditions, preoperative medications, intraoperative management, and postoperative parameters. Risk factors associated with post-CEA hematoma with P<0.05 were entered into a backward step-wise logistic regression model for multivariate analysis. RESULTS: Charts from 249 patients were reviewed and 29 cases of post-carotid endarterectomy hematoma were identified (12% incidence). Six of the initial 31 potential risk factors emerged as univariate predictors of post-CEA hematoma formation (P<0.05): general anesthesia, carotid shunt placement, intraoperative hypotension, non-reversal of heparin, neurosurgery service, and preoperative aspirin use. Following logistic regression only non-reversal of heparin, intraoperative hypotension, and carotid shunt placement were identified as multivariate predictors of post-CEA hematoma formation. More time was spent in critical care settings (ICU/PACU) (P<0.01) and there was increased perioperative mortality (P = 0.04) within the hematoma group. CONCLUSIONS: Post-CEA hematoma formation is associated with increased morbidity and mortality. Non-reversal of heparin, intraoperative hypotension, and carotid shunt placement are multi-variate predictors of post-CEA hematoma formation.

Introduction of Aedes albopictus into a La Crosse virus--enzootic site in Illinois.

In late summer and fall 1997, Aedes albopictus mosquitoes were found in Peoria, Illinois, a long recognized focus of La Crosse virus transmission. Larvae were found in tires and other artificial containers, biting adults were recovered, and eggs were collected in oviposition traps within a 25-ha area. One chipmunk trapped < 0.25 km from the infested area tested positive for neutralizing antibodies against La Crosse virus.

The effect of a novel orally active selective PDE4 isoenzyme inhibitor (CDP840) on allergen-induced responses in asthmatic subjects.

Recent studies have suggested that theophylline, a nonspecific phospho-diesterase inhibitor, has useful anti-inflammatory actions in asthma. Phosphodiesterase 4 (PDE4) represents the predominant PDE isoenzyme present in inflammatory cells. PDE4 inhibitors might, therefore, have beneficial effects in asthma. Side-effects, specifically nausea, have limited the use of existing agents. CDP840 is an orally active, potent and selective PDE4 inhibitor. We have examined the effect of CDP840 on the allergen-induced asthmatic response, its possible modes of action, and its tolerability at therapeutic doses. A total of 54 patients were recruited to three double-blind, placebo-controlled studies. The first study examined the effect of CDP840 (15 mg b.i.d. for 9.5 days) on the allergen-induced asthmatic response in patients with known dual response to allergen. A second study examined the effect of CDP840 (15 mg b.i.d. for 9.5 days) on airway responsiveness to histamine. A third study examined whether single dose CDP840 (15 and 30 mg) had significant bronchodilatory effects. In all studies, CDP840 was well-tolerated, with no patients reporting nausea. CDP840 did not lead to changes in baseline forced expiratory volume in one second (FEV1) as compared to placebo. The late asthmatic response (LAR) to allergen, expressed as area under the curve at 3-8 h (AUC3-8h), was inhibited by 30% (p=0.016), an effect which persisted to the end of the observation period. The early asthmatic response (EAR) was unaffected, and there was no bronchodilatory effect at the doses used. Treatment with CDP840 did not affect bronchial hyperresponsiveness to histamine. In conclusion, CDP840 significantly attenuated the late asthmatic response to allergen challenge in the absence of any bronchodilatory or histamine antagonist effect. This suggests that CDP840 may exert its effects via an anti-inflammatory mechanism.