Physician assistants in medical ward care: a descriptive study of the situation in the Netherlands.

RATIONALE, AIMS AND OBJECTIVES: Medical ward care has been increasingly reallocated from medical doctors (MDs) to physician assistants (PAs). Insight into their roles and tasks is limited. This study aims to provide insight into different organizational models of medical ward care, focusing on the position, tasks and responsibilities of the involved PAs and MDs. METHODS: In this cross-sectional descriptive study 34 hospital wards were included. Characteristics of the organizational models were collected from the heads of departments. We documented provider continuity by examination of work schedules. MDs and PAs in charge for medical ward care (n = 179) were asked to complete a questionnaire to measure workload, supervision and tasks performed. RESULTS: We distinguished four different organizational models for ward care: medical specialists in charge of admitted patients (100% MS), medical residents in charge (100% MR), PAs in charge (100% PA), both MRs and PAs in charge (mixed PA/MR). The wards with PAs had the highest provider continuity. PAs spend relatively more time on direct patient care; MDs spend relatively more time on indirect patient care. PAs spend more hours on quality projects (P = 0.000), while MDs spend more time on scientific research (P = 0.030). CONCLUSION: Across different organizational models for medical ward care, we found variations in time per task, time per bed and provider continuity. Further research should focus on the impact of these differences on outcomes and efficiency of medical ward care.

Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial.

BACKGROUND: In patients with mild gallstone pancreatitis, cholecystectomy during the same hospital admission might reduce the risk of recurrent gallstone-related complications, compared with the more commonly used strategy of interval cholecystectomy. However, evidence to support same-admission cholecystectomy is poor, and concerns exist about an increased risk of cholecystectomy-related complications with this approach. In this study, we aimed to compare same-admission and interval cholecystectomy, with the hypothesis that same-admission cholecystectomy would reduce the risk of recurrent gallstone-related complications without increasing the difficulty of surgery. METHODS: For this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, inpatients recovering from mild gallstone pancreatitis at 23 hospitals in the Netherlands (with hospital discharge foreseen within 48 h) were assessed for eligibility. Adult patients (aged ≥18 years) were eligible for randomisation if they had a serum C-reactive protein concentration less than 100 mg/L, no need for opioid analgesics, and could tolerate a normal oral diet. Patients with American Society of Anesthesiologists (ASA) class III physical status who were older than 75 years of age, all ASA class IV patients, those with chronic pancreatitis, and those with ongoing alcohol misuse were excluded. A central study coordinator randomly assigned eligible patients (1:1) by computer-based randomisation, with varying block sizes of two and four patients, to cholecystectomy within 3 days of randomisation (same-admission cholecystectomy) or to discharge and cholecystectomy 25-30 days after randomisation (interval cholecystectomy). Randomisation was stratified by centre and by whether or not endoscopic sphincterotomy had been done. Neither investigators nor participants were masked to group assignment. The primary endpoint was a composite of readmission for recurrent gallstone-related complications (pancreatitis, cholangitis, cholecystitis, choledocholithiasis needing endoscopic intervention, or gallstone colic) or mortality within 6 months after randomisation, analysed by intention to treat. The trial was designed to reduce the incidence of the primary endpoint from 8% in the interval group to 1% in the same-admission group. Safety endpoints included bile duct leakage and other complications necessitating re-intervention. This trial is registered with Current Controlled Trials, number ISRCTN72764151, and is complete. FINDINGS: Between Dec 22, 2010, and Aug 19, 2013, 266 inpatients from 23 hospitals in the Netherlands were randomly assigned to interval cholecystectomy (n=137) or same-admission cholecystectomy (n=129). One patient from each group was excluded from the final analyses, because of an incorrect diagnosis of pancreatitis in one patient (in the interval group) and discontinued follow-up in the other (in the same-admission group). The primary endpoint occurred in 23 (17%) of 136 patients in the interval group and in six (5%) of 128 patients in the same-admission group (risk ratio 0·28, 95% CI 0·12-0·66; p=0·002). Safety endpoints occurred in four patients: one case of bile duct leakage and one case of postoperative bleeding in each group. All of these were serious adverse events and were judged to be treatment related, but none led to death. INTERPRETATION: Compared with interval cholecystectomy, same-admission cholecystectomy reduced the rate of recurrent gallstone-related complications in patients with mild gallstone pancreatitis, with a very low risk of cholecystectomy-related complications. FUNDING: Dutch Digestive Disease Foundation.

[A man with a swelling in the palm of his hand]. / Een man met een zwelling in zijn handpalm.

A 41-year-old man had a palpable mass on the volar side of his hand. X-ray, ultrasound and MRI showed an inhomogeneous tumour with calcification. Histologic examination ruled out the suspicion of a liposarcoma. The surgeon successfully excised the ossifying lipoma, which is a rare variant of a common lipoma and can clinically and radiologically mimic malignant neoplasms.

Particle size of bone graft and method of impaction affect initial stability of cemented cups: human cadaveric and synthetic pelvic specimen studies.

We determined the effect of bone graft particle size and impaction technique on the initial stability of cemented acetabular cups. First, acetabular reconstructions were performed in human cadaveric pelvic bones in which type 2 AAOS cavitary defects were created. Reconstructions were made with small bone grafts (average 2 mm) produced by a bone mill or large bone grafts (average 9 mm) produced by hand with a rongeur. All chips were made from freshly-frozen femoral heads. Impaction was done using acetabular impactors and a hammer. We did a loading experiment with a gradually increasing dynamic load up to 3000 N. We used radiostereometric analysis (RSA) to determine cup stability. The cups were more stable when large bone grafts were used. Because of limitations of the cadaver model, we developed a synthetic acetabular model. For validation of this model, we repeated the experiments using small and large bone grafts. The results with both models were similar. In the synthetic model, we compared impaction with hammer and impactors with the reversed reaming technique using manual compression on the reamer. The latter method resulted in more migration. We recommend firm impaction with a hammer of large bone grafts for optimal stability of the cup.