bluuebunny/crossref_metadata_2025 huggingface dataset:
Feasibility and Acceptability of Remotely Monitored Pedometer-Guided Physical Activity
Authors: Darvall J. N. , Parker A. , Story D. A.
Published: January 2019

Nearly 70% of the Australian adult population are either sedentary, or have low levels of physical activity. There has been interest in addressing this problem by the ‘mHealth’, or mobile Health, arena, which is concerned with the confluence of mobile technology and health promotion. The newer generation of activity pedometers has the ability to automatically upload information, to enable aggregation and meta-data analysis of individual patient data. We conducted a ten-week pilot trial of the Fitbit Zip® pedometer using a validated tool in ten volunteers, finding it highly acceptable to both participants and investigators. Data synching was ranked as ‘very easy’ or ‘easy’ by all participants, and investigators could successfully monitor activity levels remotely. Median (interquartile range) daily step counts of participants over the ten-week trial ranged from 5471 (4591–7026) to 18779 (15031–21505) steps. Sedentary time over the study period ranged from 1.4% to 33.3% of study days. Percentage of days reaching the target activity level of >10,000 steps/day varied markedly between participants from 4.5% to 95.7%. This study demonstrates the feasibility and acceptability of a remotely monitored pedometer-guided physical activity intervention. This technology may be useful to encourage increased exercise as a form of ‘prehabilitation’ of adequately screened at-risk surgical or obstetric patients.
Current Limitations of the Assessment of Haemostasis in Adult Extracorporeal Membrane Oxygenation Patients and the Role of Point-of-Care Testing
Authors: Venkatesh K. , Nair P. S. , Hoechter D. J. , Buscher H.
Published: January 2019

Haemostatic perturbations are commonly seen in extracorporeal membrane oxygenation (ECMO) patients and remain a clinical challenge, contributing significantly to morbidity and mortality. The approach to anticoagulation monitoring and the management of bleeding varies considerably across ECMO centres. Routine laboratory tests have their limitations in terms of turnaround time and specificity of information provided. Newer point-of-care testing (POCT) for coagulation may overcome these issues, as it provides information about the entire coagulation pathway from clot initiation to lysis. It is also possible to obtain qualitative information on platelet function from these tests. Furthermore, the ability to incorporate these results into a goal-directed algorithm to manage bleeding with targeted transfusion strategies appears particularly attractive and cost effective. Further studies are required to evaluate the utility of POCT to optimise bleeding and anticoagulation management in these complex patients.
The Effect of Dabigatran on the Kaolin-Activated Whole Blood Thromboelastogram
Authors: ‘Aho A. , Byrne K.
Published: January 2019

Dabigatran is a direct thrombin inhibitor, which is increasingly likely to be encountered in patients presenting for surgery. This study examines whether there is a consistent effect of dabigatran on the thromboelastogram (TEG) and whether this correlates with the effects of dabigatran on traditional coagulation parameters. Twenty patients taking dabigatran had blood sampled for kaolin-activated whole blood TEG analysis and routine coagulation testing. There was a statistically significant correlation between thrombin clotting time (TCT) and R-time (R=0.77, P=0.0001) and between activated partial thromboplastin time (APTT) and R-time (R=0.68, P=0.0013), but not between TCT and alpha-angle (R=-0.4232, P=0.071). Despite the moderate to high correlation between the TEG R-time and the TCT and APTT, there appeared to be no consistent effect of dabigatran on the TEG. These findings suggest that use of kaolin-activated whole blood TEG does not add additional benefit to traditional coagulation tests when monitoring the effect of dabigatran.
Comparison of Bioreactance Non-Invasive Cardiac Output Measurements with Cardiac Magnetic Resonance Imaging
Authors: Trinkmann F. , Schneider C. , Michels J. D. , Stach K. , Doesch C. , Schoenberg S. O. , Borggrefe M. , Saur J. , Papavassiliu T.
Published: January 2019

Impedance cardiography measurement of cardiac output gained wide interest due to its ease of use and non-invasiveness. However, validation studies of different algorithms yielded diverging results. Bioreactance (BR) as a recent adaption differs fundamentally as the flow signal is derived from phase shifts. Our aim was to assess the accuracy and reproducibility of BR, as compared to the non-invasive gold standard-cardiac magnetic resonance imaging (CMR). We prospectively included 32 stable patients. BR was performed twice in the supine position and averaged over 30 seconds. Mean bias was 0.2 ± 1.8 l/minute (1 ± 28%, percentage error 55%) with limits of agreement ranging from −3.4 to 3.7 l/minute. Reproducibility was acceptable with a mean bias of 0.1 ± 0.9 l/minute (1 ± 14%, 27%). Low cardiac output was significantly overestimated (−1.1 ± 1.5 l/minute), while high cardiac output was underestimated (1.5 ± 1.7 l/minute), ( P=0.001), although reproducibility was unaffected. Bias and weight were moderately correlated in men (r = 0.50, P=0.02). No differences for accuracy were found in nine patients who had an arrhythmia (0.3 ± 1.4 versus 0.1 ± 2.0 l/minute, P=0.76), while clinically relevant differences were found in patients with mild aortic valve disease (1.9 ± 2.2 versus −0.3 ± 1.7 l/minute, P=0.02). Overall, BR showed insufficient agreement with CMR, overestimating low and underestimating high cardiac output states. Reproducibility was acceptable and not negatively affected by the circulatory condition. Consequently, absolute values acquired with BR should be interpreted with caution and must not be used interchangeably in clinical practice.
Defining a Reference Range for Vital Signs in Healthy Term Pregnant Women Undergoing Caesarean Section
Authors: Dennis A. T. , Hardy L.
Published: January 2019

Early warning systems (EWS), used to identify deteriorating hospitalised patients, are based on measurement of vital signs. When the patients are pregnant, most EWS still use non-pregnant reference ranges of vital signs to determine trigger thresholds. There are no published reference ranges for all vital signs in pregnancy. We aimed to define vital signs reference ranges for term pregnancy in the preoperative period, and to determine the appropriateness of EWS trigger criteria in pregnancy. We conducted a one-year retrospective study in a tertiary referral obstetric hospital. The study sample was healthy term women undergoing planned caesarean section (CS). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2) and temperature were all measured automatically and data was extracted from the medical record. Two hundred and fifty-eight women met inclusion criteria. Results were (mean ± SD [standard deviation]) SBP 118 ± 11.2 mmHg, DBP 75 ± 10.3 mmHg, HR 84 ± 10.2 /minute, respiratory rate 18 ± 1.5 /minute, SpO2 99% ± 1.0% and temperature 36.4°C ± 0.43°C. The reference ranges (mean ± 2SD) determined were SBP 96–140 mmHg, DBP 54–96 mmHg, HR 64-104 /minute, RR 15–21 /minute, SpO2 97%–100% and temperature 35.5°C–37.3°C. This study defined a reference range for vital signs in healthy term pregnant women undergoing CS. Study findings suggest that currently used criteria for EWS triggers, based on non-pregnant values, may be too extreme for timely detection of deteriorating pregnant patients. Further research examining the modified HR triggers of ≤50 and ≥110 /minute in pregnant women and their relationship to clinical outcomes is required.
Gas: The Greatest Terror of the Great War
Authors: Padley A. P.
Published: January 2019

The Great War began just over a century ago and this monumental event changed the world forever. 1915 saw the emergence of gas warfare-the first weapon of mass terror. It Is relevant to anaesthetists to reflect on these gases for a number of reasons. Firstly and most importantly we should acknowledge and be aware of the suffering and sacrifice of those soldiers who were Injured or killed so that we could enjoy the freedoms we have today. Secondly It Is interesting to consider the overlap between poison gases and anaesthetic gases and vapors, for example that phosgene can be formed by the Interaction of chloroform and sunlight. Thirdly the shadow of gas warfare Is very long and covers us still. The very agents used In the Great War are still causing death and injury through deployment in conflict areas such as Iraq and Syria. Industrial accidents, train derailments and dumped or buried gas shells are other sources of poison gas hazards. In this age of terrorism, anaesthetists, as front-line resuscitation specialists, may be directly Involved In the management of gas casualties or become victims ourselves.
Welfare of Anaesthesia Trainees Survey
Authors: Downey G. B. , McDonald J. , Downey R. G.
Published: January 2019

This study was designed to investigate levels of stress, anxiety or depression and to identify factors compounding or relieving stress in anaesthesia trainees within the Australian and New Zealand College of Anaesthetists (ANZCA) training scheme. An electronic survey was sent to 999 randomly selected trainees and 428 responses were received. In addition to demographics, psychological wellbeing was assessed using the Kessler Psychological Distress Scale (K10) and questions were asked about depression and anxiety, exacerbating factors, personal healthcare and strategies used to manage stress. The majority of respondents (73%) reported being satisfied or very satisfied with their job and training. However, 28% of respondents had K10 scores indicating high or very high distress levels. Eleven percent reported being currently on treatment for anxiety and/ or depression. Twenty-two percent reported having experienced bullying and 14% sexism. Twenty-eight percent reported that they did not have a regular general practitioner (GP), and 41% reported having not visited their GP in the previous year. Forty-seven percent of trainees reported that they self-prescribe medications. Major stressors reported were exams, critical clinical events and fear of making errors. Two stressors previously not identified in similar studies were concern about job prospects in 71% of respondents and workplace-based assessments in 51%. This survey demonstrates significant psychological impairment and poor personal healthcare amongst many trainees. Education, careful continuing assessment of trainees' welfare and a review of current support and remedial measures may be required.
Does Anyone Ever Expect to Die?
Authors: Anstey M. H. R. , Watts N. , Orford N. , Seppelt I. M. , Mitchell I.
Published: January 2019

Patients who come to the intensive care unit are amongst the sickest patients in our hospitals. Patients can be admitted to the intensive care unit unexpectedly (following accidents or sudden onset of illness) or as unplanned but not necessarily truly ‘unexpected’ admissions. These patients often have significant underlying chronic health issues, including metastatic cancer, advanced cardiac, respiratory, renal, or hepatic failure, or frailty, with a high likelihood of death in the ensuing months. Using the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program, a prospective single-day observational study across 46 Australian hospitals in 2014 and 2015, we found that less than 9% of intensive care unit patients (51/577) had an advance directive available. From these results, we provide two suggestions to increase intensive care's understanding of patients’ end-of-life wishes. First, systematically target ‘high risk of dying’ patient groups for goals of care conversations in the outpatient setting. Such groups include those where one would not be ‘surprised’ if they died within a year. Second, as a society, more conversations about end-of-life wishes are needed.
Validity Evidence of Non-Technical Skills Assessment Instruments in Simulated Anaesthesia Crisis Management
Authors: Jirativanont T. , Raksamani K. , Aroonpruksakul N. , Apidechakul P. , Suraseranivongse S.
Published: January 2019

We sought to evaluate the validity of two non-technical skills evaluation instruments, the Anaesthetists’ Non-Technical Skills (ANTS) behavioural marker system and the Ottawa Global Rating Scale (GRS), to apply them to anaesthesia training. The content validity, response process, internal structure, relations with other variables and consequences were described for validity evidence. Simulated crisis management sessions were initiated during which two trained raters evaluated the performance of postgraduate first-, second- and third-year (PGY-1, PGY-2 and PGY-3) anaesthesia residents. The study included 70 participants, composed of 24 PGY-1, 24 PGY-2 and 22 PGY-3 residents. Both instruments differentiated the non-technical skills of PGY-1 from PGY-3 residents (P <0.05). Inter-rater agreement was measured using the intraclass correlation coefficient. For the ANTS instrument, the intraclass correlation coefficients for task management, team-working, situation awareness and decision-making were 0.79, 0.34, 0.81 and 0.70, respectively. For the Ottawa GRS, the intraclass correlation coefficients for overall performance, leadership, problem-solving, situation awareness, resource utilisation and communication skills were 0.86, 0.83, 0.84, 0.87, 0.80 and 0.86, respectively. The Cronbach's alpha for internal consistency of the ANTS instrument was 0.93, and was 0.96 for the Ottawa GRS. There was a high correlation between the ANTS and Ottawa GRS. The raters reported the ease of use of the Ottawa GRS compared to the ANTS. We found sufficient evidence of validity in the ANTS instrument and the Ottawa GRS for the evaluation of non-technical skills in a simulated anaesthesia setting, but the Ottawa GRS was more practical and had higher reliability.
Anaesthetic Management of Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei: A Retrospective Audit
Authors: Shiralkar S. P. , Kerr P. , Scott J. , Sivalingam P.
Published: January 2019

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve quality of life and survival rates in patients suffering from pseudomyxoma peritonei. The procedure is long and associated with significant intraoperative blood loss. As such, the anaesthetic management of patients undergoing this procedure can be challenging. The aim of this paper is to describe our perioperative management of pseudomyxoma peritonei patients who received CRS and to report a retrospective audit of our outcomes and complications over a six-year period at a large tertiary centre. A total of 70 patients were included, of whom three (4.3%) had CRS alone, 42 (60.0%) had CRS with HIPEC, and 25 (35.7%) had CRS with HIPEC and early postoperative intraperitoneal chemotherapy. There were no intraoperative deaths. A total of four patients (5.7%) died during their hospital admission. At one-year follow-up, six patients (9.0%) had died, and at the end of the study 15 (22.4%) had died. No statistically significant difference in blood loss was seen between patients who received tranexamic acid (30 patients, 42.9%) and those who did not, but the incidence of deep venous thrombosis was much higher (10/30 versus 1/40). Different intravenous fluid strategies appeared not to influence the incidence of postoperative acute renal failure. Further research is required to evaluate the effects of intraoperative tranexamic acid and different intraoperative fluid strategies on outcomes in patients undergoing CRS with HIPEC.
Intravascular Catheters—An Ultrasound Imaging Based Observational Study of Position and Function
Authors: Hebbard P. D. , Flinn P.
Published: January 2019

Peripheral intravenous and intra-arterial catheters often block with movement of the limb in which they are inserted. Although the cause of this blockage is commonly attributed to a valve or other structure within the vein, evidence for this is lacking. We used ultrasound to assess the cause of blockage on movement, and degree of tip movement, of 62 venous and 21 radial arterial catheters. In both venous and arterial catheters, blockage was predominantly caused by impingement of the catheter on the vessel wall, with catheter kinking and spasm of the vessel also seen. Mean potential tip movement was 12.3 mm and 5.7 mm in hand and forearm venous catheters respectively and 9.5 mm in radial artery catheters. There was a significantly lower rate of blockage for forearm (20%) compared to dorsal hand venous catheters (83%, P <0.001) and 52% of radial artery catheters showed damping and blockage on wrist flexion. This study emphasises the advantages of placement of venous catheters in the straight veins of the forearm.
A Survey of the Sequelae of Memorable Anaesthetic Drug Errors from the Anaesthetist'S Perspective
Authors: McCawley D. , Cyna A. M. , Prineas S. , Tan S. G. M.
Published: January 2019

Drug errors amongst anaesthetists are common. Although there has been previous work on the system factors involved with drug error, there has been little research on the sequelae of a drug error from the anaesthetist's perspective. To clarify this issue, we surveyed anaesthetists regarding their most memorable drug error to identify associated factors and personal sequelae regarding their professional practice after the event. An online survey was sent anonymously to 989 Australian and New Zealand College of Anaesthetists (ANZCA) Fellows in March 2016 and the results were collected over the following two months. There were 295 completed surveys (29.8% response). The majority of respondents were male consultants, aged over 45 years. Reported drug errors occurred most frequently during normal working hours, and the most common drugs involved were non-depolarising muscle relaxants. In 34% of the errors, another anaesthetist was present, and their presence was felt to have contributed in 40.7% of these cases. About 20% of respondents reported that they did not receive adequate support after the event. Sleep patterns were affected in 14.4% of respondents, although very few found that the error had affected their capacity to function at work. These findings suggest that memorable drug errors can be significant enough to have adverse sequelae to anaesthetists, even if no patient harm occurs.
Postoperative Troponin Measurement as a Screening Tool for Adverse Cardiac Events in Adult Patients Undergoing Moderate Or Major Non-Cardiac Surgery
Authors: Coric D. , Smith N. A.
Published: January 2019

Elevated troponin levels within three days of surgery are strongly linked to major adverse cardiac events (MACE). However the value of screening with troponin measurements is controversial. The extent to which this is done in routine practice is uncertain. We examined the medical records of all patients ≥45 years of age undergoing moderate or major non-cardiac surgery in our tertiary referral hospital over a six-month period. We determined how many patients had a troponin (TnT) measurement recorded in the first three days postoperatively, how many of these were abnormal, and the occurrence of MACE within 30 days. Two thousand and two hundred patients underwent 2,577 operations that met the study criteria. A postoperative TnT was measured after 4.5% of operations. Thirty-eight percent of patients with a recorded TnT measurement, and 44% of those with an abnormal measurement, experienced a MACE within 30 days. The sensitivity of an abnormal TnT to detect MACE was 86%. The specificity was low at 32% with a false positive rate of 56%. Patients with an abnormal TnT result had an increased risk of MACE (23%). The ‘number needed to measure’ to detect one patient with MACE was 4.4. In our institution, postoperative TnT levels were rarely measured and were used as a diagnostic rather than as a screening tool. The high false positive rate for MACE prediction limits its potential value as a screening tool. The test could be considered useful if it leads to further investigation, and may be best considered as one component of a multivariate approach to cardiac risk evaluation and diagnosis.
Prevalence and Predictors of Persistent Post-Surgical Opioid Use: A Prospective Observational Cohort Study
Authors: Stark N. , Kerr S. , Stevens J.
Published: January 2019

Post-surgical opioid prescribing intended for the short-term management of acute pain may lead to long-term opioid use. This study was undertaken to determine the prevalence of persistent post-surgical opioid use and patient-related factors associated with post-surgical opioid use. One thousand and thirteen opioid-naïve patients awaiting elective surgery in a tertiary private hospital in Sydney were enrolled. Preoperatively, patients completed a questionnaire comprising potential predictors of persistent post-surgical opioid use. Patients underwent surgery with routine perioperative care, and were followed up at 90 to 120 days after surgery to determine opioid use. Factors associated with opioid use were assessed with logistic regression. We had an overall response rate of 95.8% (n=970) of patients, of whom 10.5% (n=102) continued to use opioids at >90 days after surgery. On surgical subtype analysis, the prevalence of persistent opioid use was 23.6% after spinal surgery, and 13.7% after orthopaedic surgery. Four factors were independently associated with persistent post-surgical opioid use in a multivariate model: having orthopaedic (odds ratio [OR] 4.6, 95% confidence interval [CI] 2.0 to 10.8, P <0.001) or spinal surgery (OR 4.0, 95% CI 1.7 to 9.2, P <0.001), anxiety (OR 2.1, 95% CI 1.1 to 4.1, P=0.03), attending pre-admission clinic (OR 3.7, 95% CI 1.6 to 8.6, P=0.002), and higher self-reported pain score at >90 days after surgery (P <0.001). More than 10% of opioid-naïve patients undergoing elective surgery experience persistent post-surgical opioid use. Identification of factors associated with persistent post-surgical opioid use may allow development of a risk stratification tool to predict those at highest risk.
The Effect of Intensive Care Unit Admission on Smokers’ Attitudes and Their Likelihood of Quitting Smoking
Authors: Polmear C. M. , Nathan H. , Bates S. , French C. , Odisho J. , Skinner E. , Karahalios A. , McGain F.
Published: January 2019

We sought to estimate the proportion of patients admitted to a metropolitan intensive care unit (ICU) who were current smokers, and the relationships between ICU survivors who smoked and smoking cessation and/or reduction six months post–ICU discharge. We conducted a prospective cohort study at a metropolitan level III ICU in Melbourne, Victoria. One hundred consecutive patients who met the inclusion criteria were included in the study. Inclusion criteria consisted of patients who were smokers at time of ICU admission, had an ICU length of stay greater than one day, survived to ICU discharge, and provided written informed consent. A purpose-designed questionnaire which included the Fagerstrom test for nicotine dependence and evaluation of patients’ attitude towards smoking cessation was completed by participants following ICU discharge and prior to hospital discharge. Participants were re-interviewed over the phone at six months post–ICU discharge. Of the 1,062 patients admitted to ICU, 253 (23%) were current smokers and 100 were enrolled. Six months post–ICU discharge, 28 (33%) of the 86 participants who were alive and contactable had quit smoking and 35 (41%) had reduced smoking. The median number of reported cigarettes smoked per day reduced by 40%. Participants who initially believed their ICU admission was smoking-related were more likely to have quit six months post–ICU discharge (odds ratio 2.98; 95% confidence intervals 1.07, 8.26; P=0.036). Six months post–ICU discharge, 63/86 (74%) of participants had quit or reduced their smoking. Further research into targeted smoking cessation counselling for ICU survivors is indicated.
Validation of Air as an Equilibration Medium in Gastric Tonometry: An in Vitro Evaluation of Two Techniques for Measuring Air Pco2
Authors: Venkatesh B. , Morgan J. , Jones R. D. M. , Clague A.
Published: January 2019

This laboratory-based bench study was undertaken to evaluate the accuracy and equilibration characteristics of air and saline respectively as CO2 equilibrating media in the silicone balloon of a gastric tonometer and to compare two methods of measuring air Pco2.

Two gastric tonometers were suspended in a bath containing 0.9% saline maintained at 37°C. Certified calibration gases at three different CO2 concentrations were bubbled into the bath. When the bath Pco2 measurement was stable the tonometers were primed with 5 ml of air and 2.5 ml normal saline respectively and allowed to equilibrate for 30 and 90 minutes. Following equilibration, samples were aspirated and analysed in duplicate in a blood gas analyser. Bias and precision were calculated from the measured and expected Pco2 values.

A consistent negative bias (21–23%) was seen with air at all three CO2 concentrations at 30 and 90 minutes with a coefficient of variation between 2.7 and 3.3%. Imprecise data were obtained with saline at different levels of CO2. A similar experimental set-up was used to compare air Pco2 measurement by a blood gas analyser and an infra-red analyser (Tonocap). Similar bias was obtained with the blood gas analyser with respect to air Pco2 measurement as in experiment 1. The infra-red analyser measurement was highly precise with negligible bias.

Air appears to be a better CO2 equilibration medium during bench testing of tonometry producing a systematic negative offset and requiring a uniform correction factor of 1.25. This correction factor is independent of equilibration time and equilibrating CO2 concentration. The use of the infra-red analyser eliminates any bias in the measurement of air Pco2 and obviates the need for a correction factor.
Airway Management for an Uncooperative Patient with Recessive Dystrophic Epidermolysis Bullosa
Authors: Ishimura H. , Minami K. , Sata T. , Murashima K. , Shigematsu A.
Published: January 2019

We describe a case of an unco-operative patient with recessive dystrophic epidermolysis bullosa in whom difficult tracheal intubation was anticipated and fibreoptic bronchoscope guided tracheal intubation was successfully achieved after induction of general anaesthesia. Other problems in airway management associated with this disorder are discussed.
Venous Embolism of Diathermy Evolved Gases Complicating Endometrial Ablation using Glycine Irrigant
Authors: Hebbard P. D.
Published: January 2019

A case is reported of venous gas embolism in a 44-year-old woman undergoing hysteroscopic endometrial ablation using glycine irrigation without gas insufflation. The postulated source of gases are the vapour and combustion products produced by the diathermy.
Subcutaneous Tunnelling of Epidural Catheters for Postoperative Analgesia to Prevent Accidental Dislodgement: A Randomized Controlled Trial
Authors: Burstal R. , Wegener F. , Hayes C. , Lantry G.
Published: January 2019

The use of subcutaneous tunnelling to prevent movement of epidural catheters was examined in a prospective controlled trial. There were 113 patients in the standard group and 100 in the tunnelled group. The groups were similar with respect to age, sex and weight. There were 176 thoracic catheters, and 37 lumbar catheters. Mean duration of catheterization in the tunnelled group was 3.5±1.3 days and in the standard group, 3.1±1.5 days. In total, 60 catheters moved significantly from their initial position: 17 (28%) moved inwards and 43 (72%) moved outwards. 159 catheters were still functioning at the time of their removal, 76 standard and 83 tunnelled. This represents 67 and 83% of the two groups respectively.

Subcutaneous tunnelling was shown to prevent clinically significant inwards (P=0.043) and outwards (P=0.0005) movement of epidural catheters and is more likely to result in a functional epidural blockade at the time of catheter removal (P=0.0084).
Postoperative Nausea and Vomiting: Development of a Management Protocol
Authors: Paech M. J. , Pavy T. J. G. , Kristensen J. H. , Wojnar-Horton R. E.
Published: January 2019

Postoperative nausea and vomiting (PONV) is still an important and common problem. Despite the introduction of new antiemetic drugs, the management of PONV remains difficult. In this article we describe the development and evaluation of a management protocol for PONV, which consists of a treatment algorithm accompanied by a nursing education program. Implementation of this management protocol has been well-accepted by staff, appears to have reduced delay in patient treatment and improved patient care, and has significantly reduced staff workload.

It is planned to use continuous quality improvement techniques to further refine the algorithm and continue assessment of its efficacy and of patient satisfaction.
Performance of the Atom 235 Syringe Infusion Pump under Hyperbaric Conditions
Authors: Story D. A. , Houston J. J. , Millar I. L.
Published: January 2019

Inotrope-dependent patients may become haemodynamically unstable during treatment in the hyperbaric chamber. One possible cause is altered performance of infusion devices. We tested six Atom 235 syringe infusion pumps under hyperbaric conditions of 2.8 atmospheres absolute in a multiplace chamber using a gravimetric method. There was a small but significant reduction in infused volume during a thirty-minute period including compression time. We concluded that altered inotrope delivery may explain at least some of the haemodynamic instability sometimes seen, although a physiologic effect of hyperbaric treatment cannot be excluded.
Intraoperative Transoesophageal Echocardiography: Impact on Adult Cardiac Surgery
Authors: Sutton D. C. , Kluger R.
Published: January 2019

Although multiple case reports have demonstrated the capability of transoesophageal echocardiography (TOE) to detect unsuspected cardiac pathology with important therapeutic implications, few studies have examined the effect of real-time interpretation of routine TOE on clinical management of a typical series of cardiac surgery patients. To assess the impact of intraoperative TOE on cardiac surgical management, we conducted a prospective observational study on 238 consecutive patients undergoing intraoperative TOE during adult cardiac surgery. Potentially important new diagnostic information was detected in 39 of 184 (21%) routine and in 53 of 54 requested TOE examinations, and led directly to different surgical procedures in 11 of 184 (6%) routine and in 12 of 54 (22%) requested TOE examinations. Our data suggests that intraoperative TOE may be a valuable tool in the routine management of adult cardiac surgical patients.
Anaesthesia for Tracheoplasty: Case Report and Review of Anaesthesia Techniques
Authors: Tan S. S.-W. , Tan G. M.
Published: January 2019

Congenital tracheal stenosis is an uncommon cause of stridor and can be associated with other anomalies. It may present anytime during childhood depending on the severity of the lesion. The anaesthetist may be involved in all stages of management of this problem; from diagnostic investigations to surgical correction.

Various methods of tracheoplasty have been described, some requiring cardiopulmonary bypass support and others may be carried out with conventional ventilatory techniques.
The Effect of Manual Lung Hyperinflation and Postural Drainage on Pulmonary Complications in Mechanically Ventilated Trauma Patients
Authors: Ntoumenopoulos G. , Gild A. , Cooper D. J.
Published: January 2019

This study questioned whether manual lung hyperinflation (MHI) and postural drainage reduced the incidence of nosocomial pneumonia or improved other outcome variables in mechanically ventilated trauma patients. Patients were withdrawn from the study if they developed nosocomial pneumonia according to a predetermined definition or on the clinical suspicion of nosocomial pneumonia by the attending intensivist.

Of the 46 patients who fulfilled all the inclusion criteria and were enrolled into the study, 22 patients were randomized to group A (physiotherapy) and 24 patients to group B (control group). Twice as many patients were withdrawn in group B (8/24) compared with group A (4/22), although the differences were not statistically significant, [X2(1, 1) = 1.36, P = 0.24]. The length of time receiving mechanical ventilation and in the ICU was similar between the two groups and there were no differences in pulmonary dysfunction (“worst” daily PaO2/FiO2 ratio) between the two groups. There were no ICU deaths in either group.

Physiotherapy as used in this study was not associated with a reduced incidence of nosocomial pneumonia based on standard clinical criteria. Nevertheless the trend to more frequent nosocomial pneumonia in the control patients suggests that a larger study in more severely injured patients with stricter clinical criteria for the definition of nosocomial pneumonia is indicated.
A Comparison of the T-Piece, Venturi T-Piece and T-Bag for Emergence with the Laryngeal Mask
Authors: Poh J. , Brimacombe J.
Published: January 2019

We have compared the performance of a standard T-piece, a Venturi T-piece and a T-bag (T-piece with a small reservoir bag) for emergence with the laryngeal mask airway in 20 awake volunteers. FiO2, ETCO2 and FiCO2 were measured at oxygen flow rates of 2, 4 and 6 l.min-1 during three different breathing patterns: normal tidal volume, respiratory rate 12 .min-1; normal tidal volume, respiratory rate 20 .min-1; high tidal volume, respirutory rate 12 .min-1. The T-piece and T-bag delivered a higher overall average FiO2 than the Venturi T-piece (P<0.00001). Compared with normal breathing, FiO2 was reduced at the higher respiratory rate and tidal volume with the T-piece and T-bag hut was not reduced with the Venturi T-piece. FiO2 increased with increasing flow rates for all devices except the Venturi T-piece during normal breathing. ETCO2 was higher during normal breathing (4.4±0.0%) compared with higher respiratory rate (3.7±0.9%) and tidal volume (3.4±0.7%) for all devices. There were no differences in overall ETCO2 between devices. The FiCO2 was never higher than 0.2% in any subject. We conclude that the T-piece and T-bag are more effective oxygen enrichment devices than the Venturi T-piece. The T-bag provides a useful visual signal about depth and frequency of respiration.
Good Clinical Research Practice: What is it and is it Possible in the Intensive Care Unit?
Authors: Scribante J. , Lipman J. , Saadia R.
Published: January 2019

With the growing quest for answers to vexing dilemmas in critically ill patients, more intensive care units are embarking on clinical research. This places increasing importance on Good Clinical Research Practice (GCRP), a set of guidelines drawn up by the Pharmaceutical Industry to assist investigators in conducting ethical, reliable scientific studies. GCRP is a combination of good basic management skills allied to ethical principles for scientific research. Based on the principles of the Declaration of Helsinki, it consists of three tenets: patient protection (ethics), credible data (science) and data control. This article describes GCRP specifically relating it to the intensive care situation, illustrating some of the concepts with practical examples. With a minimum of extra time and effort these basic-principles can be integrated as routine into all research projects.
Anaesthesia for Transmyocardial Laser Revascularization—Initial Experience with Seven Patients
Authors: Liu H. C. , Ang S. B. L. , Chen F. G.
Published: January 2019

The introduction of transmyocardial laser revascularization for ischaemic heart disease has brought with it new challenges for anaesthetists. These include acute deterioration of cardiac function, the need for emergency cardiopulmonary bypass and difficulty weaning from haemodynamic support. Recurrent arrhythmias can occur despite amiodarone prophylaxis. We describe our initial experience and the problems we encountered.
Improving the Evidence Base for Anaesthesia
Authors: Rigg J. , Cokis C. , Collins K. , Glass D. D. , Jamrozik K. , Leslie K. , Myles P. , Peyton P. , Poustie S. , Silbert B.
Published: January 2019

This paper is a brief report of the symposium, “Improving the Evidence Base for Anaesthesia and Intensive Care”, organized by the MASTER Anaesthesia Trial Study Group at the Annual Scientific Meeting of the Australian and New Zealand College of Anaesthetists, Newcastle, N.S.W., on Tuesday, May 5, 1998.
Prevalence and Prediction of Difficult Intubation in Chinese Women
Authors: Wong S. H. S. , Hung C. T.
Published: January 2019

We conducted a prospective, blind observational study to investigate the prevalence and prediction of difficult intubation in Chinese women. Two groups of Chinese women were studied (151 pregnant and 260 non-pregnant). The prevalence of difficult intubation was 1.99% in the pregnant and 1.54% in the non-pregnant group. The difference was not statistically significant. Predictive variables for difficult intubation, including modified Mallampati class, thyromental distance and atlanto-occipital extension, had high sensitivity but low positive predictive value when used alone. A shorter thyromental distance had to be used as the criterion for prediction in Chinese women. Combination of predictive variables could improve the positive predictive value.
Democracy and Infant Mortality in Less-Developed Nations: Dismantling Differences in Direct and Indirect Effects Modeling
Authors: Noble Mark D.
Published: January 2019

In recent years, many studies have focused on examining the relationship between democracy and health outcomes in developing nations. However, the overwhelming majority of this research utilizes direct-effect modeling approaches, assuming that increases in democracy are going to directly translate into improvements in well-being. Drawing on a sample of 136 less-developed nations, I first conduct a basic regression, where I find no significant impact of democracy on infant mortality. I then utilize structural equation modeling (SEM) to show significant indirect effects of democracy on infant deaths through public health spending. The results help place in context previous studies that have found inconsistent effects of democracy on health outcomes. The regression and SEM analyses demonstrate how erroneous findings can result from solely utilizing direct-effect approaches, which incorrectly treat key mediating mechanisms as competing predictors.
Improvement of the recycling of plastics in lightweight packaging treatment plants by a process control concept
Authors: Feil Alexander , Coskun Erdogan , Bosling Marcel , Kaufeld Sebastian , Pretz Thomas
Published: January 2019

In Germany, only approximately 30% by mass of plastics from lightweight packaging waste is recycled; 65% by mass is transferred to inferior residual fractions (sorting residue and mixed plastics), which are currently only utilized thermally. An increase in the recycling of valuable resources in the sense of material recycling would both contribute to the saving of resources and improve the economic situation of plant operators. It is generally known from operating and planning experience that fluctuation in the amount of material loaded into the sorting process is one of the main reasons for suboptimal recycling quotas. In particular, overfilling in the input stream leads to a deterioration of the separation result of the entire process. A novel process control concept envisages equalizing the material flow in such a way that all separation steps are operated in the intended design range. For the example of a lightweight packaging treatment process, the requirements and technological solutions for a sensor-based process control concept will be presented.
Community Pharmacists’ Perceptions of Care Following the Implementation of a Transitions-of-Care Program
Authors: Graham Jove , Tusing Lorraine D. , Gregor Christina M. , Wright Eric A.
Published: January 2019

Background:

Pharmacist-led collaborative interventions can support improved medication use and adherence during transitions of care (TOC). Community pharmacists are not always actively connected with other health-care team professionals, however, and their confidence in having necessary information may vary.

Objective:

To assess community pharmacists’ perceptions of information, care provided, and communication, before and after a postdischarge intervention designed to increase communication between inpatient and community pharmacists.

Methods:

A survey assessing 4 domains related to pharmacists’ perceptions of information and care of hospital discharge patients was developed and distributed to 106 community pharmacists before and after a TOC interventional study.

Results:

Based on 151 responses (77 baseline, 74 followup) from 84 participants, community pharmacists have high confidence in their ability to counsel and feel that they are an important part of the healthcare team. They are less confident that they have adequate information about patients and report gaps in having adequate support and resources to provide care. When a TOC intervention was implemented, there was significant improvement in community pharmacists’ feeling of having adequate information about the patients.

Conclusion:

Not having adequate information regarding patients discharged from the hospital is an area of concern for community pharmacists and a modifiable opportunity to improve TOCs.
Evaluating the Standardization of Transitions of Care in a Texas-Mexico Border Academic Family Medicine Practice
Authors: Kennedy Rachel A. , Padilla Margie E. , Andrews Sweta , Christenberry Emily J. , Winters Stella , Loya Amanda , Shokar Navkiran
Published: January 2019

Purpose

This quality improvement project aimed to assess the elements of the current workflow process that meets requirements for transitions of care from a family medicine inpatient to outpatient service following the Transitional Care Management (TCM) program developed by the Centers for Medicare & Medicaid Services. The purpose of the study was to assess the current family medicine workflow and determine whether the current process meets the criteria for billing and calculate the potential loss of reimbursement.

Methods

Interviews with key personnel, review of practice policies, and a retrospective chart review were performed for clinic patients discharged from the inpatient to outpatient family medicine service.

Results

A total of 37 patients met inclusion criteria for the chart review. Of these, 8% of patients seen at the outpatient clinic met all criteria for TCM. Potential reimbursement for those who met TCM criteria was $293.14 USD; the estimated potential TCM reimbursement for patients not meeting criteria was $1997.76 USD.

Conclusion

Standardized, team-based TCM services have shown to decrease readmission rates for high-risk patient populations. Results from this project identified processes in place at the family medicine practice to facilitate the development of a standardized transitional care service which could meet both TCM and best practice models.
A Case Report of Neurotoxicity After Prolonged Doses of Acyclovir in a Patient With Renal Dysfunction
Authors: Umoru Godsfavour O. , Shah Punit J. , Tariq Farheen
Published: January 2019

Renal dysfunction is a significant risk factor for acyclovir-induced neurotoxicity and altered mentation and myoclonic movements are the most common clinical symptoms observed. In majority of reported cases, neurological sequelae associated with acyclovir-induced neurotoxicity often mimic viral infections of the central nervous system and makes diagnosis of the former challenging. Although plasma concentrations of the drug may not always correlate with neurotoxic symptoms, obtaining serum levels of acyclovir may be helpful in confirming drug-induced neurotoxicity. Hemodialysis has been shown to significantly improve altered mentation in patients with suspected or confirmed acyclovir-induced neurotoxicity. Here, we report a definite case of acyclovir-induced neurotoxicity in a patient with end-stage renal disease. Clinical improvements in neurologic symptoms were observed following discontinuation of the drug and hemodialysis.
An investigation into aircraft loss of control and recovery solutions
Authors: Rohith G
Published: January 2019

Aircraft loss of control is an acute phenomenon that has far reaching consequences irrespective of the class and type of aircraft. In order to ensure safe aircraft operation, loss of control problem has to be addressed efficaciously. This paper investigates various factors that trigger the onset of loss of control events and recovery solutions for the same. Rather than relying on statistics alone, this paper concentrates on simulation-based investigation towards various loss of control scenarios and subsequent recovery schemes. Through bifurcation analysis, distinct abnormal dynamics have been identified and their contributions in driving the aircraft towards loss of control have been examined. The effect of steady wind on aircraft dynamics and the evolution of chaotic dynamics as a precursor to loss of control are presented. Aircraft loss of control under actuator impairment conditions are also probed into. Various loss of control recovery schemes have been investigated and a robust loss of control recovery solution based on sliding mode control is also presented.
Prosody and Function Words Cue the Acquisition of Word Meanings in 18-Month-Old Infants
Authors: de Carvalho Alex , He Angela Xiaoxue , Lidz Jeffrey , Christophe Anne
Published: January 2019

Language acquisition presents a formidable task for infants, for whom word learning is a crucial yet challenging step. Syntax (the rules for combining words into sentences) has been robustly shown to be a cue to word meaning. But how can infants access syntactic information when they are still acquiring the meanings of words? We investigated the contribution of two cues that may help infants break into the syntax and give a boost to their lexical acquisition: phrasal prosody (speech melody) and function words, both of which are accessible early in life and correlate with syntactic structure in the world’s languages. We show that 18-month-old infants use prosody and function words to recover sentences’ syntactic structure, which in turn constrains the possible meanings of novel words: Participants ( N = 48 in each of two experiments) interpreted a novel word as referring to either an object or an action, given its position within the prosodic-syntactic structure of sentences.