Greenwich Hospital Research Articles

Natural Language Processing of Clinical Documentation to Assess Functional Status in Patients With Heart Failure

Serial functional status assessments are critical to heart failure (HF) management but are often described narratively in documentation, limiting their use in quality improvement or patient selection for clinical trials. To develop and validate a deep learning natural language processing (NLP) strategy for extracting functional status assessments from unstructured clinical documentation. This diagnostic study used electronic health record data collected from January 1, 2013, through June 30, 2022, from patients diagnosed with HF seeking outpatient care within 3 large practice networks in Connecticut (Yale New Haven Hospital [YNHH], Northeast Medical Group [NMG], and Greenwich Hospital [GH]). Expert-annotated notes were used for NLP model development and validation. Data were analyzed from February to April 2024. Development and validation of NLP models to detect explicit New York Heart Association (NYHA) classification, HF symptoms during activity or rest, and frequency of functional status assessments. Outcomes of interest were model performance metrics, including area under the receiver operating characteristic curve (AUROC), and frequency of NYHA class documentation and HF symptom descriptions in unannotated notes. This study included 34 070 patients with HF (mean [SD] age 76.1 [12.6] years; 17 728 [52.0]% female). Among 3000 expert-annotated notes (2000 from YNHH and 500 each from NMG and GH), 374 notes (12.4%) mentioned NYHA class and 1190 notes (39.7%) described HF symptoms. The NYHA class detection model achieved a class-weighted AUROC of 0.99 (95% CI, 0.98-1.00) at YNHH, the development site. At the 2 validation sites, NMG and GH, the model achieved class-weighted AUROCs of 0.98 (95% CI, 0.96-1.00) and 0.98 (95% CI, 0.92-1.00), respectively. The model for detecting activity- or rest-related symptoms achieved an AUROC of 0.94 (95% CI, 0.89-0.98) at YNHH, 0.94 (95% CI, 0.91-0.97) at NMG, and 0.95 (95% CI, 0.92-0.99) at GH. Deploying the NYHA model among 182 308 unannotated notes from the 3 sites identified 23 830 (13.1%) notes with NYHA mentions, specifically 10 913 notes (6.0%) with class I, 12 034 notes (6.6%) with classes II or III, and 883 notes (0.5%) with class IV. An additional 19 730 encounters (10.8%) could be classified into functional status groups based on activity- or rest-related symptoms, resulting in a total of 43 560 medical notes (23.9%) categorized by NYHA, an 83% increase compared with explicit mentions alone. In this diagnostic study of 34 070 patients with HF, the NLP approach accurately extracted a patient's NYHA symptom class and activity- or rest-related HF symptoms from clinical notes, enhancing the ability to track optimal care delivery and identify patients eligible for clinical trial participation from unstructured documentation.

Commentary: Futility in Psychiatry.

While other medical professions have grappled with end-of-life care, the areas of palliative psychiatry, and more particularly, futility in psychiatry, have not been thoroughly addressed. The 3 cases presented in this issue illustrate how patients can succumb to a medical condition while presenting with primary psychosis (a patient with treatment-resistant schizophrenia who starves himself), secondary psychosis (a patient with small cell cancer of the lung who develops psychotic symptoms in the context of a paraneoplastic neurological syndrome), or a factitious disorder (a patient with self-induced aplastic anemia from ingesting an oral chemotherapy agent). The descriptions of these challenging cases show how collaborative teamwork among psychiatric and medical treatment teams, including the provision of palliative care, can help patients and families, even if a fatal outcome appears certain.

Abstract 11300: Identification of Two Distinct Phenotypes Among Hospitalized Covid-19 Patients Using Latent Class Analysis

Introduction: COVID-19 pneumonia is a heterogeneous disorder with a complex pathogenesis. Underlying subgroups may exist among patients who are admitted to the hospital with COVID-19 infection. Methods: We reviewed the charts of adult patients who were hospitalized primarily for COVID-19 at Greenwich Hospital. We performed latent class analysis using variables based on patient demographics (age, sex, race, and body mass index), comorbidities (hypertension, diabetes, coronary artery disease, chronic heart failure, chronic kidney disease, neurological disease, and pre-existing respiratory disease), laboratory results, and treatment information (medications received during hospitalization, hospital length of stay, maximized oxygen requirement, and requirement for intubation). Results: Two phenotypes were identified: C1 and C2. C1 (n=193) included older individuals with a higher mortality rate (25.4% vs 8.97%, p<0.001) and more comorbidities such as hypertension (88.6% vs 22.8%, p<0.001), coronary artery disease (32.1% vs 0.0%, p<0.001), chronic heart failure (20.7% vs 0%, p<0.001), diabetes mellitus (38.3% vs 17.6%, p<0.001), chronic kidney disease (25.4% vs 2.8%, p<0.001), pre-existing respiratory disease (24.9% vs 11.0%, p=0.004), and pre-existing neurological disease (32.1% vs 3.5%, p<0.001). C2 (n=290) consisted of individuals who were younger (53.7 years vs 79.5 years, p<0.001), more likely to be obese (40.3% vs. 28.0%, p=0.007), mostly male (70.3% vs 52.3%, p<0.001), and mostly non-white (69.7% vs. 28.5%, p<0.001), with higher levels of inflammatory markers such as C-reactive protein (18.3±43.4 vs. 10.7±13.7 mg/L, p=0.006) and alanine aminotransferase (209±512 vs. 96.2±204 U/L, p=0.001). Conclusions: Using latent class analysis, we identified two clinical phenotypes of patients who were admitted to the hospital for COVID-19. Our findings may reflect different pathophysiologic processes that lead to moderate to severe COVID-19 and may be useful in the identification of treatment targets and the selection of patients with severe COVID-19 disease for future clinical trials.

IDENTIFICATION OF PHENOTYPES AMONG COVID-19 DEATH USING LATENT CLASS ANALYSIS

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Certain risk factors and prognostic indicators have been identified in patients with coronavirus disease 2019 (COVID-19). However, no study has addressed the risk factor distribution pattern among patients who die from COVID-19. In this study, we used latent class analysis (LCA) to identify phenotypes and risk factor distribution patterns in hospitalized patients who died from COVID-19. METHODS: We reviewed the charts of patients who died from COVID-19 at Greenwich Hospital from February 1 to May 30, 2020. We performed LCA based on well-documented prognostic factors of COVID-19. We also compared the in-hospital laboratory results, and treatment information among the different clusters identified by LCA. To validate of the clustering results, we conducted a robust LCA of the entire COVID-19 cohort. RESULTS: 483 patients who were admitted for COVID-19 infection from February 1 to May 30, 2020, 81 patients died. Using latent cluster analysis, we identified two risk factor clusters among COVID-19 death: C1 (n=58) and C2 (n=23). In C1, patients were older (p<0.001) with a higher proportion of comorbidities such as hypertension (82.8% vs. 39.1%, p<0.001), CAD (43.1% vs. 0%, p<0.001), CHF (22.4% vs. 0%, p=0.015), and pre-existing respiratory disease (32.8% vs. 0%, p=0.004) than in C2. In C2, patients were significantly younger and were more likely to be obese (BMI ≥30 kg/m2;56.5% vs. 24.1%, p=0.012), male (87.0% vs. 58.6%, p=0.018), and non-white (60.9% vs. 15.8%, p<0.001) than in C1. Compared with patients in C1, patients in C2 showed a pattern of increased expression of inflammatory and hypercoagulable markers, including C-reactive protein (84.4±117 vs. 12.7±10.7 mg/L, p=0.008) and D-dimer (17.8±13.6 vs. 8.0±9.9 mg/L, p=0.004). The robust-test by using the entire cohort of patients hospitalized with COVID-19 had identified two clusters of risk factor patterns similar to those identified in the cohort of patients who died from COVID-19. CONCLUSIONS: Our study suggests that there are two patterns of risk factors that contributed to death in patients with COVID-19. These results indicate that different pathophysiologic processes lead to COVID-19 death and may be useful in identifying treatment targets and selecting patients with severe COVID-19 disease for future clinical trials. CLINICAL IMPLICATIONS: The results indicate that each phenotype of patients who died from COVID-19 has its distinct feature and underlying pathophysiology. Research focused on targeted therapy for each phenotype may help decrease the mortality rate among patients with severe COVID-19. DISCLOSURES: No relevant relationships by Deepa Jansen, source=Web Response No relevant relationships by Pengyang Li, source=Web Response No relevant relationships by Catherine Teng, source=Web Response

Identification of Phenotypes Among COVID-19 Patients in the United States Using Latent Class Analysis.

BackgroundCoronavirus disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) is a heterogeneous disorder with a complex pathogenesis. Recent studies from Spain and France have indicated that underlying phenotypes may exist among patients admitted to the hospital with COVID-19. Whether those same phenotypes exist in the United States (US) remains unclear. Using latent class analysis (LCA), we sought to determine whether clinical phenotypes exist among patients admitted for COVID-19.MethodsWe reviewed the charts of adult patients who were hospitalized primarily for COVID-19 at Greenwich Hospital and performed LCA using variables based on patient demographics and comorbidities. To further examine the reliability and replicability of the clustering results, we repeated LCA on the cohort of patients who died during hospitalization for COVID-19.ResultsTwo phenotypes were identified in patients admitted for COVID-19 (N = 483). According to phenotype, patients were designated as cluster 1 (C1) or cluster 2 (C2). C1 (n = 193) consisted of older individuals with more comorbidities and a higher mortality rate (25.4% vs 8.97%, p < 0.001) than patients in C2. C2 (n = 290) consisted of younger individuals who were more likely to be obese, male, and nonwhite, with higher levels of the inflammatory markers C-reactive protein and alanine aminotransferase. When we performed LCA on the cohort of patients who died during hospitalization for COVID-19 (n = 75), we found that the distribution of patient baseline characteristics and comorbidities was similar to that of the entire cohort of patients admitted for COVID-19.ConclusionUsing LCA, we identified two clinical phenotypes of patients who were admitted to our hospital for COVID-19. These findings may reflect different pathophysiologic processes that lead to moderate to severe COVID-19 and may be useful for identifying treatment targets and selecting patients with severe COVID-19 disease for future clinical trials.

Correlation between ASA Grade with reversal of Hartmann's procedure - a retrospective study.

Hartmann’s procedure involves resecting the rectosigmoid colon, closure of the distal rectal stump, and forming an end colostomy for complicated left colon diverticulitis or malignancy. Recovery from the initial operation can, in a second stage, be followed by a reversal stage with the restoration of bowel continuity. This study aimed to assess the reversal rate and its correlation with demographic data, ASA grade, and length of hospital stay. All patients who underwent Hartmann’s emergency procedure from 2014 to 2018 at Lewisham and Greenwich hospital were enrolled in this retrospective study. Data was collected from the inpatient electronic files and NELA (UK National Laparotomy Audit). 118 patients were included in the study, with 57.6% females and a median age of patients of 69 years (range 35–91). Findings of the study indicate that the most common indications for Hartmann’s procedure were diverticular complications 60% (n=71) and benign perforated sigmoid or rectosigmoid cancer 16% (n=19). The average length of hospital stay was 24 days (range n=2 – 212 days). The reversal rate was 34.9% (41/118 cases). No significant difference was observed between gender and length of hospital stay in relation to the reversal rate while there was a significant correlation between age and ASA grade in relation to reversal rate; the calculated P values were recorded as (<0.000) and (<0.009) respectively. Our results show that the highest reversal rate was observed in younger and fitter (I–II) ASA grade patients. The most common medical complication from reversal of Hartmann’s procedure was an anastomotic leak (n=6, 16.7%). Reversal rate of Hartmann’s procedure was 34.9%. The average timeframe for reversal was within 18–20 months. There was a significant correlation between age and ASA grade in relation to reversal rate.

The short-term effects of head-mounted virtual-reality on neuropathic pain intensity in people with spinal cord injury pain: a randomised cross-over pilot study.

Within-subject, randomised cross-over trial. To determine whether a commercially available 3D head-mounted (HMD) virtual reality (VR) device results in significant reductions in neuropathic pain compared to using a 2D screen device in people with spinal cord injury (SCI). Greenwich Hospital, Sydney, Australia. Sixteen men with established SCI and chronic neuropathic pain participated in a single-session randomised cross-over trial. We compared the effects of 3D HMD VR and a 2D screen application on SCI neuropathic pain intensity and levels of perceived presence. Participants reported significantly lower pain intensity after 3D HMD VR compared to 2D screen application (1.9 ± SD 1.8 versus 3.4 ± SD 1.6, mean 95% CI: 1.5, P < 0.0001). Participants reported significantly higher perceived levels of presence with the 3D HMD VR compared to 2D screen of (49.6 ± SD 8.9 versus 32.8 ± SD 11.1, mean 95% CI: 16.6, P < 0.0001). Increased perceived presence was associated with significantly lower pain intensity regardless of randomised sequencing of the two conditions (mean 95% CI: 0.06, P = 0.005). Effect size for pain reduction using 3D HMD VR was 0.80. We suggest that 3D HMD VR may provide neuropathic pain relief for people with SCI. Given the lack of cybersickness and ease of access, we propose that immersive VR could be a helpful adjunct to current pharmacotherapy. Further research is required to show that VR can be effective for more long-term reductions in SCI pain.

The Economic Institutions of Construction in London after the Great Fire

This article contributes to literature on the role of “firms” in the early modern English economy by exploring contracts for works between the Crown, the City of London, and large construction firms that built the Greenwich Hospital, City churches, and St. Paul’s Cathedral from 1670 to 1712. Primary sources show varying arrangements to pricing, mitigating risk, and securing finance occurred without the costs of intermediaries. Clients pushed financial and operating risks onto contractors through complex contracting systems that enabled and supported a number of coordination mechanisms in the market. The article argues that contracts rather than firms should be the unit of analysis for those wishing to examine productivity and changes in early modern business.

We asked our patients – ‘What do you need in a cancer rehabilitation program?’

Papers published in the literature and/or presented at rehabilitation congresses in recent years have demonstrated the efficacy of rehabilitation programs in addressing residual problems of impairment and function after cancer treatment. Functional outcomes of programs delivered to patients impacted by a cancer diagnosis are comparable to those delivered to patients with ‘benign’ disease diagnoses, as are post-discharge living arrangements and care outcomes. Whilst data to support the efficacy of rehabilitation in the context of a cancer diagnosis well justifies these programs, for the individual patient the most important thing is the lived individual narrative of their illness and associated problems. The intersection of this narrative and functional outcome measures may at times be tenuous. To address this, we undertook in-depth interviews with a purposive sample of patients at the time of their admission into the Jacaranda Cancer Rehabilitation Unit at Greenwich Hospital, and also prior to their discharge, to evaluate their own individual goals and hear the narrative of their experience in our rehabilitation program. We also convened focus groups of the medical, nursing and allied health professional members of the multidisciplinary team, to find out their experiences at the intersection of individual patient narrative, and formal rehabilitation goal setting. Both positive and negative perspectives were sought. We discovered that despite the challenges of goal setting and rehabilitation, the shared experience of a real therapeutic community between patients, families and the multidisciplinary team, lies at the heart of effective rehabilitation that puts people's lives back together, in ways that they can manage and continue with, after hospital discharge. Qualitative review of patients’ goals and their experience in rehabilitation provides a rich source of information that complements traditional quantitative outcome data.

Real wages once more: a response to Judy Stephenson

AbstractThis article examines Judy Stephenson's claim that institutional wage series such as those of Greenwich Hospital overstate the earnings of building workers by 20 to 30 per cent, and it is argued here that the conclusion is unpersuasive. Whatever adjustments to existing wage series are necessary in view of her new evidence would have no significant implications for real wages in England compared to the rest of the world. Consequently, Stephenson's findings do not call into question the high wage explanation for the industrial revolution.

Peter Joseph Wilkinson Monks

Peter Joseph Wilkinson Monks was born in Warrington, Cheshire, and studied medicine at St Bartholomew’s Hospital, London. His preclinical training was relocated to Cambridge during the war. He was a...

Empire to Nation: Art, History and the Visualization of Maritime Britain, 1768–1829, by Geoff Quilley

In 1768, Joshua Reynolds became the first president of the newly-founded Royal Academy, and Captain James Cook’s first expedition to the Pacific set sail. The two events are not directly related, but Geoff Quilley uses them as a framework for his dense but rewarding thematic exploration of six decades of British visual culture. He argues that British art retreated from imperial influences and subject-matters in the face of the threat of revolutionary France. In keeping with the title, the book’s three parts begin in the furthest reaches of Britain’s first empire and converge slowly back to the heart of the maritime nation at Greenwich: Cook’s voyages feature heavily in the essays in Part One; the Atlantic world is the subject of Part Two; and Part Three focuses on images of sailors and naval battles during and after the wars of 1793–1815. Quilley is at his most effective and innovative when closely analysing a painting or following themes through an individual artist’s work. The second half of Chapter Three, for example, provides a lucid explanation of why William Hodges chose particular subjects in a series of paintings of Pacific islands from the 1770s. Quilley also effectively contrasts the artistic motivations and shipboard roles of Hodges, the artist on Cook’s second voyage, and John Webber, the artist on Cook’s third voyage. His analysis of John Singleton Copley’s Watson and the Shark in Chapter Four is multidimensional and thorough, incorporating the significance of the racial, imperial and allusive elements of that remarkable painting. The last chapter, in which J.M.W. Turner’s Battle of Trafalgar is installed in the Naval Gallery in Greenwich Hospital, creatively uses the various competing paintings of the battle as an introduction to the historiographical and commercial competition between William James and Edward Pelham Brenton in the 1820s.

The “Poor Decayed Seamen” of Greenwich Hospital, 1705–1763

The records of the Royal Hospital for Seamen at Greenwich, usually known as Greenwich Hospital, offer a unique insight into the lives and careers of eighteenth-century seamen. Based upon a database of approximately 8000 entrants prior to 1763, this essay examines the origins, working lives and careers of the “poor decayed seamen” who inhabited the Hospital and also sheds light on the day-to-day functioning of an institution that is very well known but has hitherto received surprisingly little scholarly attention.

Ethics, Values, and Decision Making

Throughout history, using one's values in personal decision making has implied integrity, ethical behavior, and leadership. I recently viewed a fascinating short documentary by Scott Sniffin titled Home of the Brave: When Southbury Said No to the Nazis. The film describes the attempted development of a military camp by the German American Bund movement in Southbury, Connecticut, in 1937 and details the actions of the townspeople to thwart the camp's development despite the fact that doing so would mean giving up an important freedom.As the Bund was in the initial stages of developing its twenty-fifth military training site in the rural town of Southbury, the townspeople, clergy, and selectman (mayor) held an open town meeting to discuss the camp's development and its implications for the town's residents. The townspeople strongly opposed the Bund's actions and decided at that town meeting not to let the Bund finish developing its site by creating obstacles to doing so. To carry out their task, they instituted zoning laws in the community that prohibited military training camps. While not a unanimous decision, as the townspeople had enjoyed the absence of zoning laws and restrictions, the majority agreed that it was more important to act in accordance with their values, even if they had to give up one of their freedoms in the process. The townsfolk did what they felt was right, demonstrating exemplary leadership, high-values-based behavior, and self-sacrifice.Today, healthcare executives and caregivers are guided by their respective professional code of ethics, which aims to protect patients, families, employees, and others from harm and mistreatment. An organization's ethical conduct ensures the safety of all who work, visit, or are cared for within its confines.Ruth W. Brinkley, FACHE, and John J. Donnellan Jr., FACHE, authors of the feature articles in this issue, reflect on the strong influences of an ethical and valuesbased culture within an organization. They both conclude that such a culture engenders high moral decision making, empowerment, fulfillment, and success among employees.THE IMPORTANCE OF ORGANIZATIONAL VALUES AND INDIVIDUAL CO MM IT MENT TO THOSE VALUESBrinkley raises a number of points that help explain the values that the Southbury townspeople displayed 75 years ago. She states: Whether spoken or unspoken, values are important because they form the basis of culture, and culture drives performance. An organization's values and culture determine what is expendable and what is essential. At Greenwich Hospital, the service excellence culture has cascaded through all levels of the organization. From the time an employee is oriented into the facility, he or she learns what service excellence means for the hospital and is educated as to the ethical guidelines staff are expected to follow. Employees are mentored on their unit during the first year of their employment. The parameters are clearly understood and practiced, and they appeal to the inherent good within each employee.As part of our service excellence culture, employees are given permission to do the right thing for their patients. For example, if a patient leaves his or her slippers at home, the employee can purchase a new pair in the hospital's gift shop without bureaucratic hassle. It is the belief of Greenwich Hospital management, borne out in the patient satisfaction surveys that are conducted continuously, that happy patients lead to happy employees, which lead to increased patient satisfaction and heightened employee confidence to do the right thing when the right thing is in question. Employees' actions are celebrated weekly and monthly at quality award ceremonies; fear of retribution is nonexistent.Donnellan notes that Process improvement methods succeed when staff are empowered to call attention to systems that are not working well or processes that can be improved. In an environment guided by a moral compass, staff members are allowed to solve problems whose resolutions contribute to the organization's success. …

Empire to nation: art, history and the visualization of maritime Britain, 1768-1829

'Empire to Nation' offers a new consideration of the image of the sea in British visual culture during a critical period for both the rise of the visual arts in Britain and the expansion of the nation's imperial power. It argues that maritime imagery was central to cultivating a sense of nationhood in relation to rapidly expanding geographical knowledge and burgeoning imperial ambition. At the same time, the growth of the maritime empire presented new opportunities for artistic enterprise. Taking as its starting point the year 1768, which marks the foundation of the Royal Academy and the launch of Captain Cook's first circumnavigation, it asserts that this was not just an interesting coincidence but symptomatic of the relationship between art and empire. This relationship was officially sanctioned in the establishment of the Naval Gallery at Greenwich Hospital and the installation there of J. M. W. Turner's great 'Battle of Trafalgar' in 1829, the year that closes this study. Between these two poles, the book traces a changing historical discourse that informed visual representation of maritime subjects.

Transitioning Hospital-Based Nurse Leaders to Professional Doctorates

The collaboration for the project Transitioning Hospital-Based Nurse Leaders to the Practice Doctorate (Doctor of Nursing Practice [DNP] degree program) was initiated by Case Western Reserve University. Participating hospitals included Greenwich (CT) Hospital, Mt. Sinai Hospital (NYC), Carilion Health Care System (Roanoke, VA), Exeter Hospital (Exeter, NH), Shore Memorial Hospital (Atlantic City, NJ), and the North Shore Long Island Jewish Health System (Long Island, NY). The partnership is focused on collaboration that enhances both nursing education and practice. This DNP program for hospital-based nurse administrators and advanced practice nurses (APNs) has been offered onsite in these hospitals to strengthen evidence-based practice, thus improving the quality of healthcare delivered in the partner hospitals. The benefit to the educational institution is the enrichment of the teaching learning experience through inclusion and integration into the curriculum of content regarding current issues and challenges in healthcare delivery. The collaboration for the project Transitioning Hospital-Based Nurse Leaders to the Practice Doctorate (Doctor of Nursing Practice [DNP] degree program) was initiated by Case Western Reserve University. Participating hospitals included Greenwich (CT) Hospital, Mt. Sinai Hospital (NYC), Carilion Health Care System (Roanoke, VA), Exeter Hospital (Exeter, NH), Shore Memorial Hospital (Atlantic City, NJ), and the North Shore Long Island Jewish Health System (Long Island, NY). The partnership is focused on collaboration that enhances both nursing education and practice. This DNP program for hospital-based nurse administrators and advanced practice nurses (APNs) has been offered onsite in these hospitals to strengthen evidence-based practice, thus improving the quality of healthcare delivered in the partner hospitals. The benefit to the educational institution is the enrichment of the teaching learning experience through inclusion and integration into the curriculum of content regarding current issues and challenges in healthcare delivery.

Commentary on “Use of Tattooing for Camouflaging Various Scars”

As a practicing cosmetologist and tattooist, I have personally performed many restorative and reconstructive tattooing procedures over the years, and would like to commend Dr. Kim and his colleagues [1] for their openmindedness in embracing this modality. While surgical revision and other treatments such as dermabrasion and laser may be quite efficacious in refining scar contours and reducing hyperpigmentation, I believe that tattooing serves as an excellent adjunctive therapy for restoring color in cicatricial tissues. As Dr. Kim elegantly illustrates in his article, the technique is most useful in flat, hypo-pigmented scars, to emulate the melanin in surrounding normal skin, as well as the hue of adjacent hair follicles. Tattooing is also quite beneficial in replacing the crimson tones of the lip mucosa. For surgeons wishing to incorporate this skill set into their practice, I would like to share some key clinical observations that I have made in the performance of restorative tattooing to enhance the satisfaction of both the patient and the practitioner. I offer these remarks as a supplemental commentary to the article by Dr. Kim et al. In regard to anesthesia, the authors suggest that ‘‘Local anesthetic mixed with (a) vasoconstricting agent is useful because bleeding makes colors indistinct.’’ They go on to say that ‘‘pigments should be mixed before the injection or topical application of anesthetic agent, and after the patient’s complexion is fully stabilized.’’ While I do agree with the latter statement, I generally avoid using a vasoconstricting agent in scar correction since it blanches the skin and, in my experience, can make the treatment area difficult to precisely situate without intricate preprocedural markings. This is of particular significance when working near the lip vermillion as it may virtually obliterate the intrinsic coloring. Also, surgeons performing these procedures may wish to consider the use of nerve blocks rather than the local infiltration of anesthetics. This method potentially avoids variation of dermal moisture content and the subsequent alteration of tissue characteristics in the proposed area of treatment. I have found tattooing on infiltrated tissues to be less than optimal, as needle penetration and depth become less predictable. The article additionally voices the valid concern that ‘‘black pigment looks bluish when imbedded too deep.’’ This is certainly true, but I believe that ‘‘bluing’’ occurs in many of the darker pigments over time, regardless of the depth of implantation. Consider, if you will, the decorative tattoos of elderly individuals, which had been performed perhaps 40 or 50 years ago. It seems that the darker outlines uniformly undergo a blue-tinged transformation as they age within the skin. To counteract this tendency, at least in the short term, I have used small amounts of orange-based tint added to the pigment batch. This seems to have prevented bluing in the vast majority of cases at approximately 1 year, without substantially altering the color of the originally implanted material. Again, I would like to congratulate the authors on their innovative work and hope that restorative tattooing will make its way into the armamentarium of mainstream reconstructive surgery. I am most honored and greatly W. Lampeter (&) Greenwich Hospital—Yale New Haven Health, 2 1/2 Dearfield Drive, Suite #102, Greenwich, CT 06831, USA e-mail: walterlampeter@aol.com

Single-Incision Multiport Laparoendoscopic (SIMPLE) Cholecystectomy

We thank you for your most astute comments regarding our article. We address these comments based not only on our original article on a series of 10 procedures, submitted in September 2008, but also on our experience that well exceeds 100 procedures in the past 1 years. Our method has changed with our experience. For example, we no longer perform this procedure during lithotomy. We have moved from a three-port trocar technique to a more stable and flexible port platform (Gelpoint; Applied Medical, Rancho Santa Margarita, CA, USA), which allows the insertion of multiple ports. We continue to use straight instruments preferentially, with occasional need for a right-angled instrument and even less need for articulating instruments. We also continue to use a rigid 30 angled scope. These technique changes address the issues raised in your letter. First, a critical view of safety is obtained in all cases. We have found that for most procedures this indeed can be achieved with a two-instrument technique [1] (Fig. 1). Retraction is imperative to obtaining this maneuver. Instead of reflecting the fundus of the gallbladder superolaterally and the infundibulum inferolaterally, as with the three-instrument dissection technique, we retract the only the infundibulum. But we grasp the infundibulum as close to the cystic duct as possible. This is important for two reasons. First, we create sufficient tension to achieve the dissection, thereby opening up Calot’s triangle, pulling the cystic duct and artery away from the liver’s edge and the underlying common bile duct. Second, internal retraction as close as possible to the area of dissection minimizes exterior lateral hand movement, thereby eliminating hand crisscrossing and clashing. Positioning the patient in the reverse Trendelenburg and slightly left laterally recumbent position has aided us in this maneuver. However, as you point out, a two-instrument technique is not possible in all cases, most notably when the patients have a high body mass index (BMI), fatty or enlarged liver, or acute cholecystitis. In these circumstances, we add a fourth port and proceed with the traditional three-instrument dissection. Often, we add this through our single umbilical incision, but occasionally we add it through an additional port, transforming the single-incision multiport laparoendoscopic (SIMPLE) procedure into a reduced-port procedure (or in our vernacular, a ‘‘DIMPLE’’). The second issue you raised questions the maneuverability restrictions of three trocars. We have found that extending the skin incision at the time of pneumoperitoneum, using the locking trocars, minimizes restriction and preserves the small single incision. A 4-cm skin incision with maximal abdominal distention decreases to a 2– 2.5 cm incision at desufflation. Nonetheless, our early experience with the locking trocars, as you mentioned, was limiting. We have since found that the Gelpoint system allows for much more freedom of movement through the same small skin incision. The fascial incision is a single incision as well, not the ‘‘Swiss cheese’’ type of penetration from closely approximated trocars, which can be problematic [2]. Also, the fascial incision can be as large as 5 cm or more through a small 2.5-cm skin incision. In addition, the fulcrum of the instruments is more external, at the level of the concaved Gelpoint, which is located 5 cm above skin level. Finally, four ports can be placed comfortably through the Gelpoint platform. All these factors contribute to minimal restriction of movement. B. M. Molinelli (&) A. Petrotos Department of Surgery, Greenwich Hospital, Greenwich, CT, USA e-mail: ssg06830@hotmail.com

Nelson’s Surgeon William Beatty, Naval Medicine and the Battle of Trafalgar

In the lead-up to the bicentenary of Trafalgar a number of important new studies have been published about the life of Nelson and his defeat of the Combined Fleet in 1805. Despite the significant role played by the health and fitness of the British crews in securing the victory, little has been written hitherto about the naval surgeon in the era of the long war against France. This book is intended to fill the gap. Sir William Beatty (1773-1842) was surgeon of the Victory at Trafalgar. An Ulsterman from Londonderry, he had joined the navy in 1791. Before being warranted to Nelson's flagship, Beatty had served upon ten other warships, and survived a yellow fever epidemic, court martial, and shipwreck to share in the capture of a Spanish treasure ship. After Trafalgar, he became Physician of the Channel Fleet, based at Plymouth, and eventually Physician to Greenwich Hospital, where he served until his retirement in 1838. As the book makes clear in drawing upon an extensive prosopographical database, Beatty's career until 1805 was representative of the experience of the approximately 2,000 naval surgeons who joined the navy in the course of the war. The first part of the biography provides a detailed and scholarly introduction to the professional education, training, and work of the naval surgeon. But after 1805 Beatty became a member of the service elite, and his career becomes interesting for other reasons. In the final decades of his life, Beatty was far more than a senior naval physician. As a Fellow of the Royal Society, director of the Clerical and Medical Insurance Company, and director of the London to Greenwich Railway, he was a prominent figure in London's business and scientific community, who used his growing wealth to build a large collection of books and manuscripts. His later life is testimony to the much wider contribution that some naval and army medical officers made to the development of the new Britain of the nineteenth century. In Beatty's case, too, the contribution was original. By publishing in 1807 his carefully crafted Authentic Narrative of the Death of Lord Nelson, he was instrumental in forging the myth of the hero's last hours, which has become a part of the national consciousness and has helped to define for generations the concept of Britishness.

Clinic Profile: Greenwich Hospital Center for Integrative Medicine

Clinic Profile: Greenwich Hospital Center for Integrative Medicine