Tertiary Referral Facility Research Articles

Oocyte Retrieval during Laparoscopic Vaginoplasty to Reduce Invasiveness in the Treatment of Mayer-Rokitansky-Küster-Hauser Syndrome

To evaluate the treatment of patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with a combination of oocyte retrieval and surgical vaginoplasty in a single laparoscopic procedure. A case series. The study was conducted at 2 tertiary referral facilities for MRKH syndrome in Milan, Italy, between July 2017 and September 2018. Eleven patients presented with MRKH and required surgical vaginoplasty while expressing a desire for future fertility. Two experienced surgeons and an expert in assisted reproductive technology performed concomitant vaginoplasty according to the modified technique of Davydov and laparoscopic oocyte retrieval for gamete cryopreservation. Before the procedure, patients underwent extensive counseling and gave written consent. At the start of surgery, 10.4 ± 4.4 (mean ± standard deviation [SD]) oocytes were retrieved laparoscopically, and 8.8 ± 3.1 (SD) mean mature oocytes were cryopreserved. After oocyte retrieval, the steps of the modified Davydov technique were followed. The total operative time was 116 ± 16 minutes (mean ± SD), and no intraoperative/postoperative complications were observed. This is the first report of combined oocyte retrieval and vaginoplasty for patients with MRKH syndrome. The approach was found to be feasible in patients with a desire for future fertility. It is our belief that physicians treating patients with MRKH should refer patients to centers with expertise in both vaginoplasty and assisted reproductive technology.

Diagnostic yield of the SharkCore EUS-guided fine-needle biopsy

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the standard diagnostic procedure for many intrathoracic and intra-abdominal lesions. Next-generation fine-needle biopsies (FNBs) can increase diagnostic yield by procuring tissue suitable for histological processing. We evaluate the diagnostic yield and operating characteristics of the SharkCore (SC; Medtronic Corp., Minneapolis, MN) FNB in a tertiary referral facility. We performed a single-center retrospective review of SC-FNB-acquired tissue between January 2014 and March 2018. Patient demographic data, endoscopic features, and pathology data were obtained from the electronic medical record. Diagnostic yield was assessed by the ability to obtain a definitive diagnosis, defined as malignant or benign interpretations. Operating characteristics were also calculated. A total of 179 lesions were sampled with the SC-FNB in 157 patients (mean age: 63 years, 57% male). Of these, 31 lesions were concomitantly sampled with a conventional FNA needle. Most lesions were pancreatic (49%). Diagnostic yield was 86%, which was independent of lesion location, lesion size and needle gauge. Diagnostic accuracy was highest when both histology and cytology specimens were analyzed concurrently (96.5%). In patients with a history of chronic pancreatitis, accuracy, sensitivity, and negative predictive value were reduced (71.4%, 20.0%, and 69.2%, respectively). Rapid onsite evaluation (ROSE) occurred in 64.8% of cases and was more likely to be diagnostic at the time of rapid evaluation if SC-acquired tissue was utilized versus FNA-acquired tissue (P = 0.03); however, final diagnostic yield did not differ between needles (P = 0.13). SC-FNB shows high diagnostic yield and accuracy and provides diagnostic tissue for ROSE. SC-FNB is an effective alternative to conventional FNA.

Predictors in profile of referred newborns for their outcome in a tertiary newborn referral facility

Background: This study was aimed to assess newborn referral and factors contributing to outcome of referred newborns.Methods: This prospective observational study was conducted in a tertiary newborn referral facility for a period of one year. Referred newborns fulfilling inclusion criteria were enrolled in study, and assessed in terms of demographic profile, transport characteristics, physiological variables. Investigations, management of neonatal illness was done as per standard management protocols, they were followed up to their outcome.Results: Out of 2000 enrolled referred newborns, 30.10% were expired. Mean gestational age for survived newborns was 36.54±2.92 (SD) weeks, for expired newborns 35.24±3.99 (SD) weeks. Mean weight for survived newborns 2312.27 gms ±555.71 (SD), for expired newborns 1936.71 gms ±665.67 (SD). Out of total 60.05% newborns transported from periphery, had higher mortality i.e. 35% as compared to newborns transported from urban place i.e. 25%. Mean transport duration for survived newborns 61.94 minutes ±55.18 (SD), for expired newborns 89.51 minutes ±88.94 (SD). Prolonged CRT was observed in 57.45% newborns, grunting 19.70%, Cyanosis 11%, gasping 7.6%, apnea 5%, respiratory distress 39.80%, hypothermia 74.95%, and 25.50% required resuscitation on admission. Unattended delivery, self-arranged mode of transport, prolonged CRT, respiratory distress, apnea , hypothermia on admission, weight on admission(<1500gms), hypoglycaemia and duration of transport more than 1 hour found statistically significant independent variables associated with mortality of referred newborns.Conclusions: A significant number of neonatal deaths can be prevented, if referral system is structured and organized. Improper referral leads to poor physiological profile of referred newborns, which leads to their poor outcome. There are many independent variables which are affecting the outcome of referred newborns. These independent variables can be taken care in holistic way once the referral system is cultured and nurtured in existing health system.

PC-FACS

PC-FACS

A cross-sectional comparative study of perceived stigma between patients with epilepsy and patients living with HIV/AIDS in Accra, Ghana

BackgroundHealth-related stigma is a great challenge to the treatment of diseases. In epilepsy like other conditions, it causes affected individuals to conceal their illness. In this study, we described stigma perceived by patients with epilepsy at the Korle Bu Teaching Hospital (KBTH), a tertiary referral facility, and the Accra Psychiatry Hospital in Ghana (APH). We then compared the perception of stigma in patients with epilepsy to stigma perceived by persons living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (PLWHA), a chronic communicable disease stigmatized in Ghana. MethodsA total of 351 patients with epilepsy were recruited from both sites by systematic random sampling and interviewed. The Kilifi Stigma Scale for Epilepsy was used to determine individual patient's stigma score. Statistical analysis was done using multiple logistic regression analysis to control for the effect of measured independent variables that were significant on univariate analysis: age, gender, marital status, income, type of epilepsy, and the frequency of seizures, on the outcome variable. Comparative analysis of the mean stigma score in patients with epilepsy and persons living with HIV/AIDS was done using the Student's t-test and Mann–Whitney U test (Wilcoxon rank sum test). ResultsThe presence of perceived stigma using the Kilifi Stigma Score Estimation was 32.02% (62), 33.33% (49), and 28.88% (54) among respondents from KBTH, APH, and PLWHA respectively. Results from Wilcoxon rank sum test showed that the median stigma score between the three groups was significant; KBTH and APH (p-value; 0.0258), KBTH and PLWHA (p-value; 0.00001), and APH and PLWHA (p-value; 0.0000). Age (<40 years), seizure frequency, ethnic group (Ewe and Guan), and being divorced showed high odds for perceived stigma among KBTH patients with epilepsy. Having tertiary education led to lower odds for perceived stigma in epilepsy for APH patients with epilepsy. ConclusionThis study showed that epilepsy is associated with a high stigma perception. The perceived stigma was greater than stigma in PLWHAs in Accra. Stigma was affected by unemployment, ethnicity (Ewe and Guan), and uncontrolled seizures. Increasing age reduced perceived stigma and the management of patients with epilepsy in a psychiatric facility might have impacted negatively on the perceived stigma.

Perioperative antimicrobial prophylaxis and prevention of hepatobiliary surgical site infections.

To characterize the microbiology of hepatobiliary surgical site infections (SSIs) and to explore the relationship between specific antimicrobial prophylaxis regimens and the development of SSIs. Retrospective matched case-control study comparing patient, procedure, and antimicrobial prophylaxis characteristics among patients undergoing a hepatobiliary surgical procedure with and without an SSI. A tertiary referral acute-care facility. Patients undergoing procedures defined as "BILI" (bile duct, liver, or pancreas surgery) using National Healthcare Safety Network (NHSN) definitions, excluding those undergoing concomitant liver transplantation, from January 2013 through June 2016 were included in the study population. The SSIs were identified through routine infection control surveillance using NHSN definitions. All patients who developed an SSI were considered cases. Controls were selected randomly matched 2:1 with cases based on fiscal quarter of the procedure. Logistic regression modeling was performed to explore variables associated with SSI, including antimicrobial prophylaxis received. Among 975 procedures, 80 (8.2%) resulted in an SSI. Most cases involved an organism nonsusceptible to standard prophylaxis regimens, including cefazolin (68.8%), cefazolin plus metronidazole (61.3%), and ampicillin-sulbactam (52.5%). In a multivariate model, antimicrobial coverage against Enterococcus spp (aOR, 0.58; 95% confidence interval [CI], 0.17-2.04; P=.40) and against Pseudomonas spp (aOR, 2.40; 95% CI, 0.56-10.29; P=.24) were not protective against the development of an SSI. The presence of a documented β-lactam allergy was significantly associated with the development of an SSI (aOR, 3.54; 95% CI, 1.36-9.19; P=.009). Although SSIs at the study institution were associated with pathogens nonsusceptible to the most commonly used prophylaxis regimens, broader-spectrum coverage was not associated with a reduction in SSIs.

Contemporary Radiation Treatment of Prostate Cancer in Africa: A Ghanaian Experience.

PurposeData on prostate cancer (PCa) treatment in Africa remains under-reported. We present a review of the management of PCa at the cancer center of the largest tertiary referral facility in Ghana, with emphasis on curative treatment.MethodsWe retrospectively reviewed data on 1,074 patients seen at the National Center for Radiotherapy and Nuclear Medicine from 2003 to 2016. Patient and disease characteristics at presentation are presented using descriptive statistics. The χ2 and Fisher’s exact tests and Mann-Whitney U test were used to analyze differences between categorical and continuous variables, respectively. Methods of survival analysis were used to evaluate the relative risk of biochemical disease-free survival (bDFS).ResultsSeventy percent of the study population presented with localized disease. High-risk disease presentation accounted for 64.4% of these patients. Only 57.6% of patients with localized disease received curative radiotherapy. The 5-year overall survival for the curative cohort was 96% (interquartile range, 93% to 98%). The 5-year bDFS rates for low-, intermediate-, and high-risk groups were 95%, 70%, and 48%, respectively. Both Gleason score and pretreatment prostate-specific antigen were significant predictors for bDFS in multivariable analysis.ConclusionWe show that the majority of patients with PCa have locally advanced disease at the time of presentation for radiotherapy. bDFS was significantly better for low- and intermediate-risk than for high-risk disease. These data emphasize the dire need to re-evaluate screening and patient education of PCa in regions of the world with high incidence and mortality as well as the need for improved access to care and treatment delivery.

Early discharge does not increase readmission rate in patients robotic assisted radical cystectomy with enhanced recovery protocol

Objectives: We aim to assess if short LoS following robot-assisted radical cystectomy (RARC) with Enhanced Recovery Protocol (ERP) is associated with increased readmission rate and analyse the impact of rehospitalisation in tertiary versus referral hospitals on outcomes. Methods: Between April 2013 and December 2017, 255 (198 male and 57 female) patients underwent RARC with newly devised multimodal ERP that incorporated all the elements of EAU Robotic Urology Consensus. Analysis of prospectively collected data on LoS and postoperative readmission to demographic and perioperative variables was performed. Results: The median age at treatment was 71 years old, 76% were males, 72% had a BMI <30kg/m2, 81% an ASA score ≤2 and 72% a CPET anaerobic threshold ≥11. The median LOS was 5 days (1st-3rd IQR: 4-7 days). Post-operative day 4 was the most frequent day of discharge from hospital. The incidence of post-operative complications was 42% for minor (Clavien-Dindo grade ≤ II) and 8% for major (grade ≥ III) complications. The occurrence of 30- and 90-day readmission to hospital was 13.9% and 16.5% respectively. Post procedure complications were the only factor significantly associated with readmissions whilst LoS did not significantly correlate with readmissions. 41% of readmissions happened in the tertiary centre and 59% in one of the referral hospitals. 31% of readmissions were infection related (urinary, pelvic collection, lymphocele) and 28% gastrointestinal (ileus, small bowel obstruction). Of the 38 incidents, 12 were considered as potentially avoidable (back pain, scrotal oedema, oral candidiasis). Conclusion: The results from our centre demonstrate that short length of hospital stay does not affect consistently low readmission rates. This illustrates a favourable patient outcome for a procedure associated with inherent morbidity as a result of minimally invasive approach and multimodal enhanced recovery protocol. The optimisation of the post-discharge regionalised network can further reduce rehospitalisation and minimise the risk of service fragmentation within a tertiary referral facility. Disclosure of Interest: None declared.

329 Emergency Providers and Documentation of Interfacility Transferred Aortic Disease Patients

Patients with aortic disease (AoD) are often transferred from community emergency departments (EDs) to tertiary referral facilities for higher levels of care. Currently, there exist frameworks for documentation in compliance with the Health Insurance Portability and Accountability Act (HIPAA) from the American College of Emergency Physicians (ACEP) and Society of Critical Care Medicine (SCCM). These recommendations include documentation of consultation with the accepting physicians and presence of transfer consent. Additionally, the 2010 American Heart Association’s (AHA) guideline recommends fast reduction of systolic blood pressure (SBP) to ≤ 120mm Hg, heart rate (HR) ≤ 60 beats/minute (bpm), and pain management. Therefore, documenting these measures shows proper treatment of patients in the EDs. This study aims to: a) assess the compliance of ED charts containing required HIPAA elements and clinical assessments for this critically ill group of transferred AoD patients; b) to identify demographic or clinical factors associated with inadequate documentation. This is a retrospective study of AoD patients transferred to a quaternary academic referral center between 01/01/2011 and 09/30/2015. Patients were identified by ICD-9 billing codes of 441.XX. Exclusion criteria were a) not a direct interfacility transfer from a referring ED unit and b) no ED documentation. Primary outcome was percentage of charts with HIPAA compliance. Secondary outcome was percentage of charts with good clinical practice, defined as presence of triage SBP and HR, as well as ≥ 2 clinical assessments for SBP and HR both before and after AoD diagnosis. Outcomes were dichotomized (Good vs. Bad documentation). Stepwise backward regression was performed using sixteen demographic and clinical independent variables. We electronically identified 565 patients, of which 285 patients were included in analysis. One hundred and fifty-nine (56%) of the patients’ charts contained elements meeting HIPAA requirement for transfer of critically ill patients. One hundred and sixty (56%) of the patients’ charts had triage SBP and HR, as well as ≥ 2 clinical assessments before and after AoD diagnosis. Among 16 demographic and clinical factors, only Emergency Severity Index (ESI) was associated with poor HIPAA documentation, with a correlation coefficient (cc) of 0.0951 and p=0.007. For clinical documentation, three variables were negatively associated with poor documentation of frequent clinical assessment: sex (cc = -0.184, p=0.022), age (cc = -0.101, p=0.038), triage SBP (cc = -0.214, p<0.01), while triage time of day was positively associated with poor clinical documentation (cc = 0.204, p=0.011). ED provider documentation for critically ill patients with AoD is poor. Although certain demographic and clinical factors may be associated with poor documentation, emergency providers should thoroughly document their care for critically ill patients, for both clinical and legal reasons.

Bile Acid Alterations Are Associated With Insulin Resistance, but Not With NASH, in Obese Subjects

Bile acids (BAs) are signaling molecules controlling energy homeostasis that can be both toxic and protective for the liver. BA alterations have been reported in obesity, insulin resistance (IR), and nonalcoholic steatohepatitis (NASH). However, whether BA alterations contribute to NASH independently of the metabolic status is unclear. To assess BA alterations associated with NASH independently of body mass index and IR. Patients visiting the obesity clinic of the Antwerp University Hospital (a tertiary referral facility) were recruited from 2006 to 2014. Obese patients with biopsy-proven NASH (n = 32) and healthy livers (n = 26) were matched on body mass index and homeostasis model assessment of IR. Transcriptomic analyses were performed on liver biopsies. Plasma concentrations of 21 BA species and 7α-hydroxy-4-cholesten-3-one, a marker of BA synthesis, were determined by liquid chromatography-tandem mass spectrometry. Plasma fibroblast growth factor 19 was measured by enzyme-linked immunosorbent assay. Plasma BA concentrations did not correlate with any hepatic lesions, whereas, as previously reported, primary BA strongly correlated with IR. Transcriptomic analyses showed unaltered hepatic BA metabolism in NASH patients. In line, plasma 7α-hydroxy-4-cholesten-3-one was unchanged in NASH. Moreover, no sign of hepatic BA accumulation or activation of BA receptors-farnesoid X, pregnane X, and vitamin D receptors-was found. Finally, plasma fibroblast growth factor 19, secondary-to-primary BA, and free-to-conjugated BA ratios were similar, suggesting unaltered intestinal BA metabolism and signaling. In obese patients, BA alterations are related to the metabolic phenotype associated with NASH, especially IR, but not liver necroinflammation.

Diagnostic yield of small histological cores obtained with a new EUS-guided fine needle biopsy system.

As endoscopic ultrasound-guided tissue acquisition techniques evolve, there is increasing interest in obtaining optimal histological samples to improve diagnostic accuracy. In this study, we aimed to assess the tissue acquisition success rate and test performance characteristics of a novel endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) system. We performed a retrospective review of consecutive patients undergoing EUS-guided tissue sampling of solid lesions using the SharkCore fine needle system in a tertiary referral facility. At least two passes were submitted for histology and diagnostic accuracy was evaluated. Comparison standard was based on final surgical pathology or minimum six-month clinical follow-up. Seventy-nine patients underwent 85 EUS-FNB procedures. Of the 85 histology specimens, 78 (91.7%) were adequate for diagnostic examination (includes six atypical/suspicious for adenocarcinoma). The sensitivity, specificity, and accuracy for diagnosis of malignancy with FNB were 87.1, 100, and 90.6%, respectively. Cytology was simultaneously sent in 43 cases with the same needle in addition to histology. Out of the 14 cases that were atypical/suspicious for adenocarcinoma or non-diagnostic on cytology, 11 cases (78.6%) achieved definite diagnoses on histology. The overall sensitivity, specificity, and accuracy for diagnosis of malignancy combining histology and cytology were 90.3, 100, and 92.9%, respectively. No complications were reported after the procedures. In this initial experience with a new EUS-guided FNB system, obtaining small cores to submit for histological analysis was safe, technically feasible, and highly accurate. Most of the histological cores obtained via FNB yielded a definite diagnosis including in cases with equivocal cytomorphology. Further study is required to confirm these findings.

Adenosine Triphosphate Quantification Correlates Poorly with Microbial Contamination of Duodenoscopes

OBJECTIVE The aim of this study was to quantify the correlation between adenosine triphosphate (ATP) measurements and bacterial cultures from duodenoscopes for evaluation of contamination following high-level disinfection. DESIGN Duodenoscopes used for any intended endoscopic retrograde cholangiopancreatography (ERCP) procedure were included. Microbiologic and ATP data were collected concomitantly and in the same manner from ERCP duodenoscopes. SETTING A high-volume endoscopy unit at a tertiary referral acute-care facility. METHODS Duodenoscopes were sampled for ATP and bacterial contamination in a contemporaneous and highly standardized fashion using a "flush-brush-flush" method for the working channel (WC) and a dry flocked swab for the elevator mechanism (EM). Specimens were processed for any aerobic bacterial growth (colony-forming units, CFU). Growth of CFU>0 and ATP relative light unit (RLU)>0 was considered a contaminated result. Frequency of discord between among WC and EM measurements were calculated using 2×2 contingency tables. The Spearman correlation coefficient was used to calculate the relatedness of bacterial contamination and ATP as continuous measurements. RESULTS The Spearman correlation coefficient did not demonstrate significant relatedness between ATP and CFU for either a WC or EM site. Among 390 duodenoscope sampling events, ATP and CFU assessments of contamination were discordant in 82 of 390 WC measurements (21%) and 331 of 390 of EM measurements (84.9%). The EM was frequently and markedly positive by ATP measurement. CONCLUSION ATP measurements correlate poorly with a microbiologic standard assessing duodenoscope contamination, particularly for EM sampling. ATP may reflect biological material other than nonviable aerobic bacteria and may not serve as an adequate marker of bacterial contamination. Infect Control Hosp Epidemiol 2017;38:678-684.

Who seeks child and adolescent mental health care in Kenya? A descriptive clinic profile at a tertiary referral facility

BackgroundThe presence of psychiatric morbidity in the child and adolescent age group is demonstrable in various studies conducted in various settings in Kenya. This study set out to determine the psychiatric morbidity and socio-demographic profile of patients who eventually present for care at a tertiary specialist child and adolescent mental health clinic in Kenya. Knowledge of the patterns of presentation of disorders is crucial for planning of service scale up as well as serving as a useful training guide.MethodsThis was a cross sectional descriptive study of 166 patients and their guardians presenting to the child and adolescent mental health clinics at a tertiary referral hospital in Nairobi, Kenya. Data was collected using a researcher designed socio-demographic questionnaire and the Kiddie-schedule for affective disorders and schizophrenia-present and lifetime (KSADS-PL 2009 Working Draft) and analysed using Statistical Package for Social Scientists.ResultsThere were more males (56%) than females in this study and the participant’s mean age was 13.6 years. Substance abuse disorders were the most prevalent presentation (30.1%) followed by depressive disorders (13.9%), with most referrals to the clinic coming from medical practitioners and teachers. The mean time to accessing care at the clinic after the onset of symptoms was 16.6 months, with the longest time taken to specialist care being 183 months.ConclusionsThe findings from this study will go a long way to support the establishment of programs that improve timely child and adolescent mental health service delivery. The involvement of various stakeholders such as the education sector and the community is key in the development of these programs.

Does our bundle stack up! Innovative nurse-led changes for preventing catheter-associated urinary tract infection (CAUTI)

Abstract Introduction The aim of this project was to develop and implement an innovative nurse-led model of care in the use and management of indwelling urinary catheters (IUC) utilising evidence-based ‘bundle interventions' to reduce the incidence of catheter-associated urinary tract infections (CAUTI). Design and method A pre and post intervention study designed to progress in three phases was conducted in the orthopaedic ward and urology ward of a large tertiary referral facility. Phase one involved a clinical data collection pre intervention on all inpatients receiving an IUC over a 3-month period from February to April 2013. A staff survey assessed knowledge and skills and an evidence-based care bundle, nurse-led protocols, and education resources were developed through collaboration with clinicians. Phase two involved implementation and Phase three was an evaluation with the primary outcome targets being reduced IUC usage, days IUC in situ and incidence of CAUTI. Results Pre audit data revealed a high rate of IUC use: 31% of all inpatients in the orthopaedic ward and 25% in the urology ward. Compliance with current guidelines was inconsistent and documentation related to IUCs was poor. Overall CAUTI rate was relatively low at 2.2% of all patients with an IUC and was higher in the orthopaedic ward. Conclusion The development of a systematic and standardised approach to IUC care for inpatients using bundle care interventions will potentially reduce IUC use, provide a clear pathway for nurse-initiated IUC removal and reduce the incidence of catheter-associated urinary tract infections (CAUTI).

New outcomes with auditory brainstem implants in NF2 patients.

To determine factors related to high levels of speech recognition in patients with the auditory brainstem implant (ABI). Retrospective case review. International multicenter data from hospitals and tertiary referral facilities. Patients with neurofibromatosis type 2 (NF2) and bilateral vestibular schwannomas. ABIs were placed after the removal of vestibular schwannomas. Demographic and surgical data were collected from 26 patients with ABIs who achieved scores of better than 30% correct identification of sentences presented in quiet listening conditions and without lipreading cues. Scores better than 30% speech recognition of standard sentence test materials (HINT or equivalent) in quiet listening conditions were obtained in 26 of the 84 NF2 patients (31%). ABI speech recognition was correlated with surgical position, length of deafness, the number of distinct pitch electrodes, perceptual levels, and ABI stimulation rate, but not correlated with tumor size, tumor stage, the number of electrodes used, or electrophysiological recordings. This paper presents the consensus opinion from a meeting of surgeons to compare outcomes across ABI surgical centers. The consensus opinion was that brainstem trauma is a primary factor in the variability of outcomes in NF2 patients. The significant co-factors in outcomes implied that ABI surgery should be accomplished with great care to minimize physical and venous trauma to the brainstem. It is clear that high levels of speech recognition, including high levels of open-set speech recognition, are possible with the ABI even in patients with NF2 and large tumors.

Adult progressive sensorineural hearing loss: is preoperative imaging necessary before cochlear implantation?

Preoperative evaluation of cochlear implant candidate includes routine imaging to identify anatomic abnormalities that may preclude or complicate implantation, such as cochlear aplasia, absent/narrowed internal auditory canals, cochlear ossificans, or significant traumatic fracture. The aim of this study is to determine if preoperative imaging is necessary in select cochlear implant candidates, thus defraying cost and ionizing radiation. Retrospective chart review. Tertiary referral facility. Adult patients with progressive sensorineural hearing loss without evidence of head trauma, meningitis, or congenital hearing loss who underwent cochlear implantation. Diagnostic and therapeutic. Preoperative radiologic abnormalities, deviation from standard cochlear implant operation. One hundred eighteen cochlear implants met inclusion criteria; 23.7% of CT scans had a documented abnormality, including chronic otitis media (14.4%), otosclerosis (4.2%), and an enlarged vestibular aqueduct (3.4%). There were 6 eventful surgeries in patients with normal documented CT scan. Events included multiple insertion attempts (3.4%), CSF leak (2.5%), and no apparent round window (2.5%). In every case, a cochlear implant was able to be placed successfully. In the appropriately selected patient, preoperative imaging is not necessary as it does not impact the cochlear implant surgery and will defray cost and ionizing radiation.

Serum Vitamin D Profile In Black African Men with Prostate Cancer at Tertiary Referral Facility in Sub-Saharan Africa

Background: Considerable epidemiological, in vitro, in vivo and clinical data support an association between vitamin D deficiency and prostate cancer risk and outcome. Few studies have examined this association in African men with prostate cancer. The vitamin D status in patients with prostate cancer in Kenya is unknown. This study aimed to determine the profile of vitamin D levels in patients with prostate cancer and to correlate this to patient and disease characteristics. Methods: Hospital-based cross-sectional study that evaluated black African men with incident or 3-month prevalent histologically confirmed prostate cancer seeking ambulatory care at KNH. Medical history was obtained by direct interview and the information recorded in questionnaires. Treatment history, pre-diagnostic serum PSA and Gleason score were abstracted from patient records. Every participant had their anthropometric measurements taken and plasma samples drawn for 25-hydroxyvitamin D (25-VD) concentrations using the LIAISON® 25-OH automated chemiluminescent immunoassay method. The relationship between age, body mass index, pre-diagnostic serum PSA and Gleason score on vitamin D status was evaluated using bivariate and multivariate analysis. Results: 162 black African men were evaluated. The mean 25-VD was 19.15 ng/ml and 144 (88.9%) men had vitamin D deficiency (25-VD 7 (OR 2.9; 95% CI 1.5-5.5, p = 0.001) and serum PSA ≥ 50ng/ml (OR 2.2; 95% CI 1.7-5.1, p = 0.014) were associated with vitamin D deficiency (25-VD 7 was independently associated with vitamin D deficiency (OR 2.5; 95% CI 1.2 – 4.9, p = 0.01). Conclusion: Vitamin D deficiency is very common in black African men with prostate cancer, particularly in those with higher Gleason scores.

Robotic Surgery Systems

For many people, the term “robotic surgery” likely evokes one of two images. One is Asimo, the Honda robot, performing a complex heart-valve replacement with the precision and finesse of the most skilled surgeon. The other is more along the lines of an industrial robot found welding on an automotive assembly line—performing surgery by rote programming on scores of patients in a row, just like in a factory. Neither is the case. Robotic surgery is, by some accounts, the next level of minimally invasive surgery. Conventional invasive surgery involves a large incision in the body to gain access to the area and organ of interest. For example, in a conventional gallbladder removal, the surgeon first performs a laparotomy, which is an incision, usually a large one, through the abdominal wall to gain access to the interior of the torso. The problem with a laparotomy is that it is very stressful physiologically and exposes large portions of the patient’s abdominal cavity to infection. Additionally, because the incision is so large, and the surgeon needs access to a large part of the patient’s interior, the surgery is characterized by a relatively large amount of trauma to the surrounding tissue, blood loss, and postoperative pain and discomfort coupled with a prolonged healing period. To overcome the problems and side effects of the laparotomy, minimally invasive surgery was developed. Minimally invasive surgery accesses the chest or abdomen through several smaller incisions, each one typically half an inch long. Each smaller incision has a port, or a combination trocar/port is used to make the incision, to protect the surrounding tissue while a particular device is inserted through the hole. The most common items inserted are an endoscope connected to a camera, a light source (which may be part of the other devices), an insufflator, and an instrument with one or more operating channels. In the case of minimally invasive gallbladder removal, now called a laparoscopic cholecystectomy, all the associated steps (draining the gall bladder, severing it from the ducts, and removing the empty bladder) are performed through the operating channel using specially adapted instruments. In minimally invasive surgery, as few as three or four small incisions can take the place of the much larger laparotomy incision. Some surgeons also perform this procedure as “scarless surgery” by accessing the abdomen through the navel and using a specialized operating endoscope with integral illumination and operating channels. Although there technically is a scar, observers might be hard pressed to find it as it is hidden in the folds of the navel. As one would expect, the smaller incisions mean less trauma to the body as a whole, reduced blood loss, and minimal discomfort, all of which equate to a shorter healing period. Minimally invasive surgery techniques are THE FUNDAMENTALS OF ...

An Audit of Admissions to Intensive Care Unit at Kamuzu Central Hospital in Malawi

Results are presented of a retrospective audit of admissions to the Intensive Care Unit (ICU) of Kamuzu Central Hospital in Lilongwe, Malawi, which is a tertiary referral facility. The audit was conducted for a period of one year spanning from January to December, 2012. The objectives of the audit were to: describe the profile of admissions and treatment outcomes of the admissions and identify main causes of mortality in ICU of the facility. The admission book and patients’ records were reviewed retrospectively guided by a data extraction form which was specifically designed for this study. The extracted data included age, sex, referring unit, diagnosis, treatment outcome and length of stay. The data were analyzed using STATA version 10.0. A total of 253 patients were admitted to the ICU over the one year period of study. About a third of the patients (33.6% n = 85) were admitted due to postoperative surgery. There were 154 deaths representing an overall mortality of 60.9%. Sepsis was the commonest cause of death and accounted for 39.6%, n = 61 of the deaths. Younger age of less than 40 years and increased patients’ length of stay in the unit were significantly and positively associated with mortality (P

Excessive Daytime Sleepiness and Sleep Disordered Breathing in Stable Heart Failure Patients

considered preventable. Readmission monitoring is a key performance indicator for Heart Failure Management Programmes (HF-MPs). Aim: To investigate the underlying causes, contributing factors and incidence of unplanned hospital readmissions for HF patients. Methods:A sixmonth prospective studywas performed at the PrincessAlexandraHospital, a tertiary referral facility. A convenience sample of 50 adult patientsmanaged by theHF-MPwas recruited.Health literacywas assessed.All unplanned admissions were investigated with admission interview andworksheet. At six months hospital readmissions were verified by patients, patient medical records and electronic databases. Results: Participants mean age was 70 (±11.6), 38 (76%) were male, 11 (22%) had inadequate health literacy. Of the 45 (90%) patients with systolic HF, 35 (78%) had an ejection fraction (EF)≤ 30%. There were 46 unplanned readmissions during six month follow-up, 28 were HF related and involved 17 patients (HF readmissions 34%). Six of these patients had >1 readmission and six (12%) patients died. Of the patients readmitted for HF, 82% had systolic HF with EF≤ 30%, and an average length of stay of seven (±5.7) days. Thirty days readmission rate was 12%. Eighty-six percent of patients readmitted with HF were on optimal medical therapy including beta blocker, ACE inhibitor/Angiotensin II receptor antagonist and mineralocorticoid receptor antagonist. All patients received self-care education and early follow-up from multi-disciplinary HF clinicians. Conclusion:Unplanned HF readmissions in this cohort of patients with severe systolic HF are common despite optimal medical therapy and intensive HF-MPs. http://dx.doi.org/10.1016/j.hlc.2013.05.182