Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland

This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of monitoring depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon dioxide monitoring have been updated.

No clinical difference between fixed- and mobile-bearing cruciate-retaining total knee arthroplasty: a prospective randomized study

PURPOSE

It is hypothesized that mobile polyethylene bearings in total knee arthroplasty (TKA) may confer benefits with regard to range of motion and have improved clinical outcome scores in comparison with an arthroplasty with a fixed-bearing design. Our study compares clinical outcomes between patients who undergo TKA with either a rotating platform or fixed bearing using a posterior cruciate-retaining design.

METHODS

Three hundred and thirty-one patients were randomized to receive either a rotating-platform (161 patients) or a fixed-bearing (170 patients) implant. All patients were assessed pre-operatively and at 1 and 2 years post-operatively using standard tools (range of movement, Oxford Knee Score, American Knee Society Score, SF12 and Patella Score).

RESULTS

There was no difference in pre- to 2-year post-operative outcomes between the groups with regard to improvement in range of motion (10° ± 16 vs. 9° ± 15), improvement in Oxford Knee Score (-17.6 ± 9.9 vs. -19.1 ± 8.4), improvement in American Knee Society Score (49.5 ± 24.7 vs. 50.7 ± 21.0), function (23.6 ± 19.6 vs. 25.0 ± 22.5) and pain (34.9 ± 16.2 vs. 35.8 ± 14.1) subscores, improvement in SF12 Score (10.0 ± 16.3 vs. 12.3 ± 15.8) or improvement in Patella Score (9.7 ± 7.4 vs. 10.6 ± 7.1).

CONCLUSION

No difference was demonstrated in clinical outcome between patients with a rotating-platform and fixed-bearing posterior cruciate-retaining TKA at 2-year follow-up.

LEVEL OF EVIDENCE

I.

A questionnaire-based evaluation of the veterinary cordon fence separating wildlife and livestock along the boundary of the Kruger National Park, South Africa

Veterinary cordon fences are used in Southern Africa to separate wildlife from domestic animals in order to prevent transmission of infectious diseases. Such fences are a control method recognized by the World Organization for Animal Health (OIE) for establishing disease-free zones in beef exporting countries. However, few studies have evaluated the ecological impact of these physical barriers or their effectiveness at a multispecies level. We examined the permeability of one such barrier, along 357 km of the western and southern boundary of the Kruger National Park (KNP) during 2007. Information was gathered using a semi-structured questionnaire implemented among 32 teams of fence maintenance workers. Data were analyzed to identify (a) the main causes of fence damage, (b) the seasonality, location and duration of fence repairs, (c) high permeability areas for elephant (Loxodonta africana), kudu (Tragelaphus strepsiceros), impala (Aepyceros melampus), buffalo (Syncerus caffer) and warthog (Phacochoerus africanus), and (d) the influence of fence electrification, rivers and elephant damage on the frequency of observation of wildlife species outside the KNP estimated during the year. Human and elephant damage were the most common reasons for fence repairs. Elephant and buffalo were the most and least common large mammal species reported observed outside the KNP (1076 and 162 reports/year), respectively. Cattle incursions into the KNP were also reported in 44% of the fence sections. Electrification of the fence was an important factor explaining differences in estimated wildlife species observations outside the KNP during the year. Correlations between estimations of observed species suggested that fence gaps created by elephants might be used by the other wildlife species. Estimated annual counts of kudu, impala and buffalo, but not warthog, were found to correlate with elephant observations. Negative binomial regression models were developed to explore the relationships between observed estimations of different wildlife species outside the KNP the fence, electrification of fence sections and the presence of watercourses, suggesting that kudu, impala and buffalo could use elephant induced fence damage to leave the KNP. The questionnaire was able to evaluate fence integrity and identify sections where integrity was sub-optimal for separating wildlife from domestic livestock species. If combined with more quantitative methods and applied on a routine basis, it could provide an efficient and cost-effective method for monitoring the effectiveness of physical barriers to contain wildlife within protected areas such as is the case with veterinary cordon fences in Southern Africa.

Individual Mycobacterium tuberculosis universal stress protein homologues are dispensable in vitro

Mycobacterium tuberculosis has 10 universal stress proteins, whose function is unknown. However, proteomic and transcriptomic analyses have shown that a number of usp genes are significantly upregulated under hypoxic conditions and in response to nitric oxide and carbon monoxide, as well as during M. tuberculosis infection of macrophage cell lines. Six of these USPs are part of the DosR regulon and this, along with their expression pattern and the phenotypes of usp mutants in other bacterial species, suggests a potential role in the persistence and/or intracellular survival of Mtb. Knock-out mutants of individual usp genes encoding the USPs Rv1996, Rv2005c, Rv2026c and Rv2028c were generated and their growth and survival under hypoxic and other stress conditions examined. Although the majority of usp genes are highly induced in hypoxic conditions, mutation did not affect the long term survival of Mtb under these conditions, or in response to a range of stress conditions chosen to represent the environmental onslaughts experienced by the bacillus during an infection, nor during infection of mouse and human - derived macrophage cell lines. The possibility remains that these USPs are functionally redundant in Mtb.

Facilitators and barriers to recruitment for an exercise and dietary intervention study in minority breast cancer survivors

Abstract #5077

Background: Hispanic and black women with breast cancer (BC) have poorer survival than non-Hispanic whites. Lean body mass, regular physical activity, and high intake of fruits/vegetables may improve survival. However, minority BC survivors are more likely to be obese and sedentary than non-Hispanic whites, which may contribute to poorer survival. We are conducting a randomized waitlist-controlled pilot study to test the effects of 6-months of the Curves® 30-minute circuit-based exercise and high-vegetable/low-fat nutrition program, on weight loss among Hispanic and black women, and now report facilitators and barriers to recruitment. Methods: Eligibility criteria: 21-70 yrs, Hispanic/black, BMI ≥25kg/m2, sedentary, stage 0-IIIa breast cancer, no evidence of recurrent/metastatic disease, radiation/chemotherapy completed ≥6 months prior, no uncontrolled comorbidities, and non-smoker. Participants were identified by physicians and referred for screening. Barriers to study participation were assessed, including work/family responsibilities, transportation, financial resources, and perceived risks/benefits of exercise and dietary change after cancer diagnosis. Results: To date, 96 women have been referred for screening and 50 (52%) completed screening questionnaires. Of those who completed questionnaires, 43/50 (86%) were eligible, and of those who were eligible, 37/43 (86%) chose to participate. Enrolled participants are 70% Hispanic, mean age 51yrs (range:32-69), mean BMI 33.2 (±5.8) kg/m2, 64% diagnosed as AJCC stage II/III, and 70% ≤ high school education. Reasons for ineligibility (n=53) include inability to recontact (46%), uncontrolled comorbidity (21%), too busy/not convenient (15%), still undergoing treatment (11%), currently smoking (4%), and not sedentary (2%). Eligible and ineligible women were not statistically different in terms of race, BMI, or stage at diagnosis. However, ineligible women were older (P<0.01). Of the women who completed the screening questionnaire, women enrolled in the study (n=37), compared to women not enrolled (n=13), believed losing weight after cancer would prolong survival (P=0.01), making dietary changes would prevent recurrence (P=0.01), and that exercising would help them feel better (P=0.01), prevent recurrence (P=0.01), and prolong survival (P=0.046). Women not enrolled were more likely to report that exercising after a cancer diagnosis is dangerous (P=0.04). Conclusions: Recruitment of a multiethnic population to a Curves® based exercise intervention study was feasible. Patients who ultimately enrolled in this study believed that exercise and eating a healthy diet are beneficial to their health. Given that many overweight and sedentary women had pre-existing negative misconceptions about the benefits of exercise and dietary change after a BC diagnosis, and this was a key factor in predicting enrollment, educational efforts promoting healthy lifestyle behaviors should be further targeted towards this high-risk patient population.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5077.

The clinical activity of mental health nurse lecturers

Concerns have been expressed about the ability of mental health lecturers to prepare practitioners with the skills, knowledge and attitudes needed to implement the National Service Framework for mental health. Specifically mental health nurse lecturers have been criticized for lacking clinical competence and credibility, and for being out of touch with developments in service delivery. This paper presents a selection of findings from a recent review into the clinical activity of mental health lecturers in higher education institutions in England. The issues discussed include roles in practice, questioning the value of face-to-face clinical work, the benefits of being clinically active, the difficulties of clinical academic roles, barriers to maintaining clinical activity, questioning the quality of the clinical workforce, and finally strategies to facilitate clinical activity. Whilst there is support among mental health nurse lecturers for the need to engage with practice at some level, there are inconsistencies in the ways that this is being achieved. Lecturers are, however, getting together to debate how best to keep up with changes in mental health practice and delivery.

Acute hepatitis C virus seroconversion in a Scottish blood donor: HCV antigen is not comparable with HCV nucleic acid amplification technology screening

BACKGROUND AND OBJECTIVES

This study was conducted to analyse the usefulness of hepatitis C virus (HCV) core antigen tests for the confirmation of HCV infection in a donor presenting as nucleic acid amplification technology (NAT) positive but negative for antibodies to HCV (anti-HCV).

MATERIALS AND METHODS

Blood donations were screened, in parallel, for anti-HCV using the Abbott PRISM HCV Chemiluminescent immunoassay (ChLIA) and an 'in-house' HCV NAT (pools of up to 95 donations). An HCV NAT-positive antibody-negative donor was identified. Twelve follow-up samples were obtained and tested with various HCV antigen (including the recently marketed Trak-C second-generation assay) and HCV antibody assays.

RESULTS

The single HCV NAT-positive, antibody-negative donation was identified from 1 117 681 donations screened in the 4-year period, July 1999 to June 2003. The index donation was positive by Ortho HCV core antigen enzyme immunoassay (EIA) and Ortho Trak-C (second-generation HCV core antigen EIA). An archive sample, taken 127 days prior to the index donation, was negative for all HCV markers. Subsequent samples demonstrated a loss of reactivity in the Ortho HCV core antigen EIA and reduced activity in the Ortho Trak-C until day 69. Immunoblot (Ortho RIBA-3) and HCV PRISM became positive on day 62, whilst Ortho HCV ELISA was not positive until day 132 or Biorad HCV ELISA until day 160. An alternative immunoblot (Innogenetics Innolia III) was positive from day 55. RNA levels fluctuated considerably during the follow-up period, being completely undetectable by routine screening methods at the time-point around seroconversion; subsequently, antibody was detected using all assays investigated.

CONCLUSIONS

This HCV-converting blood donor provided a unique panel of samples for using to assess current (and future) HCV assay systems. The overall test results led to the conclusion that individual HCV antigen testing should not be considered as equivalent to HCV NAT minipool screening. Trak-C antigen testing may be considered as a suitable confirmatory assay for isolated HCV NAT reactivity.

The effects of testing in shifts on a clinical in-course computerized exam

PROBLEM

Testing a large medical class over two days with a single-form computer-based test has generated questions related to test security and the influence of unequal test preparation times afforded by the testing method.

METHODS

An analysis of variance (anova) design was used to compare the scores for the two days for each of the three tests. In addition, a within-student match-paired t-test of standard score differences was used to examine the relative standing of students across tests administered on different days.

RESULTS

Both the anova and the match-paired t-test failed to detect a difference between first and second day testing.

CONCLUSION

This research suggests that using a single test form with shift-based computerised assessments, spread over as many as two days, does not seriously compromise the integrity of the results. Since creating multiple unique-item forms is often not possible, shift-based testing with a single test form appears to be a fair method of accommodating a large number of students.

Increased blood-brain barrier permeability in type II diabetes demonstrated by gadolinium magnetic resonance imaging

OBJECTIVES

Patients with type II diabetes are at increased risk of cognitive impairment. The retinal and renal complications of diabetes follow microvascular damage permitting small arterioles to leak, hence the cerebral damage might also follow loss of blood-brain barrier (BBB) integrity. Magnetic resonance (MR) brain imaging with intravenous gadolinium (Gd) diethylenetriamine pentaacetic acid (Gd-DTPA) was used to identify increased BBB permeability.

METHODS

Ten well controlled type II diabetic patients aged 65-70 years and 10 controls underwent MR brain imaging with fluid attenuated inversion recovery (FLAIR); T1 weighted (T1W) volumetric imaging before; and T1W volumetric imaging at 5, 15, 30, 45, 60, and 90 minutes after intravenous Gd-DTPA. The T1W image before Gd-DTPA was subtracted from the images at each time point after Gd-DTPA. Net signal intensity was plotted against time for different brain regions. White matter hyperintensities were scored from the FLAIR image.

RESULTS

The signal intensity/time curves showed that brain signal intensity increased more in the diabetic group than controls during the first 15 minutes after Gd-DTPA, particularly in the basal ganglia (p=0.018). Signal intensity in controls peaked at five minutes and diabetics at 15 minutes. Subjects with more white matter hyperintensities had greater signal increase after Gd-DTPA, whether diabetic or not (p=0.001).

CONCLUSIONS

Increased BBB permeability with MR imaging was detected in patients with type II diabetes or white matter hyperintensities. Increased permeability of the BBB might account for some of the cerebral effects of type II diabetes, and so possibly also for the effect of other conditions that affect the microvasculature (like hypertension), on the brain.

Quantitative HOX expression in chromosomally defined subsets of acute myelogenous leukemia

We used a degenerate RT-PCR screen and subsequent real-time quantitative RT-PCR assays to examine the expression of HOX and TALE-family genes in 34 cases of chromosomally defined AML for which outcome data were available. AMLs with favorable cytogenetic features were associated with low overall HOX gene expression whereas poor prognostic cases had high levels. Characteristically, multiple HOXA family members including HOXA3-HOXA10 were jointly overexpressed in conjunction with HOXB3, HOXB6, MEIS1 and PBX3. Higher levels of expression were also observed in the FAB subtype, AML-M1. Spearmann correlation coefficients indicated that the expression levels for many of these genes were highly inter-related. While we did not detect any significant correlations between HOX expression and complete response rates or age in this limited set of patients, there was a significant correlation between event-free survival and HOXA7 with a trend toward significance for HoxA9, HoxA4 and HoxA5. While patients with elevated HOX expression did worse, there were notable exceptions. Thus, although HOX overexpression and clinical resistance to chemotherapy often coincide, they are not inextricably linked. Our results indicate that quantitative HOX analysis has the potential to add new information to the management of patients with AML, especially where characteristic chromosomal alterations are lacking.

Hepatitis B vaccinees may be mistaken for confirmed hepatitis B surface antigen-positive blood donors

BACKGROUND AND OBJECTIVES

Hepatitis B surface antigen (HBsAg) test sensitivities have gradually increased, and neutralizable weak HBsAg-positive donations, with no other hepatitis B virus (HBV) markers, have occasionally been found in our donor population. On investigation, these donors have admitted to receiving hepatitis B vaccine up to 5 days previously. A study was therefore initiated to monitor HBsAg reactivity amongst volunteers after receiving their first dose of hepatitis B vaccine.

MATERIALS AND METHODS

Eight volunteers were tested using three HBsAg assays (Abbott Auszyme, Ortho HBsAg-3 and Abbott/Murex GE34/36) on days 0, 3, 5, 7 and 10 after administration of hepatitis B vaccine.

RESULTS

Two HBsAg tests (Abbott Auszyme and Ortho HBsAg-3) did not detect HBsAg reactivity amongst the volunteers, although the Abbott Auszyme test results reached 70-80% of the manufacturer's cut-off at day 3 in two volunteers. The most recently launched assay (Abbott/Murex GE 34/36) detected seven (87%) of the eight volunteers as HBsAg reactive on day 3, and two (25%) volunteers were still reactive on day 5.

CONCLUSION

The Abbott/Murex GE 34/36 assay demonstrated HBsAg reactivity in most volunteers on day 3 and in some on day 5 after vaccination. It is therefore recommended that individuals who have recently been vaccinated with hepatitis B be deferred from blood donation for at least 7 days.