Natural Language Processing of Referral Letters for Machine Learning-Based Triaging of Patients With Low Back Pain to the Most Appropriate Intervention: Retrospective Study

BACKGROUND

Decision support systems (DSSs) for suggesting optimal treatments for individual patients with low back pain (LBP) are currently insufficiently accurate for clinical application. Most of the input provided to train these systems is based on patient-reported outcome measures. However, with the appearance of electronic health records (EHRs), additional qualitative data on reasons for referrals and patients' goals become available for DSSs. Currently, no decision support tools cover a wide range of biopsychosocial factors, including referral letter information to help clinicians triage patients to the optimal LBP treatment.

OBJECTIVE

The objective of this study was to investigate the added value of including qualitative data from EHRs and referral letters to the accuracy of a quantitative DSS for patients with LBP.

METHODS

A retrospective study was conducted in a clinical cohort of Dutch patients with LBP. Patients filled out a baseline questionnaire about demographics, pain, disability, work status, quality of life, medication, psychosocial functioning, comorbidity, history, and duration of pain. Referral reasons and patient requests for help (patient goals) were extracted via natural language processing (NLP) and enriched in the data set. For decision support, these data were considered independent factors for triage to neurosurgery, anesthesiology, rehabilitation, or minimal intervention. Support vector machine, k-nearest neighbor, and multilayer perceptron models were trained for 2 conditions: with and without consideration of the referral letter content. The models' accuracies were evaluated via F1-scores, and confusion matrices were used to predict the treatment path (out of 4 paths) with and without additional referral parameters.

RESULTS

Data from 1608 patients were evaluated. The evaluation indicated that 2 referral reasons from the referral letters (for anesthesiology and rehabilitation intervention) increased the F1-score accuracy by up to 19.5% for triaging. The confusion matrices confirmed the results.

CONCLUSIONS

This study indicates that data enriching by adding NLP-based extraction of the content of referral letters increases the model accuracy of DSSs in suggesting optimal treatments for individual patients with LBP. Overall model accuracies were considered low and insufficient for clinical application.

Role of non-invasive objective markers for the rehabilitative diagnosis of central sensitization in patients with fibromyalgia: A systematic review

BACKGROUND

Central sensitization cannot be demonstrated directly in humans. Therefore, studies used different proxy markers (signs, symptoms and tools) to identify factors assumed to relate to central sensitization in humans, that is, Human Assumed Central Sensitization (HACS). The aims of this systematic review were to identify non-invasive objective markers of HACS and the instruments to assess these markers in patients with fibromyalgia (FM).

METHODS

A systematic review was conducted with the following inclusion criteria: (1) adults, (2) diagnosed with FM, and (3) markers and instruments for HACS had to be non-invasive. Data were subsequently extracted, and studies were assessed for risk of bias using the quality assessment tools developed by the National Institute of Health.

RESULTS

78 studies (n= 5234 participants) were included and the findings were categorized in markers identified to assess peripheral and central manifestations of HACS. The identified markers for peripheral manifestations of HACS, with at least moderate evidence, were pain after-sensation decline rates, mechanical pain thresholds, pressure pain threshold, sound 'pressure' pain threshold, cutaneous silent period, slowly repeated evoked pain sensitization and nociceptive flexion reflex threshold. The identified markers for central manifestations of HACS were efficacy of conditioned pain modulation with pressure pain conditioning and brain perfusion analysis. Instruments to assess these markers are: pin-prick stimulators, cuff-algometry, repetitive pressure stimulation using a pressure algometer, sound, electrodes and neuroimaging techniques.

CONCLUSIONS

This review provides an overview of non-invasive markers and instruments for the assessment of HACS in patients with FM. Implementing these findings into clinical settings may help to identify HACS in patients with FM.

Olanzapine as an add-on, pre-operative anti-emetic drug for postoperative nausea or vomiting: a randomised controlled trial

Postoperative nausea or vomiting occurs in up to 40% in patients with multiple risk factors, despite prophylaxis. Olanzapine is an antipsychotic drug that is used to prevent nausea and vomiting in palliative care and to treat chemotherapy-induced nausea and vomiting. This study aimed to examine whether pre-operative olanzapine, as a prophylactic anti-emetic added to intra-operative dexamethasone, ondansetron and total intravenous anaesthesia, reduced the incidence of postoperative nausea or vomiting. We performed a multiply-blinded randomised controlled trial in patients aged 18-60 years with cancer at high risk of postoperative nausea or vomiting (three or four risk factors according to the Apfel criteria) plus a previous history of chemotherapy-induced nausea and vomiting. Patients were allocated at random to receive 10 mg olanzapine or placebo orally 1 h before surgery in addition to a two-drug regimen (dexamethasone and ondansetron) and propofol anaesthesia to prevent postoperative nausea or vomiting. The primary outcome was the incidence of postoperative nausea or vomiting in the first 24 h after surgery. In total, 100 patients were enrolled; 47 in the olanzapine group and 49 in the control group completed the study. The baseline characteristics of the groups were similar. The incidence of postoperative nausea or vomiting in the first 24 h after surgery was lower in the olanzapine group (12/47, 26%) than in the control group (31/49, 63%) (p = 0.008, RR 0.40 (95%CI 0.21-0.79)). Adding pre-operative oral olanzapine to intra-operative dexamethasone and ondansetron was highly effective in reducing the risk of postoperative nausea or vomiting in the first 24 hours after surgery in patients with a previous history of chemotherapy-induced nausea and vomiting and at least three Apfel risk factors for postoperative nausea or vomiting.

Validity of the Central Sensitization Inventory to Address Human Assumed Central Sensitization: Newly Proposed Clinically Relevant Values and Associations

Central sensitization cannot be directly demonstrated in humans and thus a gold standard is missing. Therefore, we used human assumed central sensitization (HACS) when associated with humans. The central sensitization inventory (CSI) is a screening questionnaire for addressing symptoms that are associated with HACS. This cross-sectional study compared patients with chronic pain and at least one central sensitivity syndrome with healthy, pain-free controls via ROC analyses. Analyses were performed for all participants together and for each sex separately. Regression analyses were performed on patients with chronic pain with and without central sensitivity syndromes. Based on 1730 patients and 250 healthy controls, cutoff values for the CSI for the total group were established at 30 points: women: 33 points; men: 25 points. Univariate and multivariate regression analyses were used to identify possible predictors for the CSI score in 2890 patients with chronic pain. The CSI score is associated with all independent factors and has a low association with pain severity in women and a low association with pain severity, age, and body mass index in men. The newly established CSI cutoff values are lower than in previous studies and different per sex, which might be of clinical relevance in daily practice and importance in research.

The C4EB study-Transvamix (10% THC / 5% CBD) to treat chronic pain in epidermolysis bullosa: A protocol for an explorative randomized, placebo controlled, and double blind intervention crossover study

Patients with the genetic blistering skin condition epidermolysis bullosa (EB) report severe pain as a consequence of skin and mucous membrane lesions including blisters, wounds, and scars. Adequate symptom alleviation is not often achieved using conventional pharmacologic interventions. Finding novel approaches to pain care in EB is imperative to improve the quality of life of patients living with EB. There are several anecdotal reports on the use of cannabinoid-based medicines (CBMs) by EB patients to reduce the burden of symptoms. However, controlled clinical investigations assessing these reported effects are lacking. As the pain quality "unpleasantness" delineates EB pain, we hypothesize the modulation of affective pain processing in the brain by way of intervention with CBMs comprising the cannabinoids Δ-9-tetrahydrocannabinol and cannabidiol-objectified by functional magnetic resonance imaging (fMRI). The C4EB study is an investigator-initiated, single-centre, randomized, double-blind, placebo-controlled and crossover trial. Adult patients with the diagnosis epidermolysis bullosa, reporting chronic pain will be eligible to participate. Following baseline measurements, participants will be randomized to receive the sublingually administered interventions placebo and Transvamix® in forward or reversed orders, each for two weeks and separated by a washout. The primary outcome is the difference in numeric rating scale pain scores between grouped interventions, using affective descriptors within the Short-form McGill Pain Questionnaire-2. Secondary outcomes include pain self-efficacy, concomitant analgesic medication-use and adverse events. Additionally, fMRI will be employed to assess brain connectivity related to neuroanatomic pain circuits at baseline, placebo and Transvamix® interventions. The study was approved by the ethical committee at the University Medical Center of Groningen in the Netherlands. Results will be submitted for publication in a peer-reviewed journal. Trial registration number: Netherlands Trial Register: NL9347 (Acronym: C4EB).

A guide for standardized interpretation of lumbar multifidus ultrasonography; an observational study

Background

Inconsistent descriptions of Lumbar multifidus (LM) morphology were previously identified, especially in research applying ultrasonography (US), hampering its clinical applicability with regard to diagnosis and therapy. The aim of this study is to determine the LM-sonoanatomy by comparing high-resolution reconstructions from a 3-D digital spine compared to standard LM-ultrasonography.

Methods

An observational study was carried out. From three deeply frozen human tissue blocks of the lumbosacral spine, a large series of consecutive photographs at 78 μm interval were acquired and reformatted into 3-D blocks. This enabled the reconstruction of (semi-)oblique cross-sections that could match US-images obtained from a healthy volunteer. Transverse and oblique short-axis views were compared from the most caudal insertion of LM to L1.

Results

Based on the anatomical reconstructions, we could distinguish the LM from the adjacent erector spinae (ES) in the standard US imaging of the lower spine. At the lumbosacral junction, LM is the only dorsal muscle facing the surface. From L5 upwards, the ES progresses from lateral to medial. A clear distinction between deep and superficial LM could not be discerned. We were only able to identify five separate bands between every lumbar spinous processes and the dorsal part of the sacrum in the caudal anatomical cross-sections, but not in the standard US images.

Conclusion

The detailed cross-sectional LM-sonoanatomy and reconstructions facilitate the interpretations of standard LM US-imaging, the position of the separate LM-bands, the details of deep interspinal muscles, and demarcation of the LM versus the ES. Guidelines for electrode positioning in EMG studies should be refined to establish reliable and verifiable findings. For clinical practice, this study can serve as a guide for a better characterisation of LM compared to ES and for a more reliable placement of US-probe in biofeedback.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05590-5.

Reply to Jensen, O.K. On the Use of Quantitative Sensory Testing to Estimate Central Sensitization in Humans. Comment on "Schuttert et al. The Definition, Assessment, and Prevalence of (Human Assumed) Central Sensitisation in Patients with Chronic Low Back Pain: A Systematic Review. J. Clin. Med. 2021, 10, 5931"

We thank Dr. Jensen for his interest [...].

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial

BACKGROUND

National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety.

METHODS

Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care.

RESULTS

Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: 'discharge from recovery room' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - 'discharge from the hospital' - possibly because of the limited resources of hospitals to improve all stop moments together.

CONCLUSIONS

Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics.

CLINICAL TRIAL REGISTRATION

NTR3568 (Dutch Trial Registry).

The Definition, Assessment, and Prevalence of (Human Assumed) Central Sensitisation in Patients with Chronic Low Back Pain: A Systematic Review

Central sensitisation is assumed to be one of the underlying mechanisms for chronic low back pain. Because central sensitisation is not directly assessable in humans, the term 'human assumed central sensitisation' (HACS) is suggested. The objectives were to investigate what definitions for HACS have been used, to evaluate the methods to assess HACS, to assess the validity of those methods, and to estimate the prevalence of HACS. Database search resulted in 34 included studies. Forty different definition references were used to define HACS. This review uncovered twenty quantitative methods to assess HACS, including four questionnaires and sixteen quantitative sensory testing measures. The prevalence of HACS in patients with chronic low back pain was estimated in three studies. The current systematic review highlights that multiple definitions, assessment methods, and prevalence estimates are stated in the literature regarding HACS in patients with chronic low back pain. Most of the assessment methods of HACS are not validated but have been tested for reliability and repeatability. Given the lack of a gold standard to assess HACS, an initial grading system is proposed to standardize clinical and research assessments of HACS in patients with a chronic low back.

Functional and morphological lumbar multifidus characteristics in subgroups with low back pain in primary care

BACKGROUND

Since the contribution of the lumbar multifidus(LM) is not well understood in relation to non-specific low back pain(LBP), this may limit physiotherapists in choosing the most appropriate treatment strategy.

OBJECTIVES

This study aims to compare clinical characteristics, in terms of LM function and morphology, between subacute and chronic LBP patients from a large clinical practice cohort compared to healthy controls.

DESIGN

Multicenter case control study.

METHOD

Subacute and chronic LBP patients and healthy controls between 18 and 65 years of age were included. Several clinical tests were performed: primary outcomes were the LM thickness from ultrasound measurements, trunk range of motion(ROM) from 3D kinematic tests, and median frequency and root mean square values of LM by electromyography measurements. The secondary outcomes Numeric Rating Scale for Pain(NRS) and the Oswestry Disability Index(ODI) were administered. Comparisons between groups were made with ANOVA, p-values<0.05, with Tukey's HSD post-hoc test were considered significant.

RESULTS

A total of 161 participants were included, 50 healthy controls, 59 chronic LBP patients, and 52 subacute LBP patients. Trunk ROM and LM thickness were significantly larger in healthy controls compared to all LBP patients(p < 0.01). A lower LM thickness was found between subacute and chronic LBP patients although not significant(p = 0.11-0.97). All between-group comparisons showed no statistically significant differences in electromyography outcomes (p = 0.10-0.32). NRS showed no significant differences between LBP subgroups(p = 0.21). Chronic LBP patients showed a significant higher ODI score compared to subacute LBP patients(p = 0.03).

CONCLUSIONS

Trunk ROM and LM thickness show differences between LBP patients and healthy controls.

Cannabinoid use and effects in patients with epidermolysis bullosa: an international cross-sectional survey study

BACKGROUND

Epidermolysis bullosa (EB) patient anecdotes and case reports indicate that cannabinoid-based medicines (CBMs) may alleviate pain and pruritus and improve wound healing. CBM use has not been characterized in the EB patient population.

OBJECTIVES

To evaluate CBM use among EB patients, including CBM types, effects on symptoms (e.g., pain and pruritus), disease process (e.g., blistering, wounds, and inflammation), well-being (e.g., sleep, appetite) and concomitant medications.

METHODS

English-speaking EB patients or caregivers completed an online international, anonymous, cross-sectional survey regarding CBM use. Respondents reported the types of CBMs, subsequent effects including perceived EB symptom alteration, changes in medication use, and side effects.

RESULTS

Seventy-one EB patients from five continents reported using or having used CBMs to treat their EB. Missing question responses ranged between 0 (0%) and 33 (46%). Most used more than one CBM preparation (mean: 2.4 ± 1.5) and route of administration (mean: 2.1 ± 1.1). Topical and ingested were the most common routes. Pain and pruritus were reported retrospectively to decrease by 3 points (scale: 0-10; p < 0.001 for both) after CBM use. Most reported that CBM use improved their overall EB symptoms (95%), pain (94%), pruritus (91%) and wound healing (81%). Most participants (79%) reported decreased use of pain medications. The most common side-effect was dry mouth (44%).

CONCLUSIONS

CBMs improve the perception of pain, pruritus, wound healing, and well-being in EB patients and reduced concomitant medication use. Nevertheless, a direct relation between the use of CBMs and reduction of the above-mentioned symptoms cannot be proven by these data. Therefore, future controlled studies using pharmaceutically standardised CBM preparations in EB are warranted to delineate the risks and benefits of CBMs.

Reducing work pressure and IT problems and facilitating IT integration and audit & feedback help adherence to perioperative safety guidelines: a survey among 95 perioperative professionals

Background

To improve perioperative patient safety, guidelines for the preoperative, peroperative, and postoperative phase were introduced in the Netherlands between 2010 and 2013. To help the implementation of these guidelines, we aimed to get a better understanding of the barriers and drivers of perioperative guideline adherence and to explore what can be learned for future implementation projects in complex organizations.

Methods

We developed a questionnaire survey based on the theoretical framework of Van Sluisveld et al. for classifying barriers and facilitators. The questionnaire contained 57 statements derived from (a) an instrument for measuring determinants of innovations by the Dutch Organization for Applied Scientific Research, (b) interviews with quality and safety policy officers and perioperative professionals, and (c) a publication of Cabana et al. The target group consisted of 232 perioperative professionals in nine hospitals. In addition to rating the statements on a five-point Likert scale (which were classified into the seven categories of the framework: factors relating to the intervention, society, implementation, organization, professional, patients, and social factors), respondents were invited to rank their three most important barriers in a separate, extra open-ended question.

Results

Ninety-five professionals (41%) completed the questionnaire. Fifteen statements (26%) were considered to be barriers, relating to social factors (N = 5), the organization (N = 4), the professional (N = 4), the patient (N = 1), and the intervention (N = 1). An integrated information system was considered an important facilitator (70.4%) as well as audit and feedback (41.8%). The Barriers Top-3 question resulted in 75 different barriers in nearly all categories. The most frequently reported barriers were as follows: time pressure (16% of the total number of barriers), emergency patients (8%), inefficient IT structure (4%), and workload (3%).

Conclusions

We identified a wide range of barriers that are believed to hinder the use of the perioperative safety guidelines, while an integrated information system and local data collection and feedback will also be necessary to engage perioperative teams. These barriers need to be locally prioritized and addressed by tailored implementation strategies. These results may also be of relevance for guideline implementation in general in complex organizations.

Trial registration

Dutch Trial Registry: NTR3568.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review

Background

Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature.

Methods

Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system.

Results

In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings – particularly for levels L4–S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases.

Discussion

Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas.

Conclusions

We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

Prospective methods for identifying perioperative risk-assessment methods for patient safety over 20 years: a systematic review

BACKGROUND

Serious preventable surgical events still occur despite considerable efforts to improve patient safety. In addition to learning from retrospective analyses, prospective risk-assessment methods may help to decrease preventable events further by targeting perioperative hazards. The aim of this systematic review was to assess the methods used to identify perioperative patient safety risks prospectively, and to describe the risk areas targeted, the quality characteristics and feasibility of methods.

METHODS

MEDLINE, Embase, CINAHL and Cochrane databases were searched, adhering to PRISMA guidelines. All studies describing the development and results of prospective methods to identify perioperative patient safety risks were included and assessed on methodological quality. Exclusion criteria were interventional studies, studies targeting one specific issue, studies reporting on structural factors relating to fundamental hospital items, and non-original or case studies.

RESULTS

The electronic search resulted in 16 708 publications, but only 20 were included for final analysis, describing five prospective risk-assessment methods. Direct observation was used in most studies, often in combination. Direct (16 studies) and indirect (4 studies) observations identified (potential) adverse events (P)AEs, process flow disruptions, poor protocol compliance and poor practice performance. (Modified) Healthcare Failure Mode and Effect Analysis (HFMEA™) (5 studies) targeted potential process flow disruption failures, and direct (P)AE surveillance (3 studies) identified (P)AEs prospectively. Questionnaires (3 studies) identified poor protocol compliance, surgical flow disturbances and patients' willingness to ask questions about their care. Overall, quality characteristics and feasibility of the methods were poorly reported.

CONCLUSION

The direct (in-person) observation appears to be the primary prospective risk-assessment method that currently may best help to target perioperative hazards. This is a reliable method and covers a broad spectrum of perioperative risk areas.

Combined tetrahydrocannabinol and cannabidiol to treat pain in epidermolysis bullosa: a report of three cases

Epidermolysis bullosa (EB) is a genetic blistering disorder characterized by intense pain related to disease pathology and care‐based interventions. Opioid‐based therapies underpin pain care in EB; however, they are unable to provide adequate analgesia in a significant proportion of patients. Cannabinoid‐based medicines (CBMs) have been studied increasingly for pain conditions of various aetiologies and pose as a novel dimension for pain care in EB. We present three patients with EB who were prescribed pharmaceutical‐grade sublingually administered CBMs comprising tetrahydrocannabinol and cannabidiol. All three patients reported improved pain scores, reduced pruritus and reduction in overall analgesic drug intake.

What's already known about this topic?

Pain is the most burdening symptom for patients suffering from severe epidermolysis bullosa (EB). Patients are exposed to numerous drug interventions, including high‐dose strong opioids, which often do not provide adequate analgesia and may induce adverse effects.

Cannabinoid‐based medicines (CBMs) have been investigated for pain of various aetiologies and show promise through their interaction with the endocannabinoid system localized to central pain circuits.

Cannabidiol has been reported to reduce wound pain in children with EB.

What does this study add?

The prescription of sublingually administered pharmaceutical‐grade CBMs may add additional value to pain‐care in EB and should be further investigated.

Linked Comment:Martinez. Br J Dermatol 2019; 180:711–712.

Plain language summary available online

Development and validation of a Self-assessment Instrument for Perioperative Patient Safety (SIPPS)

Background

Patient safety is a fundamental value of healthcare to avoid patient harm. Non‐compliance with patient safety standards may result in patient harm and is therefore a global concern. A Self‐assessment Instrument for Perioperative Patient Safety (SIPPS) monitoring and benchmarking compliance to safety standards was validated in a multicentre pilot study.

Methods

A preliminary questionnaire, based on the Dutch perioperative patient safety guidelines and covering international patient safety goals, was evaluated in a first digital RAND Delphi round. The results were used to optimize the questionnaire and design the SIPPS. For measurement and benchmarking purposes, SIPPS was categorized into seven main patient safety domains concerning all care episode phases of the perioperative trajectory. After consensus was reached in a face‐to‐face Delphi round, SIPPS was pilot‐tested in five hospitals for five characteristics: measurability, applicability, improvement potential, discriminatory capacity and feasibility.

Results

The results of the first Delphi round showed moderate feasibility for the preliminary questionnaire (81·6 per cent). The pilot test showed good measurability for SIPPS: 99·8 per cent of requested information was assessable. Some 99·9 per cent of SIPPS questions were applicable to the selected respondents. With SIPPS, room for improvement in perioperative patient safety compliance was demonstrated for all hospitals, concerning all safety domains and all care episode phases of the perioperative trajectory (compliance 76·1 per cent). SIPPS showed mixed results for discriminatory capacity. SIPPS showed good feasibility for all items (range 91·9–95·7 per cent).

Conclusion

A self‐assessment instrument for measuring perioperative patient safety (SIPPS) compliance meeting international standards was validated. With SIPPS, improvement areas for perioperative patient safety and best practices across hospitals could be identified.

The added value of bedside examination and screening QST to improve neuropathic pain identification in patients with chronic pain

Background

The assessment of a neuropathic pain component (NePC) to establish the neurological criteria required to comply with the clinical description is based on history taking, clinical examination, and quantitative sensory testing (QST) and includes bedside examination (BSE). The objective of this study was to assess the potential association between the clinically diagnosed presence or absence of an NePC, BSE, and the Nijmegen–Aalborg screening QST (NASQ) paradigm in patients with chronic (≥3 months) low back and leg pain or with neck shoulder arm pain or in patients with chronic pain due to suspected peripheral nerve damage.

Methods

A total of 291 patients participated in the study. Pain (absence or presence of neuro-pathic pain) was assessed independently by two physicians and compared with BSE (measurements of touch [finger, brush], heat, cold, pricking [safety pin, von Frey hair], and vibration). The NASQ paradigm (pressure algometry, electrical pain thresholds, and conditioned pain modulation) was assessed in 58 patients to generate new insights.

Results

BSE revealed a low association of differences between patients with either absent or present NePC: heat, cold, and pricking sensations with a von Frey hair were statistically significantly less common in patients with present NePC. NASQ did not reveal any differences between patients with and without an NePC.

Conclusion

Currently, a standardized BSE appears to be more useful than the NASQ paradigm when distinguishing between patients with and without an NePC.

Avoiding Catch-22: validating the PainDETECT in a in a population of patients with chronic pain

Background

Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system and is a major therapeutic challenge. Several screening tools have been developed to help physicians detect patients with neuropathic pain. These have typically been validated in populations pre-stratified for neuropathic pain, leading to a so called “Catch-22 situation:” “a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule”. The validity of screening tools needs to be proven in patients with pain who were not pre-stratified on basis of the target outcome: neuropathic pain or non-neuropathic pain. This study aims to assess the validity of the Dutch PainDETECT (PainDETECT_-Dlv) in a large population of patients with chronic pain.

Methods

A cross-sectional multicentre design was used to assess PainDETECT_-Dlv validity. Included where patients with low back pain radiating into the leg(s), patients with neck-shoulder-arm pain and patients with pain due to a suspected peripheral nerve damage. Patients’ pain was classified as having a neuropathic pain component (yes/no) by two experienced physicians (“gold standard”). Physician opinion based on the Grading System was a secondary comparison.

Results

In total, 291 patients were included. Primary analysis was done on patients where both physicians agreed upon the pain classification (n = 228). Compared to the physician’s classification, PainDETECT_-Dlv had a sensitivity of 80% and specificity of 55%, versus the Grading System it achieved 74 and 46%.

Conclusion

Despite its internal consistency and test-retest reliability the PainDETECT_-Dlv is not an effective screening tool for a neuropathic pain component in a population of patients with chronic pain because of its moderate sensitivity and low specificity. Moreover, the indiscriminate use of the PainDETECT_-Dlv as a surrogate for clinical assessment should be avoided in daily clinical practice as well as in (clinical-) research. Catch-22 situations in the validation of screening tools can be prevented by not pre-stratifying the patients on basis of the target outcome before inclusion in a validation study for screening instruments.

Trial registration

The protocol was registered prospectively in the Dutch National Trial Register: NTR 3030.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1094-4) contains supplementary material, which is available to authorized users.

Development of the Surgical Patient safety Observation Tool (SPOT)

Background

A Surgical Patient safety Observation Tool (SPOT) was developed and tested in a multicentre observational pilot study. The tool enables monitoring and benchmarking perioperative safety performance across departments and hospitals, covering international patient safety goals.

Methods

Nineteen perioperative patient safety observation topics were selected from Dutch perioperative patient safety guidelines, which also cover international patient safety goals. All items that measured these selected topics were then extracted from available local observation checklists of the participating hospitals. Experts individually prioritized the best measurement items per topic in an initial written Delphi round. The second (face to face) Delphi round resulted in consensus on the content of SPOT, after which the measurable elements (MEs) per topic were defined. Finally, the tool was piloted in eight hospitals for measurability, applicability, improvement potential, discriminatory capacity and feasibility.

Results

The pilot test showed good measurability for all 19 patient safety topics (range of 8-291 MEs among topics), with good applicability (median 97 (range 11·8-100) per cent). The overall improvement potential appeared to be good (median 89 (range 72·5-100) per cent), and at topic level the tool showed good discriminatory capacity (variation 27·5 per cent, range in compliance 72·5-100 per cent). Overall scores showed relatively little variation between the participating hospitals (variation 13 per cent, range in compliance 83-96 per cent). All eight auditors considered SPOT a straightforward and easy-to-use tracer tool.

Conclusion

A comprehensive tool to measure safety of care was developed and validated using a systematic, stepwise method, enabling hospitals to monitor, benchmark and improve perioperative safety performance.

Correlation of bupivacaine 0.5% dose and conversion from spinal anesthesia to general anesthesia in cesarean sections

BACKGROUND

Failed spinal anesthesia for cesarean sections may require conversion to general anesthesia. The aim of this study was to determine whether the administered spinal bupivacaine dose for performing a cesarean section under spinal anesthesia was related to the conversion rate to general anesthesia.

METHODS

Retrospective analysis was performed on 1252 electronic data and file of patients who underwent a cesarean section under spinal anesthesia between 2004 and 2011.

RESULTS

In 15 patients, spinal anesthesia was converted into general anesthesia due to block failure. Patients in whom a bupivacaine dose of 8 mg or smaller was administered had significantly higher conversion rate (3/61 (4.9%) patients and 12/1191 (1.0%) patients, respectively; p < 0.05.). The relative risk of conversion with a 8 mg dose or lower is 4.88 (95% CI 1.41 - 16.85).

CONCLUSION

This retrospective study shows that a low dose administration a bupivacaine 0.5% for spinal anesthesia in cesarean section patients elicits significantly more frequent conversion to general anesthesia.

Improving the implementation of perioperative safety guidelines using a multifaceted intervention approach: protocol of the IMPROVE study, a stepped wedge cluster randomized trial

BACKGROUND

This study is initiated to evaluate the effects, costs, and feasibility at the hospital and patient level of an evidence-based strategy to improve the use of Dutch perioperative safety guidelines. Based on current knowledge, expert opinions and expertise of the project team, a multifaceted implementation strategy has been developed.

METHODS/DESIGN

This is a stepped wedge cluster randomized trial including nine representative hospitals across The Netherlands. Hospitals are stratified into three groups according to hospital type and geographical location and randomized in terms of the period for receipt of the intervention. All adult surgical patients meeting the inclusion criteria are assessed for patient outcomes. The implementation strategy includes education, audit and feedback, organizational interventions (e.g., local embedding of the guidelines), team-directed interventions (e.g., multi-professional team training), reminders, as well as patient-mediated interventions (e.g., patient safety cards). To tailor the implementation activities, we developed a questionnaire to identify barriers for effective guideline adherence, based on (a) a theoretical framework for classifying barriers and facilitators, (b) an instrument for measuring determinants of innovations, and (c) 19 semi-structured interviews with perioperative key professionals. Primary outcome is guideline adherence measured at the hospital (i.e., cluster) and patient levels by a set of perioperative Patient Safety Indicators (PSIs), which was developed parallel to the perioperative guidelines. Secondary outcomes at the patient level are in-hospital complications, postoperative wound infections and mortality, length of hospital stay, and unscheduled transfer to the intensive care unit, non-elective readmission to the hospital and unplanned reoperation, all within 30 days after the initial surgery. Also, patient safety culture and team climate will be studied as potential determinants. Finally, a process evaluation is conducted to identify the compliance with the implementation strategy, as well as an economic evaluation to assess the costs. Data sources are registered clinical data and surveys. There is no form of blinding.

DISCUSSION

The perioperative setting is an unexplored area with respect to implementation issues. This study is expected to yield important new evidence about the effects of a multifaceted approach on guideline adherence in the perioperative care setting.

TRIAL REGISTRATION

Dutch trial registry: NTR3568.

The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events

Background

The reduction of perioperative harm is a major priority of in-hospital health care and the reporting of incidents and their causes is an important source of information to improve perioperative patient safety. We explored the number, nature and causes of voluntarily reported perioperative incidents in order to highlight the areas where further efforts are required to improve patient safety.

Methods

Data from the Hospital Incident Management System (HIMS), entered in the period from July 2009 to July 2012, were analyzed in a Dutch university hospital. Employees in the perioperatve field filled out a semi-structured digital form of the reporting system. The risk classification of the reported adverse events and ‘near misses’ was based on the estimated patient consequences and the risk of recurrence, according to national guidelines. Predefined reported incident causes were categorized as human, organizational, technical and patient related.

Results

In total, 2,563 incidents (1,300 adverse events and 1,263 ‘near-miss’ events) were reported during 67,360 operations. Reporters were anesthesia, operating room and recovery nurses (37%), ward nurses (31%), physicians (17%), administrative personnel (5%), others (6%) and unmentioned (3%). A total of 414 (16%) adverse events had patient consequences (which affected 0,6% of all surgery patients), estimated as catastrophic in 2, very serious in 34, serious in 105, and marginally serious in 273 cases. Shortcomings in communication was the most frequent reported type of incidents. Non-compliance with Standard Operating Procedures (SOPs: instructions, regulations, protocols and guidelines) was reported with 877 (34%) of incident reports. In total, 1,194 (27%) voluntarily reported causes were SOP-related, mainly human-based (79%) and partially organization-based (21%). SOP-related incidents were not associated with more patient consequences than other voluntarily reported incidents. Furthermore ‘mistake or forgotten’ (15%) and ‘communication problems’ (11%) were frequently reported causes of incidents.

Conclusions

The analysis of voluntarily reported perioperative incidents identified an association between perioperative patient safety problems and human failure, such as SOP non-compliance, mistakes, forgetting, and shortcomings in communication. The data suggest that professionals themselves indicate that SOP compliance in combination with other human failures provide room for improvement.

Meta-analysis of operative mortality and complications in patients from minority ethnic groups

BACKGROUND

Insight into the effects of ethnic disparities on patients' perioperative safety is necessary for the development of tailored improvement strategies. The aim of this study was to review the literature on safety differences between patients from minority ethnic groups and those from the ethnic majority undergoing surgery.

METHODS

PubMed, CINAHL, the Cochrane Library and Embase were searched using predefined inclusion criteria for available studies from January 1990 to January 2013. After quality assessment, the study data were organized on the basis of outcome, statistical significance and the direction of the observed effects. Relative risks for mortality were calculated.

RESULTS

After screening 3105 studies, 26 studies were identified. Nine of these 26 studies showed statistically significant higher mortality rates for patients from minority ethnic groups. Meta-analysis demonstrated a greater risk of mortality for these patients compared with patients from the Caucasian majority in studies performed both in North America (risk ratio 1·22, 95 per cent confidence interval 1·05 to 1·42) and outside (risk ratio 2·25, 1·40 to 3·62). For patients from minority groups, the length of hospital or intensive care unit stay was significantly longer in five studies, and complication rates were significantly higher in ten. Methods used to identify patient ethnicity were not described in 14 studies.

CONCLUSION

Patients from minority ethnic groups, in North America and elsewhere, have an increased risk of perioperative death and complications. More insight is needed into the causes of ethnic disparities to pursue safer perioperative care for patients of minority ethnicity.

Cross-cultural adaptation to the Dutch language of the PainDETECT-Questionnaire

BACKGROUND

The PainDETECT-Questionnaire (PDQ) helps to identify neuropathic components in patients suffering from pain. It can be used by clinicians in daily practice and in clinical trials.

AIM

The aim of this study is to perform a translation and cross-cultural adaptation of the PDQ for use in the Netherlands and Belgium.

METHODS

The first phase was to translate and cross-culturally adapt the PDQ to Dutch. The second phase was to assess the face validity in the Netherlands and Belgium using qualitative and quantitative data collection.

RESULTS

The length, the readability, and the clarity of the questionnaire were good for all patients. The questionnaire was judged to have a good layout and to be clearly organized.

CONCLUSION

The PDQ Dutch language Version is a well translated and cross-culturally adapted questionnaire, which might be useful for screening for neuropathic components of pain in the Netherlands and Belgium.

[The 'paper-based' preoperative evaluation: sometimes, a suitable alternative]

In the Netherlands, the majority of elective-surgery patients are evaluated by the anaesthesiologist at the preoperative assessment clinic. We believe that this visit can be omitted in selected patients as it has only minimal benefit, whereas its disadvantages can be substantial. Alternatively, the initial screening could be performed by the completion of a questionnaire via the telephone, via internet, by a nurse or by the surgeon. These data can then be evaluated by the anaesthesiologist; this is called the 'paper-based' preoperative evaluation. This method does require the conscientious cooperation between anaesthesiologists and surgeons; it should be clear which patients are eligible, what type of anaesthetic technique should be used, how the patient should be informed and how the informed consent is obtained. In our opinion, this paper-based evaluation combines safety and efficiency with patient-friendliness. It should be anchored in current guidelines to ensure quality.

[Fire by spontaneous combustion of oxygen cylinders]

The use of medicinal oxygen can be dangerous. The spontaneous combustion of an oxygen cylinder was the cause of a fire in an operating theatre and an emergency medical service. The fire developed after turning on the gas main while the flow supply valve was already open. Not opening the pressure reduction valve while the oxygen flow supply valve is open can prevent this type of fire. Information from the contractor shows that the probability of such an incident is 1 in a million.

[The national Dutch Institute for Healthcare Improvement guidelines 'Preoperative trajectory': the essentials]

In view of the shortcomings of the organisation of the perioperative process that have been ascertained by the Dutch Health Inspectorate (IGZ), the Inspectorate has requested hospitals and care professionals to implement measures to improve this situation. In response to the IGZ's first report, the Dutch Institute for Healthcare Improvement (CBO) has developed the national, multiprofessional guidelines entitled 'Preoperative Trajectory' which were published in January 2010. Implementation of these guidelines should improve communication between professionals and lead to standardization and transparency of the preoperative patient care process, with uniform handovers and clear responsibilities. These guidelines are the first to provide recommendations at process of care level which are intended to increase patient safety and reduce the risk of damage to patients.

Influence of needle position on lumbar segmental nerve root block selectivity

BACKGROUND AND OBJECTIVES

In patients with chronic low back pain radiating to the leg, segmental nerve root blocks (SNRBs) are performed to predict surgical outcome and identify the putative symptomatic spinal nerve. Epidural spread may lead to false interpretation, affecting clinical decision making. Systematic fluoroscopic analysis of epidural local anesthetic spread and its relationship to needle tip location has not been published to date. Study aims include assessment of epidural local anesthetic spread and its relationship to needle position during fluoroscopy-assisted blocks.

METHODS

Patients scheduled for L4, L5, and S1 blocks were included in this prospective observational study. Under fluoroscopy and electrostimulation, they received 0.5 mL of a mixture containing lidocaine 5 mg and iohexol 75 mg. X-rays with needle tip and contrast were scored for no epidural spread (grade 0), local spread epidurally (grade 1), or to adjacent nerve roots (grade 2).

RESULTS

Sixty-five patients were analyzed for epidural spread, 62 for needle position. Grade 1 epidural spread occurred in 47% of L4 and 28% of L5 blocks and grade 2 spread in 3 blocks (5%; L5 n = 1, S1 n = 2). For lumbar blocks, the needle was most frequently found in the lateral upper half of the intervertebral foramen. Epidural spread occurred more frequently with medial needle positions (P = .06).

CONCLUSION

The findings suggest (P = .06) that the risk of grade 1 and 2 lumbar epidural spread, which results in decreased SNRB selectivity, is greater with medial needle positions in the intervertebral foramen. The variability in anatomic position of the dorsal root ganglion necessitates electrostimulation to guide SNRB in addition to fluoroscopy.

Do diagnostic segmental nerve root blocks in chronic low back pain patients with radiation to the leg lack distinct sensory effects? A preliminary study

BACKGROUND

The present preliminary study documents the effects of a selective nerve root block (SNB) with short or long acting local anaesthetic compared with baseline measurements in patients with chronic low back pain radiating to the leg with maximum pain in one dermatome (L4).

METHODS

Ten consecutive patients underwent 20 controlled SNBs at L4 with ropivacaine 0.25% and lidocaine 1% in a prospective, randomized, double blind, crossover fashion. Baseline measurements included sensory function (assessed by pinprick on both unaffected and painful leg) and pain (Verbal Numeric Rating Scale; VNRS, 0-10). A change in size of areas with altered sensory function >10% and a VNRS change of 2 points were considered clinically significant. P-values<0.05 were considered statistically significant.

RESULTS

Asymptomatic hypoaesthesia, variable in extent and non-dermatomal in distribution, was present in seven patients at baseline. It appeared to be more extensive and distal with longer duration of pre-existing pain. SNB produced no consistent changes in extent and distribution of hypoaesthetic areas. Change in VNRS did not correlate with the extent of pre-block or post-block hypoaesthesia. No differences in effects were found between lidocaine and ropivacaine.

CONCLUSIONS

Pre-block assessment of sensory function is essential to assess the net effect of SNBs. In this small study group, SNBs failed to demonstrate uniform or distinct effects on sensory function.

Lumbar Segmental Nerve Blocks with Local Anesthetics, Pain Relief, and Motor Function: A Prospective Double-Blind Study Between Lidocaine and Ropivacaine

Selective segmental nerve blocks with local anesthetics are applied for diagnostic purposes in patients with chronic back pain to determine the segmental level of the pain. We performed this study to establish myotomal motor effects after L4 spinal nerve blocks by lidocaine and ropivacaine and to evaluate the relationship with pain. Therefore, 20 patients, of which 19 finished the complete protocol, with chronic lumbosacral radicular pain without neurological deficits underwent segmental nerve blocks at L4 with both lidocaine and ropivacaine. Pain intensity scores (verbal numeric rating scale; VNRS) and the maximum voluntary muscle force (MVMF; using a dynamometer expressed in newtons) of the tibialis anterior and quadriceps femoris muscles were measured on the painful side and on the control side. The median VNRS decrease was 4.0 (P < 0.00001; Wilcoxon's signed rank test), without significant differences between ropivacaine and lidocaine (Mann-Whitney U-test). A difference in effect on MVMF was found for affected versus control side (P = 0.016; Tukey test). Multiple regression revealed a significant negative correlation for change in VNRS score versus change in median MVMF (Spearman R = -0.48: P = 0.00001). This study demonstrates that in patients with unilateral chronic low back pain radiating to the leg, pain reduction induced by local anesthetic segmental nerve (L4) block is associated with increased quadriceps femoris and tibialis anterior MVMF, without differences for lidocaine and ropivacaine.

Diagnostic lumbosacral segmental nerve blocks with local anesthetics: a prospective double-blind study on the variability and interpretation of segmental effects

BACKGROUND AND OBJECTIVES

Selective spinal nerve infiltration blocks are used diagnostically in patients with chronic low back pain radiating into the leg. Generally, a segmental nerve block is considered successful if the pain is reduced substantially. Hypesthesia and elicited paresthesias coinciding with the presumed segmental level are used as controls. The interpretation depends on a standard dermatomal map. However, it is not clear if this interpretation is reliable enough, because standard dermatomal maps do not show the overlap of neighboring dermatomes. The goal of the present study is to establish if dissimilarities exist between areas of hypesthesia, spontaneous pain reported by the patient, pain reduction by local anesthetics, and paresthesias elicited by sensory electrostimulation. A secondary goal is to determine to what extent the interpretation is improved when the overlaps of neighboring dermatomes are taken into account.

METHODS

Patients suffering from chronic low back pain with pain radiating into the leg underwent lumbosacral segmental nerve root blocks at subsequent levels on separate days. Lidocaine (2%, 0.5 mL) mixed with radiopaque fluid (0.25 mL) was injected after verifying the target location using sensory and motor electrostimulation. Sensory changes (pinprick method), paresthesias (reported by the patient), and pain reduction (Numeric Rating Scale) were reported. Hypesthesia and paresthesias were registered in a standard dermatomal map and in an adapted map which included overlap of neighboring dermatomes. The relationships between spinal level of injection, extent of hypesthesia, location of paresthesias, and corresponding dermatome were assessed quantitatively. Comparison of the results between both dermatomal maps was done by paired t-tests.

RESULTS

After inclusion, data were processed for 40 segmental nerve blocks (L2-S1) performed in 29 patients. Pain reduction was achieved in 43%. Hypesthetic areas showed a large variability in size and location, and also in comparison to paresthesias. Mean hypesthetic area amounted 2.7 +/- 1.4 (+/- SD: range, 0 to 6; standard map) and 3.6 +/- 1.8 (0 to 6; adapted map; P <.001) dermatomes. In these cases, hypesthesia in the corresponding dermatome was found in 80% (standard map) and 88% of the cases (adapted map, not significant). Paresthesias occurring in the corresponding dermatome were found in 80% (standard map) compared with 98% (adapted map, P <.001). In 85% (standard map) and 88% (adapted map), spontaneous pain was present in the dermatome corresponding to the level of local anesthetic injection. In 55% (standard map) versus 75% (adapted map, P <.005), a combination of spontaneous pain, hypesthesia, and paresthesias was found in the corresponding dermatome.

CONCLUSIONS

Hypesthetic areas determined after lumbosacral segmental nerve blocks show a large variability in size and location compared with elicited paresthesias. Confirmation of an adequately performed segmental nerve block, determined by coexistence of hypesthesia, elicited paresthesias and pain in the presumed dermatome, is more reliable when the overlap of neighboring dermatomes is taken into account.

Extradural ropivacaine and bupivacaine in hip surgery

We studied 126 patients undergoing elective hip surgery; they received 20 ml of 0.5%, 0.75%, 1.0% ropivacaine or 0.5% bupivacaine extradurally in a double-blind design. Sensory block (pinprick), motor block (modified Bromage scale), quality of analgesia and neuromuscular block were assessed intermittently. Heart rate and arterial pressure were measured at regular intervals. A total of 115 patients were evaluated for efficacy. Onset of analgesia, onset of motor block and maximum cephalad spread (T4) did not differ between the groups. Duration and quality of analgesia and motor block increased with the concentration of ropivacaine. Ropivacaine 1.0% provided a longer duration of analgesia and motor block, more intense motor block and more patients with satisfactory analgesia than 0.5% bupivacaine. More patients treated with the higher concentrations of ropivacaine required treatment for hypotension and bradycardia.

High thoracic epidural sufentanil with bupivacaine: continuous infusion of high volume versus low volume

The purpose of the study was to investigate whether continuous infusion of a high volume of a sufentanil/bupivacaine mixture at a high thoracic level improves the analgesic effect of the mixture, compared with a dose-equivalent continuous low-volume infusion. In a prospective, observer-blind study, 60 patients scheduled for thoracic surgery received a thoracic epidural catheter for 3 days. The patients were randomly assigned by lot to one of two groups: a low-volume (LV) group (bupivacaine 0.75% with sufentanil 4 micrograms/mL, 1.0-1.3 mL/h), or a high-volume (HV) group (bupivacaine 0.125% with sufentanil 0.7 microgram/mL, 6-8 mL/h). On the first postoperative day significantly more patients in the LV group needed one or more epidural bolus injections because they experienced pain at rest (P < 0.05). On the second and third postoperative days there were no differences in bolus injections. Significantly more patients in the HV group did not require an extra epidural bolus injection (P < 0.05). There were no differences in the number of patients experiencing pain at exercise or in the incidence of side effects. A difference was found between both groups in the mean preoperative PaCO2 value (P < 0.05) and also for the PaCO2 values on Day 1 versus the preoperative values within the group (P < 0.05). On the first postoperative day the analgesic effects of a sufentanil/bupivacaine mixture at a high thoracic epidural level can be improved when injected at a continuous high-volume rate compared with a dose-equivalent continuous low-volume rate. This is true for pain at rest; for pain at exercise, there were no differences.

Accidental overdose of epidural bupivacaine and sufentanil

BACKGROUND AND OBJECTIVES

A case is described of an accidental high thoracic epidural infusion of 337.5 mg 0.75% bupivacaine and 180 micrograms sufentanil in less than 30 minutes. It occurred in a post-thoracotomy patient with lung cancer.

RESULTS

Severe hypotension and an extensive sensory and motor block developed. Only a mild respiratory depression was seen. The patient recovered after treatment without adverse sequelae.

Intracavernous carotid artery aneurysm presenting as recurrent epistaxis

Massive epistaxis from a leaking intracavernous carotid artery aneurysm is a rare occurrence. Such an unusual case is presented with appropriate imaging and a successful treatment program.

Hepatitis B virus infection in patients with chronic liver disease and healthy controls in north-Sulawesi, Indonesia

Markers of hepatitis-B virus (HBV) infection were determined in 42 patients with chronic liver disease (CLD) and in 42 age and sex matched healthy controls. At least one marker for HBV was found in 38 patients (90%) and in 29 controls (69%). HBsAg was present in 29 patients (69%) as opposed to 14 controls (33%; p less than 0.001). The very high prevalence of HBV infection, the significant difference with respect to HBV markers, particularly HBsAg, between patients and controls and in particular the high percentage of healthy HBV-carriers poses a considerable risk to the population of North-Sulawesi and stresses the need for HBV-vaccination.