Transitional Pain Service: Optimizing Complex Surgical Patients

PURPOSE OF REVIEW

The care of patients with complex postsurgical pain can be challenging and burdensome for the healthcare system. Transitional pain service (TPS) is a relatively new concept and has not been widely adopted in the USA. This article explores the benefits and barriers of transitional pain services and describes the development of a TPS at our institution.

RECENT FINDINGS

Evidence from a few institutions that have adopted TPS has shown decreased postsurgical opioid consumption for patients on chronic opioids and decreased incidence of chronic postsurgical opioid use for opioid-naïve patients. The development of a transitional pain service may improve outcomes for these complex patients by providing longitudinal and multidisciplinary perioperative pain care. In this article, we describe the implementation of a TPS at a tertiary medical center. Our TPS model involves a multidisciplinary team of anesthesiologists, pain psychologists, surgeons, and advanced practice providers. We provide longitudinal care, including preoperative education and optimization; perioperative multimodal analgesic care; and longitudinal follow-up for 90 days post-procedure. With our TPS service, we aim to reduce long-term opioid use and improve functional outcomes for our patients.

215 Examining the Benefits of One-To-One African Caribbean Mentoring for Prospective Medical Students

Aim

African Caribbean people are underrepresented in UK medical schools. African Caribbean Medical Mentors (ACMM) is a UK registered charity that provides one-to-one mentoring to prospective African Caribbean medical students. Mentors consist of current African Caribbean medical students and doctors. This study aimed to investigate the specific benefits provided by ACMM and the attributes of successful mentoring relationships.

Method

Participants were identified using ACMM's database of mentees and mentors enrolled within the last 3 years and an online questionnaire was distributed via Qualtrics. Questions were scored on a scale between 1 and 10 and participants were asked to explain their rankings.

Results

11 mentees and 7 mentors responded to the surveys. 63.6% and 72.7% of mentees gave a score between 8 – 10 regarding the importance of having a mentor and having a mentor that was African Caribbean respectively. All mentees reported satisfaction with their mentor, with 45.5% citing individualised interview practice and 63.6% reporting mentor support and availability as positive aspects of their mentoring relationship.

All mentors reported being satisfied with the program, with 57.1% and 71.4% giving a score between 8 – 10 regarding the importance of having a mentor and having a mentor that was African Caribbean respectively. 42.9% of mentors reported that improved methods and proactivity with communication could have improved their mentoring relationship.

Conclusion

This study suggests that one-to-one mentoring between African Caribbean mentors and mentees was helpful during medical school applications. Interview practice proved particularly useful, whilst methods and timescales of communication represent areas for improvement.

Validity and sensitivity to change of laser Doppler imaging as a novel objective outcome measure for cutaneous lupus erythematosus

OBJECTIVES

The objectives of this study were to assess the reliability of a novel objective outcome measure, laser Doppler imaging (LDI), its validity against skin biopsy histology and other clinical instruments, including localized cutaneous lupus disease area and severity index (L-CLASI) and visual analogue scale (VAS) score of photographs, and its responsiveness to clinical change with therapy.

METHODS

A prospective observational cohort study was conducted in 30 patients with active cutaneous lupus erythematosus (CLE). At baseline and 3 months, disease activity was assessed using L-CLASI and a high resolution LDI system by two assessors. Skin biopsy was scored as 0 = non-active, 1 = mild activity and 2 = active. Photographs were assessed by two clinicians using 100 mm VAS. Inter-rater reliability was analyzed using Bland-Altman limits of agreement. Correlation between histology and LDI, L-CLASI and VAS and sensitivity to change of LDI with physician subjective assessment of change (PSAC) at 3 months were analyzed using Kendall's tau-a.

RESULTS

Of 30 patients with CLE, 28 (93%) were female, mean (SD) age 48.4 (11.5) y, 25 (83%) were Caucasians, 25 (83%) had concurrent systemic lupus erythematosus and 16 (53%) were smokers. CLE subtypes were acute = 9, subacute = 8 and chronic = 13. Inter-rater agreement for LDI was fair but for VAS score of photographs was poor. In 20 patients with biopsy, correlation with histology was better for LDI (tau-a = 0.53) than L-CLASI (tau-a = 0.26) (difference = 0.27; 90% CI 0.05-0.49) or VAS score of photographs (tau-a = 0.17) (difference = 0.36; 90% CI 0.04-0.68). There was a moderate correlation between PSAC score and change in LDI (tau-a = 0.56; 90% CI 0.38-0.74; p < 0.001, n = 15).

CONCLUSION

LDI provides a reliable, valid and responsive quantitative measure of inflammation in CLE. It has a better correlation with histology compared to clinical instruments. LDI provides an objective outcome measure for clinical trials.

Detection of periodic structures through opaque metal layers by optical measurements of ultrafast electron dynamics

We report on femtosecond optical pump-probe measurements of ultrafast electron dynamics to detect the presence of gratings buried underneath optically opaque gold layers. Electron energy diffusion and cooling are found to be strongly affected by the presence and type of metal buried below the gold layer. As a result, the spatially periodic buried grating is encoded on the electron temperature near the top surface, leading to a spatially periodic modulation of the optical properties near the gold surface from which a delayed probe pulse can be diffracted. Our measurements show that these effects may be useful for optical detection and alignment applications in semiconductor device manufacturing.

Expression of hair follicle stem cells detected by cytokeratin 15 stain: implications for pathogenesis of the scarring process in cutaneous lupus erythematosus

BACKGROUND

Discoid lupus erythematosus (DLE) is a scarring disease. Although the scarring and deformity may affect any part of the body, such changes have been reported to be most obvious on the face and scalp. The pathogenesis behind this scarring process is not well understood. Once lesions have scarred, recurrent disease tends to occur at the edge of the scarred lesions but not within them.

OBJECTIVES

The fact that inflammation in DLE generally involves the bulge area of the follicles raises the possibility that damage to the stem cells of the bulge region may be one process leading to the permanent loss of follicles. The aim of this study was to investigate the role of the hair follicle stem cells which reside in the bulge region in the scarring process in cutaneous lupus erythematosus (CLE).

METHODS

We studied the reactivity of an antibody to the CD8 antigen (C8/144B), which recognizes cytokeratin (CK) 15 and preferentially immunostains hair follicle stem cells without staining the remaining hair follicle, on skin biopsies (scalp and body lesions) from patients with CLE (36 with discoid lesions and 10 with subacute lesions). Normal scalp and body biopsy specimens served as controls. The correlation between the extent of the cytotoxic inflammatory cell infiltrate (CD8+) and the presence of stem cells was investigated. Results were analysed semiquantitatively.

RESULTS

The expression of CK15 in hair follicle stem cells was variable in the DLE lesions; there was normal to moderate CK15 expression at the bulge region of hair follicles when surrounded by mild or moderate inflammatory infiltrate (CD8+), but in cases of severe inflammation, CK15 expression was weak or absent.

CONCLUSIONS

The bulge region appears to be involved in this disease as part of a broader involvement of the hair follicles; it is secondarily affected by the surrounding inflammatory cell infiltrate. Expression of C8/144B diminished and was then absent, indicating either damage to stem cells or differentiation to help in the repair process. Damage to follicular stem cells may help to explain the irreversible alopecia and the scarring process which characterize this disease.

Use of reverse transcription polymerase chain reaction for the detection of Mycobacterium leprae in the slit-skin smears of leprosy patients

The relevance of bacterial index (BI) for understanding the prognosis of leprosy patients on treatment has been extensively debated, as it does not give a very clear idea of the viability of the bacteria in patients under treatment. Here we used slit-skin smear samples of leprosy patients to test the suitability for studying viability of Mycobacterium leprae using reverse transcription polymerase chain reaction (RT-PCR). For this purpose, we recruited 13 multibacillary (MB) leprosy patients (8 lepromatous and 5 borderline lepromatous). Of these, 7 were relapse cases, 3 were under treatment (MB-MDT), 2 were new cases and 1 had completed treatment. We carried out extraction of RNA using Trizol reagent (Life Technologies, UK) from the slit-skin smear samples from these patients. The RNA preparation was then used for the RT-PCR using Mycobacterium leprae-specific primers for the fragment of 16s ribosomal RNA gene. Samples from both the new cases, 4 suspected relapse cases and 1 patient under treatment showed positive RT-PCR results. Other 6 patients whose smear samples did not show any amplification by RT-PCR were on MB-MDT from 8 to 30 months. The usefulness of the technique needs to be validated using mouse footpad technique and also should be more extensively explored for studying the viability of M. leprae, the efficacy of treatment and the presence of other mycobacteria in the slit-skin smear samples.

Changes in caries diagnostic criteria over time related to the insertion of fillings. A comparative study

The attitude toward the need for restorative treatment of carious approximal tooth surfaces changed gradually during the 1970s. The depth of the carious lesions and an assessment of their progression rate was recommended to be the basis for decisions of whether preventive measures or restorative therapy should be applied. The aim of this study was to examine whether this view on caries therapy had influenced the treatment of posterior approximal surfaces and the choice of caries diagnostic criteria in studies on changes in caries prevalence over time. The material comprised posterior bitewing radiographs and records from the annual dental care of two groups of teenagers, born in 1964 an 1971, respectively. By means of an index system every approximal surface from the distal surface of the first premolars to the mesial surface of the second molars was given a caries diagnostic score on the basis of the depth of the lesions. The fillings inserted during the same treatment period as the radiographs had been taken were then grouped on the basis of the scores. At 13 years of age the percentage of fillings inserted in teeth with carious lesions extending into the outer and those extending into the inner half of the enamel was significantly higher in children born in 1964 than those born in 1971. This was also the case with fillings inserted at 16 years of age in teeth with lesions extending into the inner half of the enamel. On the basis of these results it was concluded that comparisons between the two groups with regard to approximal caries prevalence has to be based on criteria that cover both fillings and initial and frank carious lesions. This seems to have a general bearing on comparisons between groups of the same age but with different years of birth.

Dental caries on adjacent approximal tooth surfaces in relation to order of eruption

The occurrence of dental caries on adjacent approximal molar and premolar tooth surfaces was examined on posterior bitewing radiographs. More distal surfaces of the first permanent molars were decayed than adjacent mesial surfaces of the second molars. The appearance of dental caries on adjacent premolar surfaces was related to the order of eruption; the surface that had erupted first was likely to be decayed first. Reports from other studies on adjacent approximal surfaces indicate that this conclusion has a general bearing. It therefore seems important to increase the caries resistance of already erupted teeth by preventive means before and during the eruption of adjacent teeth.

Dry skin lesions with marked hair loss in a case of BL leprosy. A case report

Skin lesions of leprosy that are anaesthetic, well defined, limited in number and dry with significant hair loss generally fit into the paucibacillary (PB) spectrum. The bacteriological index (BI) is expected to be negative or low. We have reported a case who presented with such findings but whose BI readings were high. Together with the biopsy findings the patient was classified as having borderline (BL) leprosy. The role of the skin smear examination and the misleading nature of some clinical features are highlighted. The authors feel that skin smear examinations should be performed on all leprosy patients at the time of diagnosis.

Effect of different carriers preventive measures in children highly infected with mutans streptococci

The caries preventive effect of topical application of fluoride varnish (Duraphat), ferric-aluminum-fluoride solution (FeAlF) and chlorhexidine gel was compared in 2-yr clinical study. Children with more than 10(6) mutans steptococci per ml saliva were selected and a total of 189 13-yr-old children participated in the study. The children in the fluoride groups were treated every third month with either Duraphat or FeAlF-solution. In the chlorhexidine group children with more than 2.5 x 10(5) mutans streptococci per ml of saliva were treated every third month. The mean number of new decayed and filled tooth surfaces was 3.06 in the chlorhexidine group, 5.88 in the Duraphat group, 5.33 in the FeAlF group, and 6.34 in the control group. Thus supervised antimicrobial treatment can significantly reduce the incidence of dental (caries) in children with high numbers of mutans streptococci.

Direct detection of Neisseria gonorrhoeae with monoclonal antibodies characterized by serotyping reagents

A panel of monoclonal antibodies (MAbs) directed to outer membrane protein I were generated with the ultimate aim of detecting Neisseria gonorrhoeae in patient samples by a direct immunofluorescence (IF) test. In an initial evaluation of the sensitivity of these reagents, a cocktail of six IF MAbs recognized 491 (91%) of 540 gonococci isolates from several centers in Sydney, Australia. IF MAbs designated 185 and 228 recognized serovars of WI serogroup and IF MAbs 208, 210, and 312 recognized serovars of WII/III serogroup. IF MAb 198 recognized serovars within both serogroups. Three additional IF MAbs, designated 322, 323, and 330, were then generated by using strains which failed to react with the original MAb cocktail and which belonged to particular serovars. The new cocktail of nine IF MAbs recognized 96% of the gonococcal isolates, which incidentally contained representatives of serovars shown to have a worldwide distribution in previous studies. Although subtle differences were apparent in the reaction patterns found with coagglutination (serotyping) and IF, there nonetheless seems to be merit in the approach of continually evaluating the sensitivity of diagnostic reagents such as MAbs. This is especially true with an organism such as N. gonorrhoeae, which has the capacity to regularly alter the antigenic structure of its outer membrane proteins.

The MB fraction of creatine phosphokinase. An indicator of myocardial involvement in acute pericarditis

An elevated level of the MB fraction of creatine phosphokinase (CPK) with normal serum myoglobin and normal CPK values was found in a case of acute idiopathic pericarditis. The elevated serum CPK-MB isozyme is suggested to be an indicator of myocardial involvement accompanying acute pericarditis. The normal CPK and serum myoglobin values and the pattern of rapid decrease of CPK-MB level ruled out the possibility of acute myocardial infarction.

[Mammographic observations on the growth of untreated cancer of the breast (author's transl)]

Report on 21 primary breast cancers in 19 untreated women. The longest follow-up was 1074 days, the shortest 24 days. Doubling time of the tumors was calculated with Collins formula. The necessary assessment of the volume of tumors was calculated with a simple method. Doubling time differs greatly and, in parts, greatly exceeds published data. The radiologic development is surveyed. Collins formula is discussed in its strict interpretation starting from the volume of one tumor cell. Our own results lead to conclusions on the radiologic diagnosis of breast cancer. Usually diagnosis is immediately followed by therapy. Observations on the spontaneous course of, expecially primary, cancer of the breast are therefore scanty. Larger numbers of repeated mammography of the same tumor do not exist. Clinical examinations of growth belong to earlier times, the patients even to past centuries (Bloom 1964). Systematic investigations of this type cannot be defended on ethical grounds. In order to acquire insight into spontaneous growth of this cancer one has to rely on the few cases in whom operation wa5 not done for various reasons Here repeat mammography was possible. Such cases are important in practice since repeat mammography may have to be recommended by the radiologist, our own material will be discussed.