Surgical treatment of canine urethral prolapse via urethropexy or resection and anastomosis

OBJECTIVES

The objective was to report and compare the complications and recurrence rates of urethral prolapse in dogs when treated with urethropexy, resection and anastomosis or a combined surgical technique.

STUDY DESIGN

Retrospective study.

MATERIALS AND METHODS

A total of 86 dogs were identified from the medical records of 10 veterinary referral hospitals from February 2012 and October 2022. Dogs were included if they underwent surgery for a urethral prolapse at first presentation. Complications were classified as minor or major based on the necessity of further surgical intervention. Complications leading to death were also considered major complications.

RESULTS

Seventy-nine dogs were included, urethropexy (n=44), resection and anastomosis (n=27) and a combined surgical technique (n=8). Minor complications were identified in 41 of 79 dogs (51.9%): urethropexy 19 of 44 (43.2%), resection and anastomosis 18 of 27 (66.6%) and a combined surgical technique four of eight (50%). Major complications occurred in 23 dogs (29.1%), of which 21 were recurrence (26.6%). Recurrence occurred in 17 of 44 dogs following a urethropexy (38.6%), three of 27 dogs following resection and anastomosis (11.1%) and one of eight dogs treated with a combined surgical technique (12.5%). Recurrence of a urethral prolapse was significantly more likely following urethropexy in comparison to resection and anastomosis.

CLINICAL SIGNIFICANCE

Resection and anastomosis was associated with a lower recurrence rate in comparison to urethropexy for the surgical treatment of urethral prolapse. Based on these results, we concluded that resection and anastomosis may be preferable to urethropexy for treatment of urethral prolapse at first presentation. Urethropexy, and resection and anastomosis combined surgical technique was associated with low recurrence rate; however, further studies will be needed to clarify if it provides any benefit over resection and anastomosis.

Jejunal arteriovenous malformation and multiple acquired extrahepatic portosystemic shunts in a juvenile dog, presenting with melena

A juvenile dog referred with a 1-month history of persistent melena and severe anaemia, was diagnosed with a jejunal arteriovenous malformation, and multiple acquired extrahepatic portosystemic shunts. A midline coeliotomy was performed, the jejunal arteriovenous malformation was localised intraoperatively and was successfully removed via an enterectomy. Histopathology confirmed a true arteriovenous malformation. Despite the initial improvement, the patient developed seizure episodes secondary to hepatic encephalopathy 8 months after surgery. Fifteen months after surgery, the owner opted for euthanasia due to the ongoing seizure episodes. Post-mortem histologic examination of the liver showed features consistent with portal vein hypoplasia. A congenital arteriovenous malformation should be considered as a differential diagnosis in juvenile patients with a chronic history of haemorrhage from the gastrointestinal tract. In addition, acquired portosystemic shunts may occur in patients with portal vein hypoplasia and jejunal arteriovenous malformations.

LYMPHSPIRATION: A RETURN AND RESONANCE OF TWO LYMPHOLOGISTS AT OXFORD IN 2022

An "incurable" lymphologist reflects on his life, unanswered questions, patients who became friends, and lessons learned during a brief encounter with a lymphatic soul-mate.

165 PHARMACIST-LED MEDICINES RECONCILIATION: AN OBSERVATIONAL STUDY TO EVALUATE INFORMATION SOURCES AS A QUALITY INDICATOR OF THE SERVICE

Background

Medicines Reconciliation (MR) involves obtaining a Best-Possible Medication History (BPMH) and is essential for reducing medication errors and adverse events. Recommendations on how best to undertake MR range from utilising the patient alone to using ≥2 sources (in addition to the patient). Few studies evaluate the use of >1 source as a measure of MR quality.

Methods

This observational study was undertaken in a major teaching hospital that provides a dedicated pharmacist-led MR service. Eligible patients (aged ≥65 years, admitted through the Emergency Department) were randomly recruited. MRs were compiled using 2 sources and compared to individual 1-source MRs (both in addition to patient/carer interview). Additional Medication Discrepancies (AMDs), or differences between 1-source and 2-source MR, were assessed and potential predictors analysed.

Results

A total of 114 patients were included. Community pharmacy was the most frequently used and most accurate source (full agreement in 97.4% of BPMHs). Two-thirds of MRs would not differ if either of the two sources were used in isolation, alongside patient/carer interview. The remaining MRs identified a total of 85 AMDs (1–6 per MR). The majority were drug omissions (49.4%). Most were deemed “low” potential clinical significance (59%). Higher patient/carer reliability was associated with lower incidence (p=0.001) and fewer AMDs (p=0.001).

Conclusion

Contrary to some international guidelines, using >1 source (in addition to patient/carer interview) does not add value to the BPMH in the majority of cases.

Three heads are better than one: Psychiatry trainees' experiences of a psychotherapy written case supervision group with three co-supervisors

OBJECTIVE

The aim of this project was to evaluate the experiences of Royal Australian and New Zealand College of Psychiatrists (RANZCP) trainees in a regional centre who participated in a psychodynamic psychotherapy written case supervision group with three co-supervisors.

METHOD

A web-based survey was sent to RANZCP trainees. Descriptive statistics were performed, and written feedback was analysed.

RESULTS

A total of 8 of 10 eligible trainees completed the survey. All respondents stated that the group met their training needs. The average rating of feeling understood by supervisors was 91 (maximum 100). Positive feedback was received about the variety and breadth of experience provided by the co-supervisors. Trainees felt that 1:1 supervision was important to complement group supervision.

CONCLUSIONS

The supervision group model with three co-supervisors is competently meeting the training needs of RANZCP trainees as well as providing a deep learning experience. This model may be of use in other services, particularly in regional settings.

Gastroesophageal intussusception secondary to induction of emesis with subsequent development of septic pericardial effusion after corrective surgery

A juvenile boxer dog was diagnosed with gastroesophageal intussusception that occurred after the induction of emesis with apomorphine. A ventral midline coeliotomy and diaphragmotomy were performed and the intussusception was manually reduced. Despite initial satisfactory recovery, the dog was diagnosed with cardiac tamponade 1 week post-operatively. Escherichia coli was cultured from pericardial and pleural effusion samples. During subtotal pericardiectomy surgery the pericardium was found to be markedly thickened with adhesions to the epicardium, thoracic wall and diaphragm. Substantial haemorrhage and refractory hypotension necessitated the administration of a blood transfusion during surgery. The dog entered cardiac arrest in the immediate post-operative period and cardiopulmonary resuscitation was unfortunately unsuccessful. Gastroesophageal intussusception should be considered a possible severe adverse effect of administering apomorhine to induce emesis in dogs. Additionally, septic pericardial and pleural effusions may occur post-reduction of gastroesophageal intussusception.

A system dynamics approach for understanding community resilience to disaster risk

The Western Cape is a dynamic province that is disaster-prone, particularly the vulnerable urban communities in and around its environs. Such communities are more vulnerable to wildfire, flooding, pandemic, natural and human-made hazards because of poverty and, consequently, poor living conditions such as overcrowding and non-understanding of community resilience. The inability of these communities to understand community resilience and withstand adversities affects the sustainability of initiatives to develop them. This study aims to identify the mechanisms influencing the level of understanding of community resilience in a vulnerable community and to contribute to the understanding of community resilience to disaster risk. Fieldwork was conducted in an informal settlement in South Africa. The research study was conducted in two cycles of data collection and analysis. Data in the form of observation notes, document analysis and interviews were analysed using grounded-theory principles. Ten inter-related variables or mechanisms emerged from the analysis. The theoretical model consists of four reinforcing (R) feedback loops (R1, R2, R3 and R4), respectively, which explain how the understanding of community resilience in the informal settlement maps on to the relative achievement systems archetype. Negative reinforcing behaviour would explain the lack of understanding of community resilience, while positive reinforcing behaviour indicates how an understanding of community resilience develops. In addition, the variable with the leverage to improve the mechanisms influencing the understanding of community resilience was found to be the 'level of public education and awareness'. The theory of how these variables behave in context was represented as a qualitative system dynamics model.

The psychotherapeutic practice and potential of mental health nurses: an Australian survey

Objective Mental health nurses (MHNs) have a long, under-recognised, history of engaging in psychotherapeutic practice across the spectrum of mental illness and mental health problems. There is a need for a psychotherapeutic response for people with complex or serious mental health problems within the stepped care model and in response to increased need for psychotherapeutic responses to COVID-19 and natural disasters. This project sought to identify the educational preparation and self-reported competency of MHNs to clinically undertake psychotherapy across the continuum of care. Methods Situated within a larger mixed-methods study exploring how MHNs practice psychotherapy, adapt it to routine care and envisage the future, this paper reports the findings from a survey of MHNs regarding their educational preparation, experience and competence in modalities of psychotherapy and the application of psychotherapy with specific clinical groups. Results In all, 153 MHNs responded to a request to participate in the study. In this cohort, 86% of nurses had postgraduate qualifications specific to psychotherapy and 95% had worked for over 10 years in the mental health field and had hundreds of hours of training in psychotherapy. There was a high level of self-reported competence in working with people with serious mental health problems and at-risk or vulnerable groups. Conclusions Currently, MHNs are not recognised in federal funding arrangements to procure psychotherapeutic intervention for members of the Australian population who require it. MHNs ought to be recognised as independent providers based on both the psychotherapeutic skills they possess and their specialist clinical skills of working with people across the spectrum of mental health problems. Appropriately qualified MHNs need to be funded to use their skills in psychotherapy via access to appropriate funding arrangements, such as Better Access and the National Disability Insurance Scheme. What is known about the topic? MHNs do not appear to be recognised as having postgraduate knowledge and skills in psychotherapy and other psychotherapeutic interventions. This lack of recognition has resulted in the Australian public being unable to access subsidised specialist psychotherapeutic services by this highly experienced group. Most published commentary has been around the Mental Health Nurse Incentive Program, but, to date, scholarly work related to this program has not influenced public views and policy formation despite multiple favourable evaluations. What does this paper add? This study highlights that MHNs possess a largely unrecognised and valuable skill set in psychotherapy practice that they can adapt to work with people with complex needs. What are the implications to practitioners? MHNs possess skills and experience that, if recognised and funded, could be rapidly mobilised to improve consumer outcomes across the continuum of stepped care and in response to increased need during COVID-19.

Mental health nurse psychotherapists are well situated to improve service shortfalls in Australia: findings from a qualitative study

OBJECTIVE

This paper reports the capabilities of mental health nurse (MHN) psychotherapists in Australia and their perceptions on how to best utilize their skills.

METHOD

An MHN is a registered nurse with recognized specialist qualifications in mental health nursing. One hundred and fifty three MHNs completed an online survey; 12 were interviewed.

RESULTS

Three themes were derived from a qualitative analysis of the aggregated data: psychotherapy skills of MHN psychotherapists are under-utilized; these nurses bridge gaps between biomedical and psychosocial service provision; and equitable access to rebates in the primary care sector is an obstacle to enabling access to services.

CONCLUSIONS

MHN psychotherapists are a potentially valuable resource to patients in tertiary and primary health care. They offer capacity to increase access to specialist psychotherapy services for complex and high risk groups, while being additionally capable of meeting patients' physical and social needs. Equitable access to current funding streams including Medicare rebates can enable these outcomes.

The remarkable (Disappearing Act of the) mental health nurse psychotherapist

The aim of this Australian based qualitative study was to better understand key drivers for mental health nurses to undertake training in psychotherapy, and how these capabilities are integrated into their clinical practice. Open ended reposes from a national survey of 153 mental health nurses were supplemented with data from 12 semi-structured interviews of nurses with rich experience of integrating psychotherapy and mental health nursing capabilities. Key findings emerging from the thematic analysis were that mental health nurses are providing uniquely holistic psychotherapeutic services to consumers with often complex conditions, despite overtly hostile clinical and policy contexts. These often very well qualified mental health nurse psychotherapists are different to the traditional identity of either a nurse or psychotherapist. Recommendations from the findings of this study are that where appropriately qualified, mental health nurses be granted eligible provider status for existing Medicare funding items. Finally, training and building foundational capabilities in psychotherapy is highly recommended for all mental health nurses.

Diaphragmotomy to aid exposure during hepatobiliary surgery: a multi-centre retrospective review of 31 dogs

OBJECTIVES

To report surgical technique, intra- and post-operative complications, and short- and long-term outcome following canine hepatobiliary surgery in which exposure of intra-abdominal hepatobiliary lesions was aided by diaphragmotomy.

MATERIALS AND METHODS

Clinical records from four multi-disciplinary UK-based small animal referral hospitals were retrospectively reviewed for dogs in which diaphragmotomy was performed between January 2014 and May 2019. Signalment, diagnosis, surgery performed, diaphragmotomy technique, management of diaphragmotomy and pneumothorax, intra- and post-operative complications, short-term outcome and long-term outcome were recorded.

RESULTS

Thirty-one cases were identified. The most common hepatobiliary surgeries performed alongside diaphragmotomy were single hepatic lobectomy (14/31) and cholecystectomy (11/31). The most common diagnoses were hepatocellular carcinoma (10/31), gall bladder mucocoele (7/31) and hepatic nodular hyperplasia (4/31). Peri-operative mortality rate was 9.7% (3/31 cases) though none of these deaths were considered attributable to diaphragmotomy. Post-operative complications were encountered in 67.9% (19/28) cases that survived the peri-operative period, of which 25.0% (7/28) suffered complications that were considered attributable or likely attributable to diaphragmotomy. These seven complications resolved following non-surgical intervention. Follow-up was available for 26 of 28 patients that survived to discharge at a median of 4-months (range 10 days to 24 months) following surgery and revealed no evidence of complications related to diaphragmotomy.

CLINICAL SIGNIFICANCE

Diaphragmotomy appears safe and increases abdominal exposure of hepatobiliary lesions. The benefit of improved exposure must be carefully weighed up against the risks inherent in inducing pneumothorax.

Monitoring of drinking water quality using automated ATP quantification

A microfluidic based system was developed for automated online method for the rapid detection and monitoring of drinking water contamination utilising microbial Adrenosine-5'-Triphosphate (ATP) as a bacterial indicator. The system comprises a polymethyl methacrylate based microfluidic cartridge inserted into an enclosure incorporating the functions of fluid storage and delivery, lysis steps and real-time detection. Design, integration and operation of the resulting automated system are reported, including the lysis method, the design of the mixing circuit, the choices of flow rate, temperature and reagent amount. Calibration curves of both total and free ATP were demonstrated to be highly linear over a range from 2.5-5000 pg/mL with the limit of detection being lower than 2.5 pg/mL of total ATP. The system was trialled in a lab study with different types of water, with lysis efficiency being found to be strongly dependent upon water type. Further development is required before online implementation.

C-64 The Verbal Shift Social Assessment: Examining Differences in Emotion Recognition, Attention, and Event Prediction Between Children with HFASD, ADHD, and Typically Developing Peers

Objective

A pilot study of an experimental instrument extending the ‘verbal shift’ hypothesis indicating HFASD bias towards language over nonverbal cues (Grossman, Klin, Carter & Volkmar, 2000). We hypothesized HFASD differentiates from ADHD in social video interpretation in the degree of reliance on semantic content for correct responses.

Method

68 children ages 7-13 were recruited from the community (21 HFASD, 20 ADHD, 27 Control). Children viewed video pairs of social interaction. A “masked” version preserved prosody and visual cues, but not words. An “unmasked” version was naturalistic, with interpretable spoken language. Three questions were asked following each video scene (masked presented first): 1) the emotion of an actor, 2) a question to verify child was attending, 3) prediction about what might happen next. MANCOVA with post-hoc analysis was used to examine the between-group differences on performance as measured by the number of correct responses gained when the videos were unmasked.

Results

There were no group differences in age, gender, and WASI PRI. With WASI VCI controlled, emotion recognition and prediction questions differed significantly between groups (F = 3.907, p = .025, pEta2 = .109; F = 4.725, p = .012, pEta2 = .129), with ASD having the largest unmasked>masked correct gain compared to ADHD (p = .05; p = .029) and controls (p = .009; p = .004) There were no differences between ADHD and controls. The attention question did not differ among groups; focus on the details of the videos was similar in participants regardless of diagnosis.

Conclusions

Results of this pilot study indicate that emotion recognition and event prediction may be useful diagnostic predictors when differentiating HFASD from ADHD using naturalistic video stimuli.

Measuring the effectiveness of workplace health management programs: An Australian example

The workplace can provide opportunities to support workers in adopting and sustaining health enhancing behaviours. Health promotion programs based at the workplace need not only to achieve this goal but also the continuing support of the employers. This can best be achieved by demonstrating a return on their investment. The aim of this study therefore was to develop an integrated workplace health management program which could be associated with measurable outcomes related to benefitting the institution's "bottom line". This program was based in a metropolitan surgical hospital in Melbourne, Australia from 2006 to 2010 with a total workforce of 1400 employees aged 18-74 years (86% female 14% male), The program followed two key principles of 1) building safe and familiar support networks in order to build a workplace culture where all the workers felt valued. 2) Providing time for individual workers to focus on themselves as a means to achieve early intervention and management of injuries. Insurance data generated by the Workers Compensation Authority identified the following 'bottom line' benefits over three years: injury management costs reduced by 56%; number of compensation Injury claims dropped by 46%; time to return to work post injury reduced by 68%, and; a reduction. in premiums of 43% achieved over a six-year period. Insurers world-wide calculate workers' compensation insurance premiums on injury claims history. It is concluded that such data as these can offer a reliable and 'persuasive' measure of health and injury outcomes, in workplace interventions of this nature.

In Memoriam Prof. Prof. h.c. Dr. med. Michael Földi, January 10, 1920 - October 20, 2018 "Father of Lymphology"

In Memoriam: With deep sadness the world of Lymphology learned of the death of Prof. Prof. h.c. Dr. med. Michael Földi, a ground breaking pioneer of modern Lymphology. Words alone will never fully describe or capture the breadth and depth of Michael's contribution to our lymphatic knowledge and the legacy he has left for us all.

Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis

The infiltration of local anaesthetic agents has been shown to reduce post-tonsillectomy pain. A number of recent studies have shown that the addition of agents such as clonidine and dexamethasone improve the efficacy of nerve blocks and spinal anaesthesia. The aim of this review was to determine whether additives to local anaesthetic agents improve post-tonsillectomy outcomes. Four major databases were systematically searched for all relevant studies published up to August 2016. All study designs with a control group receiving local anaesthetic infiltration and an intervention receiving the same infiltration with an added agent were included in this review. These studies were then assessed for level of evidence and risk of bias. The data were then analysed both qualitatively and where appropriate by meta-analysis. We reviewed 11 randomised controlled trial (RCTs) that included 854 patients. Due to inconsistencies in the methods used to report outcomes, both quantitative and qualitative comparisons were required to analyse the extracted data. Overall, we found that dexamethasone, magnesium, pethidine and tramadol reduce post-operative pain and analgesia use, with dexamethasone in particular significantly reducing post-operative nausea and vomiting and magnesium infiltration significantly reducing the incidence of laryngospasm. This systematic review of RCTs provides strong evidence that the use of dexamethasone and magnesium as additives to local anaesthetics reduces post-tonsillectomy pain and analgesia requirement. There is limited evidence that pethidine and tramadol have a similar effect on pain and analgesia requirement. The studies in this pooled analysis are sufficiently strong to make a level one recommendation that the addition of magnesium to local anaesthetics reduces the incidence of laryngospasm, a potentially lethal post-operative complication. Review level of evidence: 1.

A Method for Catchment Scale Mapping of Groundwater-Dependent Ecosystems to Support Natural Resource Management (Queensland, Australia)

Immediate and foreseeable threats to groundwater-dependent ecosystems (GDEs) are widely acknowledged, many linked to altered groundwater regimes including changes in groundwater flow, flux, pressure, level and/or quality (Eamus et al. in Aust J Bot 54:97-114, 2006a). Natural resource managers and other decision-makers often lack sufficient information at an appropriate scale to understand the groundwater dependency of ecosystems and ensure that GDEs are adequately considered in decision-making processes. This paper describes a new catchment scale mapping method for GDEs based on the integration of local expert knowledge with detailed spatial datasets to delineate GDEs at a scale compatible with management and planning activities. This overcomes one of the key criticisms often levelled at broader scale mapping methods-that information from local and regional experts, with significant understanding of landscape processes and ecosystems, is not incorporated into the datasets used by decision-makers. Expert knowledge is conveyed in the form of pictorial conceptual models representing the components, processes and interrelationships of groundwater within a catchment and the ecosystems dependent on it. Each mapped GDE is linked to a pictorial conceptual model and a mapping rule-set to provide decision-makers with valuable information about where, how and why GDEs exist in a landscape.

Circulating CD56dim natural killer cells and CD56+ T cells that produce interferon-γ or interleukin-10 are expanded in asymptomatic, E antigen-negative patients with persistent hepatitis B virus infection

Infection with hepatitis B virus (HBV) can result in spontaneous resolution or chronic infection, which can remain asymptomatic or can progress to cirrhosis and/or hepatocellular carcinoma. The host immune response is thought to be a major determinant of the outcome of HBV infection and virus-specific cytotoxic T lymphocytes (CTL) can mediate immunity against the virus and cause liver pathology. Antigen-nonspecific innate lymphocytes may also contribute to HBV infection and liver disease, therefore, we examined the frequencies, phenotypes, cytolytic activities and cytokine profiles of circulating natural killer (NK) cells, CD1d-restricted invariant natural killer T (iNKT) cells and CD56(+) T cells in 102 asymptomatic HBV-infected patients and compared them with those in 66 uninfected control subjects. NK cells expressing low levels of CD56 (CD56(dim)) and CD56(+) T cells were significantly expanded in the circulation of HBV-infected patients compared with control subjects. CD1d expression and iNKT cell frequencies were similar in both groups. Despite these expansions, we did not detect augmented natural or cytokine-induced cytotoxicity in the HBV-infected subjects. All lymphocyte populations studied produced interferon-γ (IFN-γ) significantly more frequently when taken from HBV-infected patients compared with when taken from healthy controls. Additionally, NK cells from the patients more frequently produced interleukin-10. As our HBV-infected cohort consisted of asymptomatic patients with low viral loads, we propose that CD56(dim) NK cells and CD56(+) T cells control HBV infection by noncytolytic mechanisms.

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Background

Improving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.

Aims

(1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs.

Design

A mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy.

Results

Of the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.

Conclusions

Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.