The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Life after PACE (Program of All-Inclusive Care for the Elderly): A retrospective/prospective, qualitative analysis of the impact of closing a nurse practitioner centered PACE site

BACKGROUND AND PURPOSE

Caring for frail older adults is a significant healthcare concern as the frailest 10% of the population account for over 70% of healthcare expenditures. Research reveals the use of comprehensive models, such as Program of All-Inclusive Care for the Elderly (PACE), leads to improved functional outcomes for participants and cost savings through decreased utilization. This study examines how closing a PACE program impacts health outcomes of previously enrolled participants.

METHODS

Data were collected every 6 months for 2 years via phone surveys on 34 former participants enrolled in the program at the time of the closure. The survey included questions regarding satisfaction with care, activities of daily living (ADLs), instrumental ADLs (IADLs), emergency department (ED) visits, hospitalizations, and use of home health services. Deaths and nursing home placements were monitored. Outcomes were compared during and post-PACE.

CONCLUSIONS

Higher numbers of ED visits, hospitalizations, and nursing home placements occurred post-PACE. PACE/post-PACE differences in ADL and IADL scores were not significant, nor were death rates. Higher satisfaction existed with PACE versus non-PACE care.

IMPLICATIONS FOR PRACTICE

Comprehensive care programs such as PACE are effective in reducing healthcare utilization, thus limiting costs. Further work is required to maintain, develop, and support comprehensive models similar to PACE.

A qualitative analysis of patient and family perspectives of palliative care

BACKGROUND

To provide truly patient-centered palliative care services, there is a need to better understand the perspectives and experiences of patients and families. Increased understanding will provide insight into the development of health care team competencies and organizational changes necessary to improve patient care.

OBJECTIVE

Our aim was to explore patient and family perceptions of palliative care services at the end of life or during serious illness and to identify facilitators and barriers to receipt of palliative care services.

METHODS

In-depth, semi-structured patient and family interviews were conducted, transcribed, and independently reviewed using grounded theory methodology and preliminary interpretations. A combined deductive and inductive iterative qualitative approach was used to identify recurring themes. The study was conducted in a physician-led, not-for-profit, multispecialty integrated health system serving three large, western, rural states. A purposive sample of 14 individuals who received palliative care services were interviewed alone or with their families for a total of 12 interviews.

RESULTS

Presence, Reassurance, and Honoring Choices emerged as central themes linked to satisfaction with palliative care services. Themes were defined as including health care professional attributes of respect, approachability, genuineness, empathy, connectedness, compassion, sensitivity, an ability to listen, good communication, provision of information, empowerment, and timeliness. Honoring Choices included those pertaining to treatment, spirituality, and family needs.

CONCLUSIONS

At end of life or during times of serious illness, patients and families identified behaviors of Presence, Reassurance, and Honoring Choices as important. According to patients/families, health care providers must be compassionate and empathetic and possess skills in listening, connecting, and interacting with patients and families.

Ethanol-like effects of thiopental and ketamine in healthy humans

The gamma-aminobutyric acid-A (GABA(A)) and N-methyl-D-aspartate (NMDA) receptors mediate aspects of the behavioural effects of alcohol. Prior studies reported drugs that block NMDA receptors or facilitate GABA(A) receptor function produce ethanol-like effects in humans. The purpose of this study was to compare the ethanol-related effects of two pharmacological agents with known NMDA and GABA(A) receptor activity. As part of an ongoing, larger study, 28 subjects (age, 21-30) with no personal or family histories of alcoholism were administered subanesthetic doses of the GABA(A) receptor agonist thiopental, the NMDA receptor antagonist, ketamine and placebo on three separate test days. Various ethanol-related measures were administered. At doses of thiopental and ketamine that produced similar levels of sedation and cognitive effects, both agents produced significant ethanol-like effects and subjective intoxication. However, the intensity of the ethanol-like effects of ketamine was greater than that of thiopental. In addition, ketamine produced alterations in perception that were not produced by thiopental. These data provide further support for a model where GABA(A) receptor facilitation may contribute significantly to ethanol effects associated with social drinking, whereas NMDA receptor antagonism may contribute to relatively greater extent to features of ethanol 'intoxication'.

Ethanol-glycine irrigating fluid for transurethral resection of the prostate in practice

OBJECTIVE

To evaluate the usefulness of a tracer of 1% ethanol in 1. 5% glycine in the early detection of irrigation fluid absorption during transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

Patients (120) undergoing TURP were irrigated with 1% ethanol in 1.5% glycine solution and their expired air tested for alcohol every 10 min during the procedure.

RESULTS

In all, 112 patients were assessed; over half of the patients absorbed the irrigation fluid and they had a significantly lower postoperative serum sodium concentration (P < 0.002). Fourteen patients (12.5%) absorbed over 500 mL and two (1.8%) developed clinical features of the TUR syndrome. The experience of the surgeon, the weight of resected chips and the operative duration were not significantly predictive of absorption.

CONCLUSION

A tracer amount of ethanol in the irrigant is reliable for detecting absorption. Irrigating fluid absorption was unpredictable, thus supporting the case for routine monitoring.

Cachexia and anorexia: cancer's covert killer

Cachexia and anorexia are often not observed at the time of diagnosis of cancer. While the initial medical intervention for cancer patients includes antitumor therapy and pain management, the consequences of cachexia and anorexia may be ignored, to the detriment of the patient's quality of life and his or her potential response to chemotherapy. The importance of a well-defined therapeutic strategy to treat cachexia is in order if the patient's overall wellbeing is to improve. Presented is a review of the pharmacological management of anorexia and cachexia, including a four-step ladder approach to medical management.

Inner-city adolescents' awareness of emergency contraception

OBJECTIVES

To assess the awareness of emergency contraception (EC) among inner-city adolescents attending a general primary health care clinic.

METHOD

197 patients filled out an anonymous 28-item survey on sexual activity, experience with contraceptives, attitude toward pregnancy, experience with pregnancy, awareness of and intent to use EC.

RESULTS

71% of the sample was sexually experienced; 90% had been active within six months of the clinic visit. While 81% of the sexually experienced segment of the sample had ever used contraceptives, 53% reported having had sex at least once during the past six months without using contraception. Fifty-seven percent "worried" following unprotected intercourse about a potential pregnancy; 32% of the sample had been involved in a pregnancy. Only 30% of the sexually experienced had heard of EC, but more than 87% stated they would use it if the need arose in the future.

CONCLUSIONS

Urban adolescents are at high risk for unintended pregnancy due to inconsistent contraceptive use and/or method failure. Level of awareness of EC was low in our sample, particularly as compared to adult women in the United States, and to women of all ages (including teenagers) in European countries. Intent to use EC was high, however, indicating a strong desire to avoid unintended pregnancy. Attention should be focused on increasing both adolescent awareness of and access to EC.

Nursing case management: affecting quality and cost

North Mississippi Health Services' nursing case management program has been deemed a success by all parties involved, especially the patients. High-risk patients with specific chronic health problems receive an enhanced level of care and experience significant reductions in cost, length of stay, and repeat hospitalizations. Quality of life for many of these patients is also improved. These outcomes are made possible by assigning a registered nurse to case manage or coordinate care for these patients.

Differential expression of SPARC and thrombospondin 1 in wound repair: immunolocalization and in situ hybridization

SPARC and thrombospondin 1 (TSP-1) are secreted glycoproteins expressed by similar types of cells in culture and in tissues. To compare these two proteins in vivo, we analyzed the differential expression of SPARC and TSP-1 during wound repair. Full-thickness incision wounds were made in rats and biopsied at 12 hr-14 days. Antibodies against SPARC revealed an increased proportion of immunoreactive fibroblastic cells at the wound edge at 3 days with maximal numbers at 7 days. In situ hybridization for SPARC produced results consistent with those of immunohistochemistry. With combined immunohistochemistry and in situ hybridization, some of the macrophages at the wound edge expressed SPARC mRNA. In contrast, immunoreactivity for TSP-1 was extracellular; expression at the wound edge was noted at 12 hr and was maximal at 1-2 days. TSP-1 mRNA was found in the thrombus, but not at the wound edge. In conclusion, SPARC and TSP-1 have contrasting roles during wound healing. SPARC expression from the middle through late stages of repair was consistent with its previously proposed functions in remodeling; in contrast, the transient expression of TSP-1 early in repair might facilitate the action of other proteins in recruitment and/or proliferation of cells in the healing wound.

DTPA renal scan assessment of renal allograft dysfunction in rats

The precise cause of allograft dysfunction after renal transplantation often cannot be established by non-invasive means. In clinical practice, radionuclide scans form an integral part of the clinician's armamentarium in the assessment of these patients. Unfortunately, in the clinical setting more than one pathological process may be responsible for the impaired function, making it difficult to correlate the scan appearances with the pathology. In this study in rats we compared the renal DTPA scan appearances of the various pathological processes which may cause renal allograft dysfunction in the immediate post-transplant period.

Evidence for dual infection of rabbits with the human retroviruses HTLV-I and HIV-1

Rabbits experimentally infected with HTLV-I and HIV-1 produced antibody to various viral proteins, and viral DNA could be detected by gene amplification using the polymerase chain reaction. HTLV-I genes were detected in cell lines derived from infected rabbits, and in some cases, both HIV-1 and HTLV-I DNA sequences were demonstrated in peripheral blood cells taken from rabbits one year after experimental infection. The polymerase chain reaction procedure was used to demonstrate the presence of HTLV-I gag, env and tax genes and HIV-1 gag and env genes. The amplified fragments were identified by size and by hybridization to specific probes. The ability of rabbits to support simultaneous infection with HTLV-I and HIV-1 will allow in vivo studies of the possible synergistic effects of these important human pathogens.

Partial expiratory flow-volume curves in young children

The purpose of this study was to examine the variability and possible uses of partial maximal expiratory flow-volume curves as a measurement of lung function in young children. Repeated partial flow-volume curves followed by measurement of resting lung volume were obtained from 45 healthy children and 12 with generally mild lung disease caused by cystic fibrosis; the age range was 3 to 6 yr. At each test session, each child completed 3 runs; for each run, values of functional residual capacity, maximal flow at functional residual capacity, and maximal flow compensated for lung size were obtained. Within-subject, day-to-day, and among-subject variabilities in the healthy group were very close to those reported for similar flow rates and lung volume in older subjects who are able to produce a full forced vital capacity. When compensated for lung volume, healthy boys had significantly lower flow rates than did girls. Test sensitivity and specificity were such that the cystic fibrosis and healthy groups were easily discernible. Among-subject variability of flow rates in healthy children was large enough to make the accurate detection of mild airways dysfunction in any given individual difficult.

Periosteal thickening as a manifestation of trauma in infancy

This paper reports the findings in a study of the incidence of periosteal elevation in children and its possible relationship to child abuse. Two separate sets of radiographs of the skeleton of children were taken for a variety of diagnostic purposes. The suspected abuse set consisted of 59 radiographs taken for suspected child abuse. The mean age for all patients examined was 1.22 years whereas, the mean age for patients with cortical thickening was 0.5 years, suggesting that cortical thickening occurs in a relatively young population. Cortical thickening was assessed by reason for examination. A significant difference (p = .05) was detected with 6/8 (75%) of the patients with cortical thickening from the suspected child abuse groups and only 2/8 (25%) of the patients from the seizure-diagnostic category. The two infants who were noted to have periosteal elevation but were not suspected of abuse had experienced unusual circumstances, one was wearing an abduction splint and the other was a severely hypotonic premature. It is our impression that periosteal thickening is not a normal finding in infants and does not represent a consequence of normal infant care practices. In each case in which cortical thickening was detected, there was evidence to suggest that the child had experienced abnormal or rough handling. As a result of these findings, we believe that cortical thickening of the long bones detected on radiograph is an indication of child abuse.