Improving the surgical consenting process for patients with acute hip fractures: a pilot quality improvement project

Abstract Background: Consenting patients for trauma procedures following hip fracture is a key stage in the treatment pathway from admission to the operating theatre. Errors in this process can result in delayed procedures which may negatively impact patient recovery. The aim of this project was to identify and reduce errors in our consenting process for patients with capacity. Methods: Consent forms for all adult patients with capacity admitted for surgical repair of traumatic hip fracture were reviewed over a 4-week period. The baseline measurement (n = 24), identified errors in three key process measures: clarity of documentation, failure to record procedure-specific risks and not offering a copy of the consent form to the patient. Pre-printed stickers and targeted teaching were then introduced as quality improvement measures. Their impact was evaluated over subsequent 4-week review of the same patient demographic, with further refinement of these interventions being carried out and re-evaluated for a final cycle. Results: Cycle 1 (n = 26) following targeted teaching demonstrated a reduction in abbreviations from 38 to 20%, while doubling the documentation of discussion of procedure-specific risks from 31 to 72%. More patients were offered a copy of their consent form, rising from 12 to 48%. Cycle 2 (n = 24) saw the introduction of pre-printed “risk of procedure” stickers. Although clarity measures continued to improve, quality of pre-procedure risk documentation remained static while the number of forms being offered to patients fell to 8%. Conclusions: Our project would suggest that while pre-printed stickers can be useful memory aids, specific teaching on consenting produces the greatest benefit. The usage of such tools should therefore be limited, as adjuncts only to specific training. Keywords: Checklists, Control charts/run charts, Reminders, Surger

Sikh Patronage of Hindustani Music and Śabad Kīrtan in Colonial Punjab, 1857-1947

Despite cohabiting overlapping social spheres, north India’s music traditions are too often studied in isolation from one another, negating their inherent interrelatedness. Adopting a more inclusive approach with regard to two major traditions of north India, in this study I explore how both Hindustani music and śabad kīrtan, the sacred music of the Sikhs, enjoyed patronage under the prolific network of Sikh patrons that comprised an important aspect of colonial Punjab’s sociocultural landscape. The distinct influence of aspects of Punjabi society and culture, the unique circumstances surrounding the rise of Sikh patronage, combined with the prominent place of rāg music in Sikh religious tradition, gave rise to an unparalleled environment of music patronage that challenges many modern assumptions about the nature of Hindustani music and its social context during the colonial period. Attending to the Sikh courtly sphere, my study highlights how the developments of Hindustani music in colonial Punjab relate to the broader geopolitics surrounding the 1857 rebellion, harbouring critical insights in relation to the emergence of modern Punjabiyat. Exploring the circulation of Gurmukhi manuscripts on musicology in the Sikh religious sphere up until the late nineteenth century, I highlight a localised tradition of Hindustani musicology, its multivalent character, and links to local music practice. In response to the radical political and discursive shifts wrought by colonialism, I show how in the early twentieth century, through the novel medium of print, the musicological literary output of the Sikhs was co-opted under the new label of gurmat saṅgīt, functioning as a form of symbolic capital in process of Sikh identity formation. Finally, drawing on ethnographic as well as archival research on both sides of the Indo-Pak border, I highlight the multidimensional role of the rabābīs within Sikh religious tradition historically, thus challenging modern musicology-centric understandings of the śabad kīrtan tradition in the process. Attempting to transcend postcolonial discourse and boundaries, this thesis offers a lens through which we might better understand the significant intersection between music traditions in a region like Punjab whilst also offering an alternative perspective on prevailing conceptions of Punjabiyat

Identifying Risk Factors Associated with Inappropriate Use of Acid Suppressive Therapy at a Community Hospital

Purpose. By examining the prescribing patterns and inappropriate use of acid suppressive therapy (AST) during hospitalization and at discharge we sought to identify the risk factors associated with such practices. Methods. In this retrospective observational study, inpatient records were reviewed from January 2011 to December 2013. Treatment with AST was considered appropriate if the patient had a known specific indication or met criteria for stress ulcer prophylaxis. Results. In 2011, out of 58 patients who were on AST on admission, 32 were newly started on it and 23 (72%) were inappropriate cases. In 2012, out of 97 patients on AST, 61 were newly started on it and 51 (84%) were inappropriate cases. In 2013, 99 patients were on AST, of which 48 were newly started on it and 36 (75%) were inappropriate cases. 19% of the patients inappropriately started on AST were discharged on it in three years. Younger age, female sex, and 1 or more handoffs between services were significantly associated with increased risk of inappropriate AST. Conclusion. Our findings reflect inappropriate prescription of AST which leads to increase in costs of care and unnecessarily puts the patient at risk for potential adverse events. The results of this study emphasize the importance of examining the patient’s need for AST at each level of care especially when the identified risk factors are present

Does time of surgery influence the rate of false-negative appendectomies?:A retrospective observational study of 274 patients

Background Multiple disciplines have described an “after-hours effect” relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours. Methods Electronic operative records for all non-infant patients (age > 4 years) operated on at a single centre for presumed acute appendicitis were retrospectively reviewed over a 56-month period (06/17/2012–02/01/2017). The primary outcome measure of unknown diagnosis was compared between those performed in regular hours (08:00–17:00) or off hours (17:01–07:59). Pre-clinical biochemistry and pre-morbid status were recorded to determine case heterogeneity between the two groups, along with secondary outcomes of length of stay and complication rate. Results Out of 289 procedures, 274 cases were deemed eligible for inclusion. Of the 133 performed in regular hours, 79% were appendicitis, compared to 74% of the 141 procedures performed off hours. The percentage of patients with an unknown diagnosis was 6% in regular hours compared to 15% off hours (RR 2.48; 95% CI 1.14–5.39). This was accompanied by increased numbers of registrars (residents in training) leading procedures off hours (37% compared to 24% in regular hours). Pre-morbid status, biochemistry, length of stay and post-operative complication rate showed no significant difference. Conclusions This retrospective study suggests that the rate of unknown diagnoses for acute appendicitis increases overnight, potentially reflecting increased numbers of unnecessary procedures being performed off hours due to poorer diagnostic accuracy. Reduced levels of staffing, availability of diagnostic modalities and changes to workforce training may explain this, but further prospective work is required. Potential solutions may include protocolizing the management of common acute surgical conditions and making more use of non-resident on call senior colleagues

Designing Clinical Trials for Combination Immunotherapy: A Framework for GlioblastomaCombining Immunotherapy for Glioblastoma

Immunotherapy has revolutionized treatment for many hard-to-treat cancers but has yet to produce significant improvement in outcomes for patients with glioblastoma. This reflects the multiple and unique mechanisms of immune evasion and escape in this highly heterogeneous tumor. Glioblastoma engenders profound local and systemic immunosuppression and is remarkably effective at inducing T-cell dysfunction, posing a challenge to any immunotherapy-based approach. To overcome these mechanisms, multiple disparate modes of immune-oriented therapy will be required. However, designing trials that can evaluate these combinatorial approaches requires careful consideration. In this review, we explore the immunotherapy resistance mechanisms that have been encountered to date and how combinatorial approaches may address these. We also describe the unique aspects of trial design in both preclinical and clinical settings and consider endpoints and markers of response best suited for an intervention involving multiple agents

Weaving indigenous agricultural knowledge with formal education to enhance community food security : school competition as a pedagogical space in rural Anchetty, India

In communities from the remote rural regions of Anchetty, young learners’ informal learning experiences often come through interactions with local agriculture and the environment in which they and their families work and learn. These informal learning experiences are essential to what are otherwise called ‘indigenous knowledge systems’. For primary school students in Anchetty, the ways in which they engage in learning community-based agricultural knowledge are challenged by school-based formal education processes. Using a school competition as a pedagogical strategy for integrative space, this paper supports and explores the meaning and characteristics of indigenous agricultural knowledge (IAK)

Enhancing T Cell Chemotaxis and Infiltration in Glioblastoma

Glioblastoma is an immunologically ‘cold’ tumor, which are characterized by absent or minimal numbers of tumor-infiltrating lymphocytes (TILs). For those tumors that have been invaded by lymphocytes, they are profoundly exhausted and ineffective. While many immunotherapy approaches seek to reinvigorate immune cells at the tumor, this requires TILs to be present. Therefore, to unleash the full potential of immunotherapy in glioblastoma, the trafficking of lymphocytes to the tumor is highly desirable. However, the process of T cell recruitment into the central nervous system (CNS) is tightly regulated. Naïve T cells may undergo an initial licensing process to enter the migratory phenotype necessary to enter the CNS. T cells then must express appropriate integrins and selectin ligands to interact with transmembrane proteins at the blood–brain barrier (BBB). Finally, they must interact with antigen-presenting cells and undergo further licensing to enter the parenchyma. These T cells must then navigate the tumor microenvironment, which is rich in immunosuppressive factors. Altered tumoral metabolism also interferes with T cell motility. In this review, we will describe these processes and their mediators, along with potential therapeutic approaches to enhance trafficking. We also discuss safety considerations for such approaches as well as potential counteragents

Synthesis of crosslinked methacrylic acid-co-ethyleneglycol dimethacrylate polymers for the removal of copper and nickel from water

385-393Crosslinked copolymers based on methacrylic acid and ethyleneglycol dimethacrylate were prepared by suspension polymerization and investigated for their ability to remove copper and nickel at trace level from heavy metal polluted water. The copolymers were characterized for physico-chemical properties like surface area, porosity and scientific weight capacity. The Langmuir and Freundlich adsorption isotherms were used to represent the experimental data. Saphn-Schlunder and Morris-Webber models applied to determine the external and intraparticle diffusion coefficients. The absorption process follows first order kinetics and the specific rate constant Kr was obtained by the application of Lagergan equation. Concentration ratios of 1:60 and 1:30 have been achieved for nickel and copper respectively under dynamic conditions

Synthesis of crosslinked methacrylic acid-co-N,N'-methylene bis acrylamide sorbents for recovery of heavy metal ions from dilute solutions

371-377Several crosslinked porous copolymers of methacrylic acid-N,N'-methylene bis acrylamide were synthesized by suspension polymerisation using benzoylperoxide as the initiator. They were characterized for physico-chemical properties like, surface area, porosity and scientific weight capacity. The sorbents were further studied for adsorption of nickel and copper ions from spiked metal ion solutions in static and dynamic conditions. Concentration ratios of 1:60 and 1:30 have been achieved for nickel and copper ions respectively