The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Disabled by the Discourse: Two families’ narratives of inclusion, exclusion and resistance in education

This qualitative study is based on the narratives of two families who each parent a young disabled child. It focuses on the children’s and families’ experiences of inclusion and exclusion within educational settings and the implications of these experiences for pedagogical change. New Zealand’s policy and curriculum contexts are considered in relation to education, disability and inclusion. I examine how the families’ perspectives and experiences interact with dominant, deficit discourses of disability. In my interpretation of the family narratives I identify particular disciplinary mechanisms that operate as tools and tactics of disabling power-knowledge production (Foucault, 1977, 1980). I argue that the policing of disabled children and families’ participation are primary processes and outcomes of these disciplinary mechanisms. The study uses a Disability Studies in Education (DSE) framework to understand and approach disability as socially, politically and culturally constructed. The assumptions underlying traditional Western educational knowledge and norms are critiqued from a counter-narrative based on experiences of disability. I use DSE research and literature to challenge knowledge regimes that interpret disability as an individual deficit requiring ‘special’ intervention and treatment. I argue that a ‘disability critique’ makes an important contribution to understanding the workings and effects of Western, Eurocentric knowledge traditions on children and families. This research further argues that exclusion is experienced by those within and outside of the dominant culture. I envisage the main research audience of this thesis to be early childhood and primary school teachers, teacher educators, early intervention and special education personnel, therapists and medical professionals. The stories and experiences of the families in this research may support teachers and other professionals to critically reflect on, and make changes to their thinking and practices. I hope to contribute to the growing body of research that can be used to support parents and families of disabled children in their efforts to promote educational change and to support the full inclusion of their children as valued people and learners within their educational contexts. I develop two main arguments in this research. The first is that in order to transform education, deficit discourses and their effects must be named and understood. The second is that New Zealand educationalists can build on existing, local frameworks to develop critical, narrative and relational pedagogies to transform exclusionary power relations and support inclusive experiences for all children and their families. I argue that approaches to disability and education based on a belief that exclusion is ‘inevitable’ and that creating a fully inclusive education system and society is an impossible dream, should be challenged and rejected. A lack of optimism and vision reproduces exclusion, and leads to weak reforms at best. Disabled children and their families deserve and have a right to an inclusive life and education and this requires people at all levels of society to take responsibility

Assessment of thrombin generation measured before and after cardiopulmonary bypass surgery and its association with postoperative bleeding

Background: Bleeding after cardiopulmonary bypass (CPB) is a major cause of morbidity and mortality and consumes large amounts of blood. Identifying patients at increased risk of bleeding secondary to hemostatic impairment may improve clinical outcomes by allowing early intervention. Methods: This present study recruited 77 patients undergoing CPB and measured coagulation screens, coagulation factors, TEG®, Rotem® and thrombin generation (TG) before surgery and 30 min after heparin reversal. The tests were analyzed to investigate whether they identified patients at increased risk of excess bleeding (defined as > 1000 mL) in the first 24 h postoperatively. Results: Patients who bled > 1000 mL had a lower: platelet count (P < 0.02), factors (F)IX, X and XI (P < 0.005), endogenous thrombin potential (ETP) and an initial rate of TG (P < 0.02) and higher activated partial thromboplastin time (aPTT) (P < 0.001) than patients who bled < 1000 mL. Receiver operating characteristic (ROC) analysis was significant for post-operative TG and aPTT (P < 0.001). Furthermore, reduced pre-operative TG was associated with increased postoperative bleeding (P < 0.02). Pre- and postoperative TG were correlated (q = 0.7, P < 0.001). TEG®, Rotem® and prothrombin time (PT) at either time point were not associated with increased bleeding. Conclusion: These data suggest that pre-operative defects in the propagation phase of hemostasis are exacerbated during CPB, contributing to bleeding post-CPB. TG taken both pre- and postoperatively could potentially be used to identify patients at an increased risk of bleeding post-CPB