Expedited Recovery Pain Management Pathway for Minimally Invasive Repair of Pectus Excavatum (MIRPE)

Introduction: Pectus Excavatum (PEX) is the most common anterior chest wall deformity. While minimally invasive repair of pectus excavatum (MIRPE) has improved perioperative outcomes, there continue to be opportunities to optimize postoperative pain management and reduce length of stay (LOS). We compared the impact of a multimodal expedited protocol utilizing a combination of systemic and regional analgesia (with single shot paravertebral truncal blocks), along with coping techniques (such as meditation), and physical therapy, with systemic analgesia on LOS and opioid requirements. Methods: 51 patients underwent MIRPE with an expedited recovery protocol in comparison with 112 historical control patients at a single center over 18 years. LOS and opioid analgesic morphine milliequivalent (MME) were compared. Data were stratified for age, biological sex, and Haller index (HI) to identify potential confounding variables. Results: There was no difference in age or HI between cohorts. LOS was reduced by 59.1% in the enhanced recovery group compared to the historic group (1.8 days vs 4.4 days, SD=0.5664 and 0.9503 respectively, P\u3c 0.0001). On postoperative day (POD)1, the expedited patients required an average of 100.7 MME (IQR 61.65-124.3) compared to 123.6 MME (IQR 79.5-161.1) for historic control patients (P=0.04). Cumulative MME for POD0-2 was 34.8% less in the expedited recovery patients (P= Conclusions: This MIRPE expedited recovery pain protocol using a standardized multimodal analgesia strategy and regional anesthesia is a safe and effective therapeutic plan that results in decreased opioid analgesic requirements and a significantly decreased LOS

Necrotizing Enterocolitis following Gastroschisis Repair: An Update

Purpose: Necrotizing enterocolitis (NEC) is a known complication of gastroschisis with an incidence above the expected rate in the neonatal population. While many physicians today are aware of this association, the last publication to explore this association in detail and identify possible risk factors of NEC in gastroschisis patients was published over twenty years ago. From our large database of patients with gastroschisis managed by a single group of pediatric surgeons, we reviewed our experience and the recent literature to update what is known about gastroschisis and NEC. Methods: From 2001 to 2017, a gastroschisis registry was maintained. Data from 218 gastroschisis patients were reviewed. Patient demographics and hospital course were reviewed. Patients with confirmed NEC were compared to those without NEC. Results: Two hundred eighteen patients were born with gastroschisis during the time frame of this study. We observed a 5% rate (11 of 218) of NEC. Five patients (45%) developed recurring NEC and 4 patients (36%) were readmitted for NEC development following initial discharge. Variables associated with NEC included low gestational age (P=0.016) and low birth weight (P=0.003). Patients born prior to 37 weeks gestation had a 4.8 times greater risk of developing NEC than those born at term. Rates of IUGR were not statistically different between NEC and non-NEC patients. The method of delivery (cesarean vs vaginal), use of a silo, and form of nutrition were not significantly associated with NEC development. Conclusions: The overall incidence of NEC has decreased compared to earlier reports. NEC does complicate the hospital course for patients, significantly increasing duration of in-hospital treatment. NEC in gastroschisis differs in comparison to traditional NEC, presenting later in life. Risk factors identified include low gestational age and low birth weight. Avoiding elective preterm deliveries may decrease the rate of NEC in gastroschisis

The Debrisoft ® monofilament debridement pad for use in acute or chronic wounds: A NICE medical technology guidance

As part of its Medical Technology Evaluation Programme, the National Institute for Health and Care Excellence (NICE) invited a manufacturer to provide clinical and economic evidence for the evaluation of the Debrisoft ® monofilament debridement pad for use in acute or chronic wounds. The University of Birmingham and Brunel University, acting as a consortium, was commissioned to act as an External Assessment Centre (EAC) for NICE, independently appraising the submission. This article is an overview of the original evidence submitted, the EAC’s findings and the final NICE guidance issued. The sponsor submitted a simple cost analysis to estimate the costs of using Debrisoft® to debride wounds compared with saline and gauze, hydrogel and larvae. Separate analyses were conducted for applications in home and applications in a clinic setting. The analysis took an UK National Health Service (NHS) perspective. It incorporated the costs of the technologies and supplementary technologies (such as dressings) and the costs of their application by a district nurse. The sponsor concluded that Debrisoft® was cost saving relative to the comparators. The EAC made amendments to the sponsor analysis to correct for errors and to reflect alternative assumptions. Debrisoft® remained cost saving in most analyses and savings ranged from £77 to £222 per patient compared with hydrogel, from £97 to £347 compared with saline and gauze, and from £180 to £484 compared with larvae depending on the assumptions included in the analysis and whether debridement took place in a home or clinic setting. All analyses were severely limited by the available data on effectiveness, in particular a lack of comparative studies and that the effectiveness data for the comparators came from studies reporting different clinical endpoints compared with Debrisoft®. The Medical Technologies Advisory Committee made a positive recommendation for adoption of Debrisoft® and this has been published as a NICE medical technology guidance (MTG17).The Birmingham and Brunel Consortium is funded by NICE to act as an External Assessment Centre for the Medical Technologies Evaluation Programme

Veterinarians’ knowledge and experience of avian influenza and perspectives on control measures in the UK

Background: The scale of the outbreak of highly pathogenic avian influenza (HPAI) in 2021–23 due to the influenza A/H5N1 virus is unprecedented. Methods: An online survey was designed to explore veterinarians’ experiences of and confidence in treating avian species, experiences of dealing with suspected HPAI and perspectives on control measures in the UK. The survey ran between December 2021 and March 2022. Results: Survey responses were received from 26 veterinarians. Although veterinarians are well placed to communicate HPAI-related information and guidance, a lack of confidence around treating birds and dealing with suspected cases of HPAI represent key barriers for non-specialist practices, and this limits opportunities to educate clients. Limitations: This study presents the views of a small group of self-selected respondents and may over-represent veterinarians with existing interests in avian species and/or avian influenza and who engage with online fora. Conclusions: Improved training and resources designed to increase confidence with avian species, along with guidance on diagnosing and reporting notifiable diseases, are needed for first opinion practices. Governing bodies should clarify regulations on treating birds in veterinary practices when HPAI outbreak numbers are high

Interrater Reliability of mHealth App Rating Measures: Analysis of Top Depression and Smoking Cessation Apps

Background: There are over 165,000 mHealth apps currently available to patients, but few have undergone an external quality review. Furthermore, no standardized review method exists, and little has been done to examine the consistency of the evaluation systems themselves. Objective: We sought to determine which measures for evaluating the quality of mHealth apps have the greatest interrater reliability. Methods: We identified 22 measures for evaluating the quality of apps from the literature. A panel of 6 reviewers reviewed the top 10 depression apps and 10 smoking cessation apps from the Apple iTunes App Store on these measures. Krippendorff’s alpha was calculated for each of the measures and reported by app category and in aggregate. Results: The measure for interactiveness and feedback was found to have the greatest overall interrater reliability (alpha=.69). Presence of password protection (alpha=.65), whether the app was uploaded by a health care agency (alpha=.63), the number of consumer ratings (alpha=.59), and several other measures had moderate interrater reliability (alphas>.5). There was the least agreement over whether apps had errors or performance issues (alpha=.15), stated advertising policies (alpha=.16), and were easy to use (alpha=.18). There were substantial differences in the interrater reliabilities of a number of measures when they were applied to depression versus smoking apps. Conclusions: We found wide variation in the interrater reliability of measures used to evaluate apps, and some measures are more robust across categories of apps than others. The measures with the highest degree of interrater reliability tended to be those that involved the least rater discretion. Clinical quality measures such as effectiveness, ease of use, and performance had relatively poor interrater reliability. Subsequent research is needed to determine consistent means for evaluating the performance of apps. Patients and clinicians should consider conducting their own assessments of apps, in conjunction with evaluating information from reviews

UK Flockdown: Exploring the knowledge, attitudes and practices of backyard poultry keepers surrounding Highly Pathogenic Avian Influenza (HPAI)

The scale of the current outbreak of highly pathogenic avian influenza (HPAI) due to the A/H5N1 virus in the United Kingdom is unprecedented. In addition to its economic impact on the commercial poultry sector, the disease has devastated wild bird colonies and represents a potential public health concern on account of its zoonotic potential. Although the implementation of biosecurity measures is paramount to reducing the spread of HPAI in domestic and commercial settings, little is known about the attitudes and perspectives of backyard poultry keepers who often keep their flocks in close proximity to the public. A large nationwide survey of backyard poultry keepers was undertaken in December 2021–March 2022, contemporaneous with the enforcement of an Avian Influenza Prevention Zone (AIPZ) and additional housing measures in England, Scotland and Wales. The survey explored keepers’ understanding of the clinical manifestations of HPAI, compliance with housing and biosecurity measures, attitudes towards obligatory culling on confirmation of HPAI in their flocks, and the potential use of vaccination to control HPAI. Summary statistical analysis of the closed question responses was supplemented with qualitative data analysis and corpus linguistic approaches to draw out key themes and salient patterns in responses to open text questions. Survey responses were received from 1,559 small-scale poultry keepers across the United Kingdom. Awareness of the HPAI outbreak was very high (99.0%). The majority of respondents learned of it via social media (53%), with Defra (49.7%), British Hen Welfare Trust (33.8%) and the APHA (22.0%) identified as the principal sources of information. Analysis revealed that backyard keepers lacked knowledge of the clinical signs of avian influenza and legal requirements relating to compliance with biosecurity measures. Some respondents dismissed the seriousness of HPAI and were unwilling to comply with the measures in force. The issue of obligatory culling proved highly emotive and some expressed a lack of trust in authorities. Most respondents (93.1%) indicated a willingness to pay for vaccination if the option was availableCommunications on biosecurity measures that are relevant to large-scale industrial setups are inappropriate for backyard contexts. Understanding the barriers that backyard keepers face is essential if official agencies are to communicate biosecurity information effectively to such groups. Lack of trust in authorities is likely to make elimination of the virus in the UK difficult. We make recommendations for tailoring HPAI-related information for backyard contexts, to aid future HPAI control measures in the UK

A new typology of forms of international collaboration

Purpose – The purpose of this paper is to analyse the inconsistent use of terminology in international collaboration, and develop a clearer typology that reflects the commercial and practical realities of modern business. Design/methodology/approach – A critique of existing typologies provided the basis for the development of a more practical framework. The new typology was populated with the most prominent collaborative forms to emerge from the analysis of academic research and commercial practice. Findings – “Structure” and “purpose” emerged as the most logical determinants in differentiating and classifying collaborative forms. Actual commercial ventures mapped on to the new typology demonstrate a good fit between these two considerations and the collaboration strategies adopted. Originality/value – This work contributes much needed clarity in differentiating and classifying forms of collaboration. The key determinants of structure and purpose reflect more accurately the commercial and practical realities of modern business, and offer practitioners and researchers a logical means of mapping and analyzing collaboration strategy