The temporal evolution of a facial pain syndrome associated with neurovascular contact:a case report

BACKGROUND: Trigeminal autonomic cephalalgias are primary headaches characterized by unilateral pain and cranial autonomic symptoms. However, associated autonomic symptoms have also been reported in other headaches and facial pains, e.g. trigeminal neuralgia, with the clinical differentiation proving a complex task. CASE: A 54-year-old man presented with right-sided, sharp, intense facial pain in the distribution area of the trigeminal nerve. Pain duration was from seconds to a few minutes, and trigger factors included ipsilateral touching of the skin and hair. Over the next ten years, symptoms progressed and changed presentation, also displaying as right-sided, severe, orbital pain, lasting 60 to 90 minutes, with conjunctival injection and rhinorrhea. Neurological examination was normal. Numerous medications were tried with limited or no effect. In 2010, magnetic resonance imaging revealed a right-sided deviation of the basilar artery at the level of pons, creating neurovascular contact with the trigeminal nerve. Microvascular decompression was performed, and symptoms resolved within days. CONCLUSION: Differentiating between trigeminal autonomic cephalalgias and trigeminal neuralgia with autonomic symptoms can be challenging. The distinct change and evolution over time in the clinical presentation of the patient’s head pain suggests a temporal plasticity of the pain in head and facial syndromes, irrespective of underlying pathoanatomic features

Challenges in out-of-hospital cardiac arrest - A study combining closed-circuit television (CCTV) and medical emergency calls

AbstractThe aim of this study was to explore challenges in recognition and initial treatment of out-of-hospital cardiac arrest (OHCA) by using closed-circuit television (CCTV) recordings combined with audio recordings from emergency medical calls.MethodAll OHCA captured by CCTV in the Capital Region of Denmark, 15 June 2013–14 June 2014, were included. Using a qualitative approach based on thematic analysis, we focused on the interval from the victim's collapse to the arrival of the ambulance.ResultsBased on the 21 CCTV recordings collected, the main challenges in OHCA seemed to be situation awareness, communication and attitude/approach. Situation awareness among bystanders and the emergency medical dispatchers (dispatcher) differed. CCTV showed that bystanders other than the caller, were often physically closer to the victim and initiated cardiopulmonary resuscitation (CPR). Hence, information from the dispatcher had to pass through the caller to the other bystanders. Many bystanders passed by or left, leaving the resuscitation to only a few. In addition, we observed that the callers did not delegate tasks that could have been performed more effectively by other bystanders, for example, receiving the ambulance or retrieving an Automated External Defibrillator (AED).ConclusionCCTV combined with audio recordings from emergency calls can provide unique insights into the challenges of recognition and initial treatment of OHCA and can improve understanding of the situation. The main barriers to effective intervention were situation awareness, communication and attitude/approach. Potentially, some of these challenges could be minimized if the dispatcher was able to see the victim and the bystanders at the scene.A team approach, with the dispatcher responsible for the role as team leader of a remote resuscitation team of a caller and bystanders, may potentially improve treatment of OHCA

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London