Open cholecystectomy: exposure and confidence of surgical trainees and new fellows

The laparoscopic approach to cholecystectomy has overtaken open procedures in terms of frequency, despite open procedures playing an important role in certain clinical situations. This study explored exposure and confidence of Australasian surgical trainees and new fellows in performing an open versus laparoscopic cholecystectomy.An online survey was disseminated via the Royal Australasian College of Surgeons to senior general surgery trainees (years 3-5 of surgical training) and new fellows (fellowship within the previous 5 years). The survey included questions regarding level of experience and confidence in performing an open cholecystectomy and converting from a laparoscopic to an open approach.A total of 135 participants responded; 58 (43%) were surgical trainees, 58 (43%) were fellows and 19 (14%) did not specify their level of training. Respondents who were involved in more than 20 open cholecystectomy procedures as an assistant or independent operator compared with those less exposed were more likely to feel confident to independently perform an elective open cholecystectomy (87.8% vs. 57.3%, P = 0.001), independently convert from a laparoscopic to open cholecystectomy (87.8% vs. 58.7%, P = 0.001) and independently perform an open cholecystectomy as a surgical consultant based on their level of exposure as a trainee (73.2% vs. 45.3%, P = 0.004).This study suggests the need to ensure surgical trainees are exposed to sufficient open cholecystectomies to enable confidence and skill with performing these procedures when indicated. Greater recognition of the need for exposure during training, including meaningful simulation, may assist

Radiological recovery protocols for outpatient liver biopsy, vertebroplasty, and peripheral angiography: a systemic review

Same-day discharges after interventional and diagnostic radiological procedures occur in many health facilities. Evidence-based recovery protocols are essential to provide high-quality nursing care. The systemic review examines recovery protocols for three outpatient radiological procedures to look at variations in clinical practice. A systematic review of recovery protocols for liver biopsy, vertebroplasty, and peripheral angiography with titles and abstracts of articles were reviewed for relevance, followed by sourcing of the full text for relevant articles and data extraction. In total, 450 articles pertaining to liver biopsy, 930 articles pertaining to vertebroplasty, and 735 articles pertaining to peripheral angiography were identified; 17, 8, and 13 articles, respectively, were deemed relevant. For liver biopsy, there were 13 primary research articles with the remainder from secondary sources (i.e., protocols and guidelines). All vertebroplasty articles were secondary. There were 10 primary research articles for peripheral angiography. Overall, 13 of 38 articles were nursing authored. Marked variations in recovery management, particularly with timing of observations and mobility, were observed. In conclusion, there is varied practice with a limited evidence base to guide postprocedural recovery protocols for liver biopsy, vertebroplasty, and peripheral angiography. Evidence-based review of current practice to inform protocol refinement is recommended

Factors affecting the performance of public out-patient services

Objective.: The delivery of public out-patient services is an essential part of complex healthcare systems, but the contribution of public out-patient services is often ill defined and poorly evaluated. The aim of this study was to identify and better understand those factors that may affect the performance of out-patient services to provide health service managers, clinicians and executives with a conceptual framework for future decision-making processes. Methods.: The present qualitative research involved five exploratory case studies. These case studies were conducted across two specialties at hospitals in the Metro North Hospital and Health Service in Queensland. Data were obtained from 38 interviews and 15 focus groups, and were analysed to identify common themes. Further analysis helped identify the most significant factors and build a conceptual framework for understanding the relationships between those factors and their effect on performance. Results.: Across both specialties there were 10 factors (scheduling, performance, service framework, categorisation or prioritisation of patients, internal and external stakeholders, resources, service demand, culture, system challenges and medical stakeholders) identified that may affect the performance of out-patient services. These factors were condensed into five core domains: culture, stakeholders, resources, demand and system reform. Conclusion.: Strategies to address the five core domains identified may provide a framework for sustainable improvement in the delivery of out-patient services. What is known about the topic?: The provision of specialist out-patient services is an essential element of health service delivery. Access to specialist services in the public sector is challenging because of the escalating demand associated with an increasing and aging demographic. The factors that may affect the delivery of out-patient services need to be addressed for long-term sustainable improvement. What does this paper add?: This paper provides a conceptual framework grounded in rigorous qualitative data analysis for understanding the internal and external factors that affect waiting times for specialist out-patient services. The results of this qualitative research indicate that there are five core domains that may influence waiting times in the public out-patient setting. When these domains are addressed at the strategic, tactical and operational levels, they have the potential to provide significant improvement in the delivery of out-patient services. What are the implications for practitioners?: This paper guides the attention of relevant stakeholders towards the five core domains identified (culture, stakeholders, resources, demand and system reform) that influence the performance of waiting times at the operational, tactical and strategic levels within the public hospital setting

Time to wait: a systematic review of strategies that affect out-patient waiting times

Objective: Out-patient waiting times pose a significant challenge for public patients in need of specialist evaluation and intervention. The aim of the present study was to identify and categorise effective strategies to reduce waiting times for specialist out-patient services with a focus on the Australian healthcare system. Methods: A systematic review of major health databases was conducted using the key terms ‘outpatient*’ AND ‘waiting time’, ‘process*’ AND ‘improvement in outpatient clinics’. Identified articles were assessed for their relevance by sequential review of the title, abstract and full text. References of the selected manuscripts were scanned for additional relevant articles. Selected articles were evaluated for consistent and emerging themes. Results: In all, 152 articles were screened, of which 38 were included in the present review. Numerous strategies identified in the articles were consolidated into 26 consistent approaches. Three overarching themes were identified as significantly affecting waiting times: resource realignment, operational efficiency and process improvement. Conclusions: Strategies to align resources, increase operational efficiency and improve processes provide a comprehensive approach that may reduce out-patient waiting times. What is known about the topic? Out-patient waiting times are a challenge in most countries that seek to provide universal access to health care for all citizens. Although there has been extensive research in this area, many patients still experience extensive delays accessing specialist care, particularly in the public health sector. The multiple factors that contribute to bottlenecks and inefficiencies in the referral process and affect patient waiting times are often poorly understood. What does this paper add? This paper reviews the published healthcare literature to identify strategies that affect specialist out-patient waiting times for patients. The findings suggest that there are numerous operational strategies that affect waiting times. These strategies may be categorised into three overarching themes (resource alignment, operational efficiencies and out-patient processes) that, when actioned in a coordinated approach, have the potential to significantly reduce out-patient waiting times. What are the implications for practitioners? This paper identifies evidence-based strategies for aligning resources, improving operational efficiency and streamlining processes, which may provide improvements to specialist out-patient waiting times for patients. Addressing the identified organisational, person-related, cultural and attitudinal factors will assist health system managers and health practitioners target the most appropriate improvement activities to reduce waiting times

Respiratory burns: A clinical review

Respiratory injury in burns occurs as a result of thermal, chemical or systemic inflammatory effects. Inhalation injury occurs in up to 40% of patients admitted to hospital following burns. Three stages in the evolution of inhalation injury are described. The early phase (first 48 hours) is associated with pulmonary edema, acute respiratory distress syndrome, airway obstruction, and carbon monoxide and cyanide toxicity. During the middle phase (days to weeks), pneumonia and venous thromboembolism may develop. Late sequelae (months to years post burn injury), while uncommon, include reactive airways dysfunction syndrome, bronchiolitis obliterans and tracheal stenosis. Specific interventions early in the management of inhalation injury are necessary to prevent worsening the injury and minimizing late sequelae

Perceptions of pregnant women regarding antidepressant and anxiolytic medication use during pregnancy

Objective: The objective of this study was to explore attitudes and decision-making by pregnant women regarding antidepressant and anxiolytic use during pregnancy. Method: An observational study at an outer metropolitan hospital in Brisbane, Queensland. Pregnant women presenting for their first antenatal clinic visit were invited to complete a questionnaire. Participants were asked about current or previous antidepressant/anxiolytic use, influences on drug decision-making and the adequacy of information received. Perceptions were measured on a 7-point Likert scale. Results: A total of 503 pregnant women were surveyed. The background prevalence of anxiety and depression was 30.0% (151), with 9.3% (47) respondents using antidepressant or anxiolytic medications during the current pregnancy. Of these 47 women, 68% ceased these medications during or while trying to become pregnant, most commonly due to potential side effects to the baby (16), health professional advice (8) and symptomatology that was under control (7). While the effect was modest, decision-making was most strongly influenced by general practitioners, family and the internet. Conclusions: Most women cease antidepressant/anxiolytic medication before and during pregnancy for reasons other than stability of condition. This study reveals an unmet need for accessible reliable information to guide pregnant women and their care providers

Antenatal and postnatal radiologic diagnosis of holocarboxylase synthetase deficiency: a systematic review

Background: Holocarboxylase synthetase deficiency results in impaired activation of enzymes implicated in glucose, fatty acid and amino acid metabolism. Antenatal imaging and postnatal imaging are useful in making the diagnosis. Untreated holocarboxylase synthetase deficiency is fatal, while antenatal and postnatal biotin supplementation is associated with good clinical outcomes. Although biochemical assays are required for definitive diagnosis, certain radiologic features assist in the diagnosis of holocarboxylase synthetase deficiency. Objective: To review evidence regarding radiologic diagnostic features of holocarboxylase synthetase deficiency in the antenatal and postnatal period. Materials and methods: A systematic review of all published cases of holocarboxylase synthetase deficiency identified by a search of Pubmed, Scopus and Web of Science. Results: A total of 75 patients with holocarboxylase synthetase deficiency were identified from the systematic review, which screened 687 manuscripts. Most patients with imaging (19/22, 86%) had abnormal findings, the most common being subependymal cysts, ventriculomegaly and intraventricular hemorrhage. Conclusion: Although the radiologic features of subependymal cysts, ventriculomegaly, intraventricular hemorrhage and intrauterine growth restriction may be found in the setting of other pathologies, these findings should prompt consideration of holocarboxylase synthetase deficiency in at-risk children

Changes in B-type natriuretic peptide and related hemodynamic parameters following a fluid challenge in critically ill patients with severe sepsis or septic shock

Severe sepsis or septic shock.The aim of this study is to examine the effect of a fluid challenge on the B-type natriuretic peptide (BNP) and the hemodynamic state.This observational study was conducted in an intensivist-led academic, mixed medical-surgical Intensive Care Unit.Focused transthoracic echocardiogram, plasma BNP, and hemodynamic measurements were recorded at baseline and following a 500 ml fluid challenge in thirty patients. Independent predictors of the percentage (%) change in stroke volume (SV) were sought. Next, these independent predictors were assessed for a relationship with the percentage change in BNP.Multiple linear regressions, Wilcoxon rank-sum test, -test, and Pearson's correlation were used. Data analysis was carried out using SAS. The 5% significance level was used.Using a multiple regression models, the percentage increase in SV was independently predicted by the percentage increase in mean arterial pressure, left ventricular end-diastolic volume/dimension (LVEDV/LVEDd), ejection fraction, and a decrease in Acute Physiology and Chronic Health Evaluation II score ( < 0.0001). Preload, measured using LVEDV1 (before the fluid challenge) was significantly larger in the fluid nonresponders (%SV increas