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The Nuffield Department of Surgical Sciences is the academic department of surgery at the University of Oxford, and hosts a multidisciplinary team of senior clinical academic surgeons, senior scientists, junior clinicians and scientists in training.
FIGO postpartum intrauterine device initiative: Complication rates across six countries.
OBJECTIVE: To record and analyze complication rates following postpartum intrauterine device (PPIUD) insertion in 48 hospitals in six countries: Sri Lanka, India, Nepal, Bangladesh, Tanzania, and Kenya. METHODS: Healthcare providers were trained in counselling and insertion of PPIUD via a training-the-trainer model. Data were collected on methodology, timing, cadre of staff providing care, and number of insertions. Data on complications were collected at 6-week follow-up. Statistical analysis was performed to elucidate factors associated with increased expulsion and absence of threads. RESULTS: From May 2014 to September 2017, 36 766 PPIUDs were inserted: 53% vaginal and 47% at cesarean delivery; 74% were inserted by doctors. Follow-up was attended by 52%. Expulsion and removal rates were 2.5% and 3.6%, respectively. Threads were not visible in 29%. Expulsion was less likely after cesarean insertion (aOR 0.33; 95% CI, 0.26-0.41), following vaginal insertion at between 10 minutes and 48 hours (aOR 0.59; 95% CI, 0.42-0.83), and when insertion was performed by a nurse (aOR 0.33; 95% CI, 0.22-0.50). CONCLUSION: PPIUD has low complication rates and can be safely inserted by a variety of trained health staff. Given the immediate benefit of the one-stop approach, governments should urgently consider adopting this model.
Factors influencing the likelihood of acceptance of postpartum intrauterine devices across four countries: India, Nepal, Sri Lanka, and Tanzania.
OBJECTIVE: To examine the factors that positively influenced the likelihood of accepting provision of postpartum intrauterine devices (PPIUDs) across four countries: Sri Lanka, Nepal, Tanzania, and India. METHODS: Healthcare providers were trained across 24 facilities in counselling and insertion of PPIUDs as part of a large multicountry study. Women delivered were asked to take part in a 15-minute face-to-face structured interview conducted by in-country data collection officers prior to discharge. Univariate analysis was performed to investigate factors associated with acceptance. RESULTS: From January 2016 to November 2017, 6477 health providers were trained, 239 033 deliveries occurred, and 219 242 interviews were conducted. Of those interviewed, 68% were counselled on family planning and 56% on PPIUD, with 20% consenting to PPIUD. Multiple counselling sessions was the only factor resulting in higher consent rates (OR 1.30-1.39) across all countries. Odds ratios for women's age, parity, and cadre of provider counselling varied between countries. CONCLUSION: Consent for contraception, specifically PPIUD, is such a culturally specific topic and generalization across countries is not possible. When planning contraceptive policy changes, it is important to have an understanding of the sociocultural factors at play.
Clinical outcomes of postpartum intrauterine devices inserted by midwives in Tanzania.
OBJECTIVE: To assess the rate of complications following immediate postpartum insertion of intrauterine devices (IUDs) by trained midwives in Tanzania. METHODS: A prospective cohort study of women who underwent immediate postpartum IUD (PPIUD) insertions provided by midwives between December 31, 2016 and October 15, 2017. Midwives received standardized training via the FIGO initiative. Women who returned 6 weeks after delivery were evaluated for complications. Outcomes of interest were uterine infection, IUD expulsion, medical removal of IUD, and method discontinuation. RESULTS: There were 40 470 deliveries, 2347 (5.8%) PPIUD insertions, and 1013 (43.2%) women with a PPIUD who returned for a follow-up visit in the program-affiliated clinics. Midwives were providers in 596 (58.8%) of these follow-up cases and clinicians in 417 (41.2%) cases. All PPIUD insertions by midwives were transvaginal and among them 43 (7.2%) had PPIUD-related complications by the end of sixth week. These complications included 16 (2.7%) cases of uterine infection, 14 (2.3%) IUD expulsions, 26 (4.4%) IUD removals, and 33 (5.5%) with overall method discontinuation. Only one case had uterine infection severe enough to warrant hospitalization. CONCLUSION: PPIUD insertion by trained midwives in Tanzania compares favorably with results reported from other settings.
Randomised trial showing that lidocaine should be 'squirted' through a peritoneal drain before it is removed
A block randomised, non-blinded trial was performed to see if injecting lidocaine down a surgical drain could reduce the pain associated with its removal. A total of 36 women who had a closed suction intraperitoneal drain after elective gynaecological surgery were randomly allocated to conventional drain removal or drain removal 5 - 10 min after squirting 10 ml 2% lidocaine down the drain tube. We found that the pain associated with removal of the drain is variable but can be reduced significantly with lidocaine. The median pain score (95% range) during drain removal was 3.0 (2.5 - 5.0) in the group allocated lidocaine compared with 5.5 (4.6 - 6.5) if lidocaine was not used (median difference = 2.0; 95% confidence interval for the difference between medians is 1 - 3.5). In summary, the median pain score was halved by injecting lidocaine down the drain tubing before removal. © 2007 Informa UK Ltd.
Is there a correlation between vascular loops and unilateral auditory symptoms?
To assess whether contact of a vascular loop formed by the anterior inferior cerebellar artery (AICA) with the eighth cranial nerve correlated with unilateral auditory symptoms so as to produce a “vascular compression syndrome.” Prospective evaluation of patients with unilateral auditory symptoms using magnetic resonance imaging (MRI) scans to identify contact of a vascular loop with the eighth cranial nerve. One hundred twelve patients with idiopathic unilateral auditory symptoms (42 women and 70 men, mean age of 51 years) were evaluated with MRI. Location of the vascular loop and contact with the eighth cranial nerve were assessed in each case. The asymptomatic contralateral ears of the patients were used as controls. A power analysis had determined the size of the sample to be studied. The arterial loop was found to be in contact with the eighth cranial nerve in 28 (25%) of the 112 symptomatic ears and in 24 (21.4%) of the asymptomatic (control) ears. The statistical analysis revealed that the difference was not statistically significant. The results suggest that radiologic demonstration of contact between a vascular loop formed by the AICA and the eighth cranial nerve on MRI scans should be considered a normal anatomic finding and should not, on its own, be used to support the diagnosis of a “vascular compression syndrome.” © 1998 American Laryngological, Rhinological and Otalogical Society, Inc.
Communication Between Anaesthesia Providers for Clinical and Professional Purposes: A Scoping Review
Background: Anaesthesia providers in all contexts need to be able to communicate with colleagues to meet a variety of clinical and professional needs, including physical help, advice and support as well as learning, supervision and mentorship. Such communication can be regarded as a ‘social resource’ which underpins anaesthesia providers’ practice, but which has not itself been extensively studied. The objective of this scoping review is to provide an overview of the literature related to communication among anaesthesia providers to meet clinical and professional goals, focusing on the modalities, contexts and purposes or outcomes of such communication, as well as which providers are involved.Methods: We conducted a scoping review using the JBI methodology to examine the current literature available, searching the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL and Google Scholar. Papers were eligible for inclusion where they primarily addressed the subject of communication between trained anaesthesia providers for any clinical or professional purpose (excluding purely social interactions). Data were charted for the location and cadre of providers represented, means of communication and the situation, purposes and outcomes of communication.Results: 3872 records were identified for screening, and 225 papers were ultimately included. Communication was reported both as a variable influencing a wide range of clinical and nonclinical outcomes and as an outcome in itself which might be modified by other factors. It was also considered in a smaller group of studies as a resource with varying availability to anaesthesia providers. Physician providers were well represented in included documents, but nurse anaesthetists, clinical officers and other nonphysician, nonnurse anaesthetists were far less commonly included. The majority of identified studies on communication between anaesthesia providers originated from and related to high‐income countries.Conclusion: Communication between anaesthesia providers affects all aspects of their practice and has implications for both patient outcomes and workforce capacity. More research is necessary to understand how the availability of communication as a resource affects patient care and health worker well‐being, particularly in low‐ and middle‐income contexts and among nonphysician anaesthesia providers.
Protocol for a randomised phase 3 trial evaluating the role of Finasteride in Active Surveillance for men with low and intermediate-risk prostate cancer: the FINESSE Study.
BACKGROUND: Prostate cancer (PCa) is the most common male malignancy in the western world. Many men (40%) are diagnosed with localised low or intermediate-risk PCa, which is suitable for active surveillance (AS). AS affords careful monitoring to identify changes in otherwise non-life-threatening cancers. While AS reduces overtreatment (and quality of life impact), long-term compliance can be poor, with many men undergoing radical treatment after starting AS. METHODS AND ANALYSIS: Finasteride in Active Surveillance for men with low and intermediate-risk prostate cancer (FINESSE) is a prospective, open-label, two-arm, phase 3 trial, in which men with low or intermediate PCa are randomised (1:1) to receive AS with or without finasteride (5 mg once a day for 2 years). Randomisation is stratified by age and PCa risk. AS includes regular prostate-specific antigen testing, MRI scans and the offer of repeat biopsy (at 3 years, or if imaging suggests progression). Additional MRI scans and/or biopsies will be performed for biochemical or clinical indications. We aim to recruit 550 men (aged 50 to 75 years) from up to eight sites. Active outpatient follow-up will be for 3-5 years (depending on date recruited), followed by passive registry-based follow-up for up to 10 years. Primary outcome is adherence to AS. Secondary outcomes include rates and type of disease progression, treatments received (for PCa and benign prostatic enlargement), overall and PCa-specific mortality, an understanding of patients/professionals views of this approach and health-related quality of life. An external panel of experts blinded to allocation will review all AS cessation and progression events. Trial pathologist's and radiologist's, blinded to allocation, will review representative cases. Analysis is Intention to Treat. ETHICS AND DISSEMINATION: The study received Health Research Authority and South-Central Oxford Research Ethics Committee (14/12/2021: 21/SC/0349) and CTA/MHRA (29/12/2021: 21304/0274/001-0001) approvals. Results will be made available to providers and researchers via publicly accessible scientific journals. TRIAL REGISTRATION NUMBER: ISRCTN16867955.
Tray Rationalization in Pediatric Day Surgery: A Sustainable Quality Improvement Project.
BACKGROUND: Climate change poses a major threat to human health. The decontamination of used surgical equipment has been identified as a "carbon hotspot" in theaters. Surgical tray rationalization, which removes enough instruments to shrink the tray size, has a significant impact on carbon footprint, providing that there is not an increase in individually wrapped instruments used. METHODS: Using the sustainability in quality improvement framework, we rationalized the surgical tray used for pediatric open herniotomies at the Oxford University Hospitals John Radcliffe site. Data on instrument utilization and individually wrapped instruments were prospectively collected. Our tray redesign had no threshold utilization rate for instrument exclusion and focused on removing enough instruments to reduce the tray size. To calculate impact, we used established data on carbon emissions and financial cost and surveyed staff attitudes toward the redesigned tray. RESULTS: The tray at baseline included 55 instruments. The tray size was reduced by 50% with the removal of 22 instruments. Following our intervention, the median instrument utilization rate increased from 27% to 74% with no significant increase in individually wrapped instruments. The redesigned tray reduced carbon emissions from 4243 gCO2e to 2559 gCO2e and reduced financial cost from £48.66 to £29.63 per tray per decontamination cycle, approximating to 383,952 gCO2e and £4338.84 saved annually. All surveyed staff members (n = 25) agreed that the redesigned tray was easy to prepare and felt positive about the effort to reduce environmental impact. CONCLUSIONS: This quality improvement project shows the impact possible by using an established simple and effective framework that can be replicated by healthcare professionals without a background in planetary health to ensure future surgical tray rationalization efforts that maximize environmental impact.
Spatial transcriptomic analysis of virtual prostate biopsy reveals confounding effect of tissue heterogeneity on genomic signatures.
Genetic signatures have added a molecular dimension to prognostics and therapeutic decision-making. However, tumour heterogeneity in prostate cancer and current sampling methods could confound accurate assessment. Based on previously published spatial transcriptomic data from multifocal prostate cancer, we created virtual biopsy models that mimic conventional biopsy placement and core size. We then analysed the gene expression of different prognostic signatures (OncotypeDx®, Decipher®, Prostadiag®) using a step-wise approach with increasing resolution from pseudo-bulk analysis of the whole biopsy, to differentiation by tissue subtype (benign, stroma, tumour), followed by distinct tumour grade and finally clonal resolution. The gene expression profile of virtual tumour biopsies revealed clear differences between grade groups and tumour clones, compared to a benign control, which were not reflected in bulk analyses. This suggests that bulk analyses of whole biopsies or tumour-only areas, as used in clinical practice, may provide an inaccurate assessment of gene profiles. The type of tissue, the grade of the tumour and the clonal composition all influence the gene expression in a biopsy. Clinical decision making based on biopsy genomics should be made with caution while we await more precise targeting and cost-effective spatial analyses.