Publications by authors named "Khurram Khan"

72 Publications

Utilisation of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Manoeuvre for Transcystic Intrahepatic Access.

Ann Surg 2021 Apr 14. Epub 2021 Apr 14.

University Hospital Monklands, Lanarkshire, Scotland, UK NHS Greater Glasgow and Clyde, Glasgow, UK.

Objective: This study aims to examine the indications, techniques and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the Wiper Blade Manoeuvre (WBM) for transcystic intrahepatic choledochoscopy.

Summary Background Data: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particulary with the increasing role of transcystic exploration.

Methods: The indications, techniques and operative and postoperative data on choledeochoscopy collected prospectively during 1320 transcystic and choledochotomy explorations were analysed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochocoscopes.

Results: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilised more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. 20 retained stones (2.1%) were encountered but no choledochoscopy related complications.

Conclusions: Choledochoscopy should always be performed during a choledochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilised in over 50% of explorations, increasing their rate of success. When attempted, the transcystic Wiper Blade Manoeuvre achieves intrahepatic access in 70-80%. It should be part of the training curriculum.
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http://dx.doi.org/10.1097/SLA.0000000000004912DOI Listing
April 2021

Empowerment of Parents of Children With Cleft Lip and Palate by Objective Scoring of Patient Information Websites.

J Craniofac Surg 2021 Mar 22. Epub 2021 Mar 22.

Birmingham Women's and Children's Hospital NHS Trust, Birmingham, United Kingdom.

Background: Whether a new diagnosis or for ongoing care, the Internet is now an established and massively frequented resource for parents and patients with cleft lip and/or palate. The purpose of this study was to assess the correlation between the first 50 ranked websites for cleft lip and palate via the Google search engine versus those ranked with an objective patient information scoring tool.

Methods: The first 50 websites ranked by Google were recorded for the search items "Cleft Lip," "Cleft Palate" and "Cleft Lip and Palate." Quality assessment was performed using the DISCERN score, an objective and validated patient information website scoring tool. The Google rank was compared to the DISCERN rank to assess for correlation. The top five websites for each search item were then ranked by blinded cleft health professionals for quality.

Results: Based on Google ranking, 36% of websites were the same across the search terms used. The DISCERN ranking scores demonstrated no evidence of positive or negative correlation when compared to Google ranking. In the top 10 DISCERN ranked websites for each search item, 4 websites appear in the top 10 Google rankings.

Conclusion: This is the first study that demonstrates that high-quality information on cleft lip and palate is available on the Internet. However, this may be difficult and confusing for parents and patients to access due to the ranking system used by internet search engines. Cleft healthcare professionals should be aware of these problems when recommending websites to families and patients.
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http://dx.doi.org/10.1097/SCS.0000000000007631DOI Listing
March 2021

Case report: incidental findings of COVID-19 infection on positron emission tomography/computed tomography for staging of a giant gastric gastrointestinal stromal tumor.

Pan Afr Med J 2020 11;35(Suppl 2):28. Epub 2020 May 11.

Department of Surgery, University Hospital Hairmyres, East Kilbride, Scotland, UK.

We report the incidental finding of COVID-19 in a 59-year-old male, with no significant cardiorespiratory past medical history who underwent a fluorodeoxyglucose positron emission tomography (FDG-PET) scan for investigation of a likely gastric gastrointestinal stromal tumor (GIST). There may be significant discrepancies between clinical symptoms and radiological severity with COVID-19 infection. FDG-PET scanning has the potential to complement traditional radiological imaging in COVID-19 in diagnosis of subclinical diagnosis or early stage disease, as well as monitoring disease progression.
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http://dx.doi.org/10.11604/pamj.supp.2020.35.2.23167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875735PMC
March 2021

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates.

Surg Endosc 2021 Feb 2. Epub 2021 Feb 2.

Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.

Background: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.

Methods: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.

Results: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.

Conclusion: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.
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http://dx.doi.org/10.1007/s00464-021-08316-1DOI Listing
February 2021

The ABCESS System for Chronic Wound Management: A New Acronym for Lower Extremity Wound Management.

Wounds 2020 Nov;32(suppl 11):S1-S25

Resident, Temple University School of Podiatric Medicine, Philadelphia, PA.

The authors propose a new acronym to promote teaching and learning evidence-based care for wounds of the lower extremity, maximizing healing potential, and assuring the ability to adapt to everchanging new technologies. ABCESS is a comprehensive framework for the assessment of a patient with a lower extremity wound. Wound care clinicians benefit from a system that is broad enough to include new guidelines and technologies as they appear. The TIME/DIME model has been used for many years to assist clinicians in thorough wound bed management. In order to expand the model to be able to address all aspects of lower extremity wound healing, ABCESS was developed. TIME has recently also been expanded to TIMERS in an attempt to address this. The ABCESS acronym was originally developed at the Temple University School of Podiatric Medicine to use as a teaching tool and organizational aid for students of wound healing. Each letter was used as a framework to aid the wound care clinician in performing a complete assessment of the patient with chronic wounds of the lower extremity: All of the patient, including a complete history, physical assessment, and systemic disease overview (with nutrition) to assess the physical aspects of the patient presenting with a wound; wound Bed management to include Bioload, Biofilm, cellular assessment of Biomarkers using polymerase chain reaction/DNA analysis, and wound Biopsy; Circulation to include arterial, venous, and lymphatic circulation; Edema, Exudate, and Erythema management focusing on dressing and compression choices; Skin protection and treatment to include wound edge, periwound skin, and offloading management; Social, Societal, and Spiritual factors, including assessment of the immediate social environment, the wider societal limiting factors, and personal, spiritual, and psychological issues affecting this patient's wound care.
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November 2020

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure.

Surg Endosc 2020 Oct 16. Epub 2020 Oct 16.

Centro Hospitalar de Leiria, Leiria, Portugal.

Background: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.

Aims And Methods: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.

Results: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.

Conclusion: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.
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http://dx.doi.org/10.1007/s00464-020-08093-3DOI Listing
October 2020

Angiotensin converting enzyme inhibitors do not increase the risk of poor outcomes in COVID-19 disease. A multi-centre observational study.

Scott Med J 2020 Nov 1;65(4):149-153. Epub 2020 Sep 1.

ST6 in General Surgery, Department of Surgery, University Hospital Hairmyres, UK.

Background And Aims: Hypertension is associated with an increased risk of severe outcomes with COVID-19 disease. Angiotensin Converting Enzyme (ACE) inhibitors are widely used as a first line medication for the treatment of hypertension in the UK, although their use was suggested in early reports to increase the risk associated with SARS-CoV-2 infection.

Methods: A prospective cohort study of hospitalised patients with laboratory confirmed COVID-19 was conducted across three hospital sites with patients identified on the 9th April 2020. Demographic and other baseline data were extracted from electronic case records, and patients grouped depending on ACE inhibitor usage or not. The 60-day all-cause mortality and need for intubation compared.

Results: Of the 173 patients identified, 88 (50.8%) had hypertension. Of these 27 (30.7%) used ACE inhibitors. We did not find significant differences in 60-day all-cause mortality, the requirement for invasive ventilation or length of stay between our patient cohorts after adjusting for covariates.

Conclusion: This study contributes to the growing evidence supporting the continued use of ACE inhibitors in COVID-19 disease, although adequately powered randomised controlled trials will be needed to confirm effects.
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http://dx.doi.org/10.1177/0036933020951926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468667PMC
November 2020

Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions.

JSLS 2020 Jul-Sep;24(3)

Department of General Surgery, University Hospital Monklands.

Background & Objective: Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS.

Methods: A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared.

Results: Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, = .000) and more patients underwent emergency LC (50.7% vs 41.5%, = .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% = .000, 30.9% vs 3.7% = .000, 1.8% vs 0.9% = .000, respectively). There was no significant difference in the open conversion rate or complications.

Conclusion: HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.
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http://dx.doi.org/10.4293/JSLS.2020.00043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434399PMC
January 2021

Impact of the COVID-19 pandemic on core surgical training.

Scott Med J 2020 Nov 9;65(4):133-137. Epub 2020 Aug 9.

ST6 in General Surgery, University Hospital Hairmyres, East Kilbride, Scotland, UK.

Background And Aims: COVID-19 pandemic has caused significant disruption in training which is even more pronounced in the surgical specialties. We aim to assess the impact of COVID-19 pandemic on core surgical training.

Methods: All core surgical and improving surgical trainees in West of Scotland region were invited to participate in an online voluntary anonymous survey via SurveyMonkey.

Results: 28 of 44 (63.6%) trainees responded, 15 (53.6%) were CT1/ST1. 14 (50.0%) working in teaching hospital and 15 (53.6%) working in general surgery. 20 (71.4%) felt that due to the pandemic they have less opportunity to operate as the primary surgeon. 21 (75.0%) have not attended any outpatient clinics. 8 (28.6%) did not have any form of access to the laparoscopic box-trainer. 20 (71.4%) felt their level of confidence in preforming surgical skills has been negatively impacted. 18 (64.3%) found it difficult to demonstrate progress in portfolio. 21 (75.0%) trainees have not attended any teaching. 10 (35.7%) trainees have been off-sick. 8 (28.6%) trainees have felt slightly or significantly more stressed.

Conclusion: COVID-19 pandemic has an unprecedented negative impact on all aspects of core surgical training. The long term impact on the current cohort of trainees is yet to be seen.
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http://dx.doi.org/10.1177/0036933020949217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424606PMC
November 2020

The impact of socioeconomic status on 30-day mortality in hospitalized patients with COVID-19 infection.

J Med Virol 2021 02 13;93(2):995-1001. Epub 2020 Aug 13.

Department of Surgery, University Hospital Hairmyres, East Kilbride, Scotland, UK.

Socioeconomic status (SES) impacts outcome in a number of diseases. Our aim was to compare the outcome of hospitalized coronavirus disease 219 (COVID-19) patients in low and high SES group. Prospective cohort study of hospitalized patients with confirmed COVID-19 in three acute hospitals. Electronic case notes were analyzed for baseline characteristics and admission investigations. Scottish index for multiple deprivation (SIMD) was used to divide patients into two groups: more deprived (SIMD 1-5) and less deprived (SIMD 6-10) and results compared. Poor outcome was defined as either need for intubation and/or death. One hundred and seventy-three patients were identified, one was excluded. One hundred and eight (62.8%) were males, mean age was 68.5 ± 14.7 years. Commonest comorbidity was hypertension 87 (50.6%). One hundred and seventeen (68.0%) patients were in more deprived group. Baseline characteristics, admission blood profile and reason for admission were evenly matched in both groups. Outcomes were comparable in both groups: transfer to critical care (27.4% vs 27.3%; P = .991), intubation (18.8% vs 20.2%; P = .853), 30-day all-cause mortality (19.7% vs 14.5%; P = .416) and overall poor outcome (30.8% vs 30.9%; P = .985). Median time to discharge was 7 days longer (17 vs 10 days; P = .018) and median time to death was 4.5 days longer in more deprived group (17 vs 12.5 days; P = .388). Contrary to recent literature on COVID-19 in other geographical areas, our study suggests that the SES does not have any impact on outcome of hospitalized patients with COVID-19, however it negatively impacts length of stay.
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http://dx.doi.org/10.1002/jmv.26371DOI Listing
February 2021

Urgent Versus Standard Colonoscopy for Management of Acute Lower Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

J Clin Gastroenterol 2020 07;54(6):493-502

Department of Surgery, Division of General Surgery.

Background: Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospitalization. However, the optimum timing of colonoscopy following patient presentation remains unclear. This systematic review and meta-analysis aims to evaluate the effect of urgent versus standard colonoscopy timing on management of acute LGIB.

Materials And Methods: Medline, EMBASE, CENTRAL, and PubMed were searched up to January 2020. Randomized controlled trials were eligible for inclusion if they compared patients with hematochezia receiving urgent (<24 h) versus standard (>24 h) colonoscopy. Nonrandomized observational studies were also included based on the same criteria for additional analysis. Pooled estimates were calculated using random effects meta-analyses and heterogeneity was quantified using the inconsistency statistic. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

Results: Of 3782 potentially relevant studies, 4 randomized controlled trials involving 463 patients met inclusion criteria. Urgent colonoscopy did not differ significantly to standard timing with respect to length of stay (LOS), units of blood transfused, rate of additional intervention required, or mortality. Colonoscopy-related outcomes such as patient complications, rebleeding rates, and diagnosis of bleeding source did not differ between groups. However, meta-analysis including nonrandomized studies (9 studies, n=111,950) revealed a significantly higher rate of mortality and complications requiring surgery in the standard group and shorter LOS in the urgent group. Overall GRADE certainty of evidence was low in the majority of outcomes.

Conclusions: Timing of colonoscopy in acute LGIB may not significantly affect patient outcomes. Timing should therefore be decided on a case-by-case basis.
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http://dx.doi.org/10.1097/MCG.0000000000001329DOI Listing
July 2020

Comorbid conditions associated with painful temporomandibular disorders in adolescents from Brazil, Canada and France: A cross-sectional study.

J Oral Rehabil 2020 Apr 5;47(4):417-424. Epub 2020 Jan 5.

Dental Department, Jewish General Hospital, Montreal, QC, Canada.

Background: Painful temporomandibular disorder (TMD) is common among adolescents. Presence of painful comorbidities may worsen painful TMD and impact treatment effectiveness.

Objective: The aim of this study was to assess the association between painful TMD and comorbidities.

Methodology: In this cross-sectional study, adolescents were recruited in Montreal (Canada), Nice (France) and Arceburgo (Brazil). Reliable instruments were used to assess painful TMD and comorbidities. Multivariable logistic and linear regression analyses were conducted to assess the study aims.

Results: The prevalence of self-reported painful TMD was estimated at 31.6%; Arceburgo (31.6%), Montreal (23.4%) and Nice (31.8%). Painful TMD was more common among girls than boys (OR = 1.96). Painful TMD was associated with a higher number of comorbidities (OR = 1.77); Arceburgo (OR = 1.81), Montreal (OR = 1.80) and Nice (OR = 1.72). A stronger association was found between painful TMD and headaches (OR = 4.09) and a weaker one with stomach pain (OR = 1.40). Allergies were also related to painful TMD (OR = 1.43).

Conclusion: Painful TMD was associated with comorbidities. Headaches were consistently associated with painful TMD. Other associations were modified by sex and/or covariates related to the cities where participants were recruited.
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http://dx.doi.org/10.1111/joor.12923DOI Listing
April 2020

Dog-Bite Injuries to the Craniofacial Region: An Epidemiologic and Pattern-of-Injury Review at a Level 1 Trauma Center.

J Oral Maxillofac Surg 2020 Mar 14;78(3):401-413. Epub 2019 Nov 14.

Senior Research Associate, Center for Health Services and Outcomes Research and Trauma Research, Charleston, WV.

Purpose: The purpose was to determine the incidence, etiologic factors leading to injury, and demographic composition of patients sustaining dog-bite injuries of the craniofacial region at a regional referral level 1 trauma center. These findings may assist primary and affiliated health care providers, educators, and policy makers in developing and implementing strategies to prevent serious dog-bite injuries, particularly in the individuals most vulnerable-children and elderly persons.

Patients And Methods: We performed a retrospective observational and descriptive review of dog bite-related injuries solely managed by the Section of Maxillofacial Surgery at Charleston Area Medical Center in West Virginia. Patient information was derived from an existing database on dog-bite injuries of the craniofacial region, electronic health records, and animal encounter records.

Results: We reviewed 182 patient records distributed among several breed categories. The results showed a disturbing trend toward more severe injuries, especially in younger children, and a reversal in gender, with girls bitten more than boys. Young children incurred more extensive facial injuries, including fractures. The data showed that compared with other dog breeds, pit bull terriers inflicted more complex wounds, were often unprovoked, and went off property to attack. Other top-biting breeds resulting in more unprovoked and complex wounds included German shepherds, Rottweilers, and huskies. Management of facial wounds took place more often in the operating room, especially in younger children, with increased hospital stays. Of the patients, 19 (10.4%) had fractures and 22 (12%) underwent a rabies vaccination protocol.

Conclusions: This study showed a disturbing trend toward more severe dog-bite injuries in young children and a greater incidence of bites in girls than in boys among several biting breeds of dogs. The public health implications of aggressive biting breeds and risks of severe injury in the home environment were discussed.
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http://dx.doi.org/10.1016/j.joms.2019.11.002DOI Listing
March 2020

Transcranial Doppler waveform changes due to increased cerebrovascular resistance and raised intracranial pressure in a patient with cirrhosis: A difference in shapes, not in numbers.

J Clin Ultrasound 2020 Jan 27;48(1):59-63. Epub 2019 Nov 27.

Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia.

We report and discuss a case that illustrate the clinical utility of transcranial Doppler (TCD) ultrasound in a patient with cirrhosis. A 43-year-old female presented with acute decompensation of cirrhosis with hepatic encephalopathy, requiring mechanical ventilation. TCD showed low diastolic flow velocities and high pulsatility index (PI) consistent with increased cerebrovascular resistance (CVR). The flow velocities and PI normalized over a period of few days and correlated well with neurological improvement after treatment. Subsequently, the patient developed a large intracerebral hemorrhage with mass effect. The TCD measurements in intracranial hypertension were similar to those with cirrhosis and hepatic encephalopathy. However, the windkessel notch in the systolic phase of TCD waveform, related to the distensibility of arterial wall, was absent during raised intracranial pressure (ICP). The absence of a windkessel notch may help to differentiate a high downstream resistance due to raised ICP from increased CVR.
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http://dx.doi.org/10.1002/jcu.22799DOI Listing
January 2020

Transcranial Doppler ultrasound in posterior reversible encephalopathy syndrome: A case report.

Authors:
Khurram S Khan

Anaesth Intensive Care 2019 Jul 18;47(4):392-396. Epub 2019 Aug 18.

Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia.

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http://dx.doi.org/10.1177/0310057X19869698DOI Listing
July 2019

Quality optimisation in colonoscopy: a function of time of colonoscopy or bowel preparation.

Pan Afr Med J 2019 26;32:205. Epub 2019 Apr 26.

Hairmyres Hospital, General Surgery, Colorectal Department, Glasgow, United Kingdom.

To test the hypothesis claimed in recent studies that quality of bowel preparation for colonoscopy could be influenced by the time of the day colonoscopy is performed. Do patients in morning list have better bowel preparation than those on the afternoon list? Retrospective analysis of 736 consecutive patients who had colonoscopy from 1 August to 31 December 2012. Patients with poor bowel preparation (Boston Bowel Prep Score 6 or less) were identified (n = 242). Colonoscopy reports of these patients analysed. Patients were stratified into two groups (am and pm) and results compared. Mean patient age 63.9 years (range 19-89). Male to female ratio 1:1. 92% of patients were given Moviprep. for bowel preparation. 32.9% (242/736) of patients were identified as having inadequate bowel preparation. 37.7% of morning list patients had poor bowel preparation. 26.7% of afternoon list patients had poor bowel preparation. 14.7% (108/736) had incomplete colonoscopy, of which 26.9% (29/108) were due to poor bowel preparation. The commonest reasons for incomplete examination were patient discomfort & bowel looping. Our study demonstrates that morning session patients had poorer bowel preparation than the afternoon session patients in contrast to published evidence in recent literature. This implies that timing of bowel preparation is probably more important than timing of colonoscopy. Poor bowel preparation does not seem to have a significant impact on the colonoscopy failure rate in this series.
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http://dx.doi.org/10.11604/pamj.2019.32.205.16016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620080PMC
July 2019

The Benefit of Fentanyl in Effective Sedation and Quality of Upper Endoscopy: A Double-Blinded Randomized Trial of Fentanyl Added to Midazolam Versus Midazolam Alone for Sedation.

J Can Assoc Gastroenterol 2019 May 9;2(2):86-90. Epub 2018 Aug 9.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Aims: Our goals were to compare the effect of adding fentanyl to midazolam in a double-blinded, randomized, placebo-controlled trial and determine if fentanyl enhances sedation, increases adverse events or effects time of the procedure or discharge.

Methods: Patients 18 to 65 years scheduled for outpatient upper endoscopy were eligible for the study. Patients were randomized to receive either 100 mcg/2 mL of Fentanyl or 2 mL of placebo IV with a double-blinded protocol. All patients received 2 mg of intravenous midazolam initially. Additional midazolam could be given to achieve adequate sedation.

Results: There were 68 patients randomized to the Fentanyl group and 69 patients to the placebo group. The mean dose of midazolam was 4.0 mg for the Fentanyl group and 5.2 mg for placebo group (=0.003). Both endoscopist and nurse independently rated sedation to be better in the fentanyl group (=0001). The patient did not perceive any difference in sedation (=0.4). Procedure time was significantly shorter in the Fentanyl group (8.5 versus 11.1 minutes, =0.001), with no difference in the discharge time. There was significantly less retching observed in patients in the fentanyl group (<0.001). There were no major complications.

Conclusions: Endoscopists and nurses found adding fentanyl significantly improved sedation, led to a shorter procedure time, and allowed for less midazolam to be used per case. It did not affect the patient experience of sedation and was safe. Fentanyl use for routine outpatient upper endoscopy should be considered as a safe option to improve procedural sedation.NCT:01514695 (www.clinicaltrials.gov)Accepted as an abstract for the Canadian Digestive Diseases Week meeting in February 2014.
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http://dx.doi.org/10.1093/jcag/gwy041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507285PMC
May 2019

Resident Survey on Gastroenterology Training in Canada.

J Can Assoc Gastroenterol 2019 Apr 24;2(1):44-48. Epub 2018 May 24.

Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Background: Gastroenterology training in Canada is guided by the Royal College of Physicians and Surgeons of Canada. Resident perspectives on training and the degree of heterogeneity across training programs have not been previously surveyed.

Aim: This study aims to evaluate the current Canadian adult gastroenterology training experience from a resident perspective and provide insight into the heterogeneity among training programs.

Method: A survey designed by three current gastroenterology residents was distributed to trainees attending the Gastroenterology Residents-in-Training course at Canadian Digestive Diseases Week 2018. Categorical data from the survey was analyzed in table format. Other continuous data was converted to dichotomous data and analyzed in groups of small and large programs, the large program defined as greater than six trainees.

Results: The overall response rate was 45 of 56 (80%), representing 13 of 14 accredited training sites. Mandatory rotations and core procedures varied widely across respondents, with only inpatient training consistent across all sites. Small programs had a higher call burden (=0.039), but staff were more likely to be available to cover call if the resident coverage was unavailable (=0.002). There were nonsignificant trends in small programs in the inability to take a post-call day (=0.07) and a resident perception of being well trained (=0.07).

Conclusions: There is heterogeneity across programs in mandatory rotations and core procedures. With the upcoming shift to competency-based medical education, it is an opportune time to re-evaluate and perhaps standardize how gastroenterology training is delivered in Canada.
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http://dx.doi.org/10.1093/jcag/gwy024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507274PMC
April 2019

What We Do: Greater Palatine Medializing Foraminal Osteotomy for Repair of the Wide Cleft Palate.

Cleft Palate Craniofac J 2019 09 12;56(8):1080-1082. Epub 2019 Feb 12.

1 Birmingham Children's Hospital, Birmingham, United Kingdom.

Wide cleft palates (>15-mm gap) present a number of challenges to the surgeon tasked with their repair ( Bardach, 1999 ). Eliminating the need for secondary surgery due to fistula formation can reduce additional anesthetic and scarring risks and optimize early speech development. Greater palatine foraminal osteotomy is a useful surgical adjunct that allows additional medial movement of oral mucoperiosteal flaps to aid in tension-free closure of the oral layer. We use a technique similar to that described by Seibert in 1995 with a few modifications. Closure of the nasal layer in these wide clefts can be achieved using a sphenoid flap, a technique recently published by our unit ( Khan et al, 2018 ).
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http://dx.doi.org/10.1177/1055665619829386DOI Listing
September 2019

Diagnostic laparoscopy to investigate unexplained lactic acidosis in critically ill patients - A descriptive single centre cohort study.

Ann Med Surg (Lond) 2018 Dec 13;36:231-234. Epub 2018 Nov 13.

Department of Surgery, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, G75 8RG, Scotland, UK.

Introduction: Unexplained lactic acidosis (LA) in a critically ill patient often prompts investigations to rule out any reversible intra-abdominal cause. Equivocal results can lead to an emergency laparotomy (EL) with subsequent high morbidity and mortality rates. Our objective was to determine the clinical impact of urgent diagnostic laparoscopy (UDL) in such patients.

Methods: This was a descriptive single-centre cohort study. UDL on 28 consecutive critically ill patients with unexplained LA who were referred to a single surgeon over 16 years period were analysed. UDL was proformed either at bedside or in theatre without prior computerised tomography (CT) scan. Patient's demographics, ASA grade, referral route and intraoperative findings were analysed.

Results: Eighteen patients underwent bedside UDL in the critical care setting and further 10 had UDL in theatre. Fourteen patients had normal UDL, out of these 10 had LA secondary to low cardiac output states. Fourteen patients had positive UDL findings. Seven patients had features of mesenteric ischaemia, two had gangrenous gallbladder, two had hepatic ischaemia, one patient had acute pancreatitis, one had gangrenous uterus and one had gastric volvulus. Five of the 14 patients with positive UDL were converted to laparotomy for definitive management. In total, of the 28 patients in the cohort, 23 patients avoided EL.

Conclusion: UDL is useful and feasible investigation for unexplained LA in the critically ill patients and it can avoid unnecessary EL in many patients. We would recommend the use of UDL as a safe and feasible investigation in such patients.
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http://dx.doi.org/10.1016/j.amsu.2018.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260236PMC
December 2018

Reel Syndrome: An Atypical Cause for Inappropriate Shocks in a Patient with Automated Implantable Cardioverter Defibrillator (AICD).

Cureus 2018 Feb 27;10(2):e2237. Epub 2018 Feb 27.

Department of Cardiology, Coney Island Hospital, Brooklyn, USA.

A 71-year-old woman, with the past medical history of heart failure with reduced ejection fraction (EF) and automated implantable cardioverter defibrillator (AICD) placement (for low EF 5-10%) in 2015, presented in February 2017 with the complaint of AICD shocks following an episode of vomiting. She denied any chest pain, abdominal pain, shortness of breath, palpitation, or dizziness. Electrocardiogram (EKG) on admission showed ectopic atrial rhythm with premature ventricular contractions in bigeminies, anterior fascicular block, and left axis deviation. On examination of the cardiovascular system, there was a normal S1 heart sound with a loud A2. There was no jugular venous distention on the neck or pitting edema on the legs. Laboratory studies showed no elevation of cardiac enzymes. Evaluation with chest x-ray showed the right ventricular lead had migrated to the right atrium and the defibrillator generator was flipped with leads coiled around it in transverse axis. AICD interrogation was performed which revealed inappropriate shocks were due to atrial fibrillation with rapid ventricular rate and loss of capture of the right ventricular lead. The diagnosis of Reel syndrome was made, and an electrophysiologist was consulted for replacement of the AICD. Reel syndrome is a variant of Twiddler's syndrome, which is a rare complication of pacemaker implantation. It manifests with the rotation of generator on transverse axis with leads coiling around it. Twiddler's syndrome, on the other hand, is the rotation of the generator on its long axis, which causes damage to the leads by twisting. Reel syndrome is usually observed within months from the placement of the generator compared to Twiddler, which takes years to occur. Twiddler and Reel's syndromes have similar contributing factors, such as female gender, obesity, large pocket, old age, dementia, and deep brain stimulation. Our patient only had two risk factors, namely, the sex and age. We propose that every patient with a pacemaker malfunction and AICD shocks should have a posterior-anterior (PA) chest x-ray and a lateral chest x-ray in addition to AICD interrogation. Twiddler's syndrome is effortlessly observed because of the twisting of dual leads compared to Reel syndrome, which is not straightforward because of the lack tortuosity of the leads.
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http://dx.doi.org/10.7759/cureus.2237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6438687PMC
February 2018

Use of the Sphenoid Flap in Repair of the Wide Cleft Palate.

Cleft Palate Craniofac J 2018 03 14;55(3):437-441. Epub 2017 Dec 14.

1 West Midlands Regional Centre for Cleft Lip & Palate, Birmingham Children's Hospital, Birmingham, United Kingdom.

Objective: In wide palatal defects, closure of the nasal layer can prove a considerable challenge. Mobilizing nasal flaps posteriorly usually facilitates soft palate closure. However, the defect is often too wide within the hard palate; hence, bilateral vomerine flaps are frequently required. Despite this, there is often a small defect in the nasal layer at the posterior septum (typically equating to the hard-soft palate junction), which has to be left to heal by secondary intention with the resulting increased risk of fistula formation and the potential deleterious long-term effect on speech due to cicatricial migration of the reconstructed levator sling anteriorly. We describe our experience in the use of the sphenoid flap to obtain tension-free primary closure of the nasal layer.

Methods: A retrospective multi-center study assessing all sphenoid flap procedures undertaken at both Birmingham Children's Hospital and Great Ormond Street Hospital. Key demographic and medical data was collected pre-, peri-, and postoperatively across the 2 sites.

Results: A total of 66 patients underwent the use of a sphenoid flap to aid closure of the nasal layer. The average age at time of repair was 9.7 months. More than half (55%, n = 36) were isolated cleft palates, and 35% (n = 23) were BCLPs. Forty-two percent of all patients had Robin sequence. The average cleft width was 14.4 mm. The overall fistula rate was 25.8% (n = 17).

Conclusions: We describe the operative technique, indications, and our experience in the use of the sphenoid flap in wide cleft palate repair.
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http://dx.doi.org/10.1177/1055665617732781DOI Listing
March 2018

A Systematic Review of the Role of Robotics in Plastic and Reconstructive Surgery-From Inception to the Future.

Front Surg 2017 15;4:66. Epub 2017 Nov 15.

Reconstructive Surgery and Regenerative Medicine Research Group (ReconRegen), Institute of Life Science, Swansea University Medical School, Swansea, United Kingdom.

Background: The use of robots in surgery has become commonplace in many specialties. In this systematic review, we report on the current uses of robotics in plastic and reconstructive surgery and looks to future roles for robotics in this arena.

Methods: A systematic literature search of Medline, EMBASE, and Scopus was performed using appropriate search terms in order to identify all applications of robot-assistance in plastic and reconstructive surgery. All articles were reviewed by two authors and a qualitative synthesis performed of those articles that met the inclusion criteria. The systematic review and results were conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines.

Results: A total of 7,904 articles were identified for title and abstract review. Sixty-eight studies met the inclusion criteria. Robotic assistance in plastic and reconstructive surgery is still in its infancy, with areas such as trans-oral robotic surgery and microvascular procedures the dominant areas of interest currently. A number of benefits have been shown over conventional open surgery, such as improved access and greater dexterity; however, these must be balanced against disadvantages such as the lack of haptic feedback and cost implications.

Conclusion: The feasibility of robotic plastic surgery has been demonstrated in several specific indications. As technology, knowledge, and skills in this area improve, these techniques have the potential to contribute positively to patient and provider experience and outcomes.
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http://dx.doi.org/10.3389/fsurg.2017.00066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5694772PMC
November 2017

Defunctioning stoma- a prognosticator for leaks in low rectal restorative cancer resection: A retrospective analysis of stoma database.

Ann Med Surg (Lond) 2017 Sep 19;21:114-117. Epub 2017 Jul 19.

Hairmyres Hospital, South Lanarkshire NHS Trust, United Kingdom.

Aims: Low anterior resection (LAR) has higher risk of anastomotic leak with its attendant morbidity -mortality. De-functioning loop ileostomy (DLI), claimed to mitigate the consequences of anastomotic leak, has been questioned in recent years. This study aims to evaluate the impact of ileostomy on LAR.

Methods: A retrospective analysis of stoma database. 136 patients with stoma (March 2011-July 2015) were assessed. Data was analysed in respect to LAR anastomotic leak rate, impact on morbidity-mortality, short and long-term stoma complications, rate of ileostomy reversal and reasons for non-reversal.

Results: 45 patients had loop ileostomy for LAR. Male (28) to female (17) ratio was 1.65:1 with median age of 69 (IQR: 56-75.5). Only 3 anastomotic leaks (3/45, 6.5%) occurred, all treated conservatively with no mortality. 29 had reversal, average reversal time is 10 months (3-24) and 5 awaiting. Reasons for non-reversal included patients' choice (7), death from cardiac cause (1), chemotherapy (1), unfit for surgery (1) and failed reversal (1). Acute complications included high output & reversible AKI (1), bleeding (3) and minor complications (6) as skin excoriation, separation and appliance issues. Parastomal hernia was repaired during reversal (12/15).

Conclusions: De-functioning ileostomy for LAR is a safe procedure with low morbidity. Most stomas are reversible. Series highlights a late reversal contrary to the nationally recommended guidelines. Most interestingly, the study demonstrated de-functioning mitigated clinical consequences of anastomotic leak to an extent that reoperation was avoidable, in keeping with recent meta-analysis indicating a significantly low anastomotic leakage rates and reoperation. Larger study is invaluable to substantiate findings.
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http://dx.doi.org/10.1016/j.amsu.2017.07.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567768PMC
September 2017

THD and mucopexy: Efficacy and controversy.

Ann Med Surg (Lond) 2017 Sep 21;21:89-92. Epub 2017 Jul 21.

Hairmyres Hospital, UK.

Aims: Transanal haemorrhoidal dearterialisation and mucopexy has evolved in recent years as a popular minimally invasive non-excisional surgery for symptomatic prolapsing haemorrhoids. The long-term outcome of this procedure however, remains to be established. We aim to analyse the long-term outcome of THD-mucopexy in the management of prolapsing haemorrhoids based on the evidence of a prospective data from a single institution.

Methods: A prospective data was collected on 100 consecutive cases of grade 3 and 4 symptomatic haemorrhoids between the period 03/2010 and 06/2015 who underwent the procedure as a day case under general anaesthetic. Overall median follow up was for two years with average age of 54.4 ranges from 34 to 79 and gender ratio of 61% Male and 39% Female. Pre-and postoperative symptoms were assessed with a view to evaluate the nature of complications and long-term recurrence rate.

Results: [Table: see text].

Conclusion: THD mucopexy is a safe and effective minimally invasive modality for prolapsing symptomatic haemorrhoids with acceptable complication rates and a recurrence rate of 13% majority of which could be dealt with a repeat procedure. Long terms follow up and randomised (THD VS Haemorrhoidectomy) multicentre trials are warranted to compare its efficacy with that of conventional excisional surgery.
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http://dx.doi.org/10.1016/j.amsu.2017.07.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536384PMC
September 2017

Anatomical Study of the Cervical and Interosseous Talocalcaneal Ligaments of the Foot with Surgical Relevance.

Cureus 2017 Jun 22;9(6):e1382. Epub 2017 Jun 22.

Department of Molecular, Cellular and Biomedical Sciences, CUNY School of Medicine.

There is conflicting evidence regarding the morphology and orientation of the cervical ligament (CL) and interosseous talocalcaneal ligament (ITCL). The morphology of the CL and its relationship to the ITCL were studied to obtain an understanding of these structures. Twenty-six feet (13 left, 13 right) were obtained from formalin-fixed cadavers (14 females, four males) with the mean standard deviation (SD) age at death 80.9 (12.9) years. All measurements were made with a digital caliper. The length and width of the foot, the width and height of the talus, were measured. The talus was cut coronally to expose the ITCL and qualitative observations were noted. The mean (SD) heights and widths of the CL at the anterior, posterior, superior, and inferior points were 8.27 (2.52), 13.95 (5.96), 9.15 (2.45), and 11.90 (4.30) mm, respectively. The mean (SD) thicknesses of the CL at the superoanterior, superoposterior, inferoanterior, inferoposterior, and central points were 0.62 (0.24), 1.05 (0.30), 0.70 (0.26), 1.20 (0.34), and 0.97 (0.31) mm, respectively. The fibers of the CL are oriented at a slight superoanterior to inferoposterior angle, whereas the fibers of the ITCL are oriented in a slight superomedial to inferolateral angle. The fibers of the CL and ITCL overlap inside the tarsal sinus with the CL positioned anteriorly, which helps to distinguish the two ligaments. In this study, we identified the morphometrics of the CL and described the CL and ITCL qualitatively. These results are relevant to introducing innovative techniques for reconstructive surgery of the subtalar ligaments in order to repair, for example, subtalar instability.
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http://dx.doi.org/10.7759/cureus.1382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522015PMC
June 2017

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study.

Surg Endosc 2017 07 8;31(7):2959-2967. Epub 2016 Nov 8.

Department of Surgery, Royal Alexandra Hospital, Corsebar Road, Paisley, PA2 9PN, Scotland, UK.

Background: Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors.

Methods: Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012-2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded.

Results: 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20-0.60 95% CI and 0.47; 0.25-0.88, respectively).

Conclusion: Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.
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http://dx.doi.org/10.1007/s00464-016-5313-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487844PMC
July 2017

Using a simple handover to improve the timing of gentamicin levels.

BMJ Qual Improv Rep 2015 14;4(1). Epub 2015 Jul 14.

NHS Lanarkshire.

The aminoglycoside gentamicin is commonly used in many NHS trusts to cover gram negative organisms in intra-abdominal sepsis and sepsis of unknown origin. As a result it often forms an important part of thew "Sepsis 6" protocol on surgical wards. Despite it's effectiveness, the antibiotic is well known to have nephrotoxic and ototoxic side effects, making monitoring of serum levels vital. In Hairmyres Hospital, a busy district general hospital in Lanarkshire, levels are typically taken at six to 14 hour post-dose intervals, with the result guiding further gentamicin dosing. A baseline measurement was performed highlighting that 42.2% of these levels were taken after the 14 hour limit. This was thought to have serious implications for patient's, as levels designed to protect them from side effects whilst maintain g an effective antimicrobial action were not being performed properly. As a result, a "gentamicin handover" was introduced to the wards in order to ease the workload on junior staff and improve handover between teams. During our short project the number of late levels initially dropped to 33.3% after one week, falling further to 28.6% following the second week of intervention. From our results it is clear that while more intervention is required gentamicin prescription, this project highlights how a simple intervention to improve ward handover can create a very noticeable improvement in the quality of patient care within a small time period.
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http://dx.doi.org/10.1136/bmjquality.u207727.w3081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693051PMC
January 2016

Are we meeting current standards in medicines reconciliation? A study in a District General Hospital.

BMJ Qual Improv Rep 2015 30;4(1). Epub 2015 Sep 30.

Hairmyres Hospital, NHS Lanarkshire.

Introduction: Inadequate medicines reconciliation on admission is often identified as a major cause of patient morbidity, with poor access to patient's regular medications often cited as a barrier to care. In the surgical admission unit of our district general hospital, drug charts are completed by junior doctors who do not have access to the Emergency Care Summary (ECS) thus making it difficult to accurately complete admission drug charts.

Methods: Our initial measurement of all acute surgical admissions revealed that 49% of patients had an accurate medicines reconciliation upon admission, increasing to 75% within 24 hours of admission. It was clear from this data that our current practice needed improvement in order to ensure patient safety. Resultantly the junior medical staff were provided with ECS accounts and teaching to aid the process of medicines reconciliation.

Results: Following the introduction of access to ECS and junior doctor education, a further two data cycles were completed. On the first cycle, the number of accurately completed drug charts increased to 62% on admission and 86% at 24 hours. After the second cycle 57% were complete on admission increasing to 84% at 24 hours.

Conclusion: Our project has shown that by providing junior doctors with medicines reconciliation education and access to patients' pre-admission medications through a nationwide electronic system resulted in a considerable increase in the completion of medicine reconciliation.
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http://dx.doi.org/10.1136/bmjquality.u207508.w3002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693049PMC
January 2016

Cryptanalysis and Improvement of "A Secure Password Authentication Mechanism for Seamless Handover in Proxy Mobile IPv6 Networks".

PLoS One 2015 18;10(11):e0142716. Epub 2015 Nov 18.

Center of Excellence in Information Assurance, King Saud University, Riyadh, Saudi Arabia.

Proxy Mobile IPv6 is a network-based localized mobility management protocol that supports mobility without mobile nodes' participation in mobility signaling. The details of user authentication procedure are not specified in this standard, hence, many authentication schemes have been proposed for this standard. In 2013, Chuang et al., proposed an authentication method for PMIPv6, called SPAM. However, Chuang et al.'s Scheme protects the network against some security attacks, but it is still vulnerable to impersonation and password guessing attacks. In addition, we discuss other security drawbacks such as lack of revocation procedure in case of loss or stolen device, and anonymity issues of the Chuang et al.'s scheme. We further propose an enhanced authentication method to mitigate the security issues of SPAM method and evaluate our scheme using BAN logic.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0142716PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4651333PMC
June 2016
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