Foreskin surgery under local anaesthetic – OK? Or oh no!

Aim: Foreskin surgical procedures such as circumcision, prepuceplasty, frenuloplasty, dorsal slit, reduction of paraphimosis etc. in the adult male is usually performed by both general surgeons and urologists. Our aim was to evaluate the acceptance of performing these procedures in the day procedure unit or in the emergency unit under penile block. 
Method: Fifty patients who underwent foreskin surgeries under local anaesthetic (LA) were evaluated with their experience. Twenty patients who underwent circumcision, 20 patients who underwent foreskin preserving operations such as frenuloplasty or prepuceplasty and 10 patients who underwent other procedures such as reduction of paraphimosis (five) and dorsal slit (five) were included inthe study. The patients were asked about their symptoms such as pain or discomfort during local infiltration of lignocaine, any discomfort during the actual procedure, post-operative discomfort and general acceptance. All the patients were given penile block using smaller size needle (25 gauge, 5/8th inch orange sterile luer slip hypodermic needle) and 1% plain lignocaine. Thirty doctors from general surgery (10), urology (10) and emergency medicine (10) participated in the survey. They were asked about their opinion, confidence and preference about performing foreskin surgical procedures under LA. This included both junior trainees, middle grade doctors and consultants. The majority of middle grade doctors and consultants were fairly confident in performing procedures under LA, whereas the junior trainees in surgery, urology and emergency were lacking confidence. 
Conclusion: Penile block is a safe and effective way ofproviding sufficient anaesthesia for foreskin surgeries. Thetechnique is easy to learn. It reduces post-operative pain aswell. It can reduce the risk and cost of administering generalanaesthesia. doctors who are in training surgical specialityand emergency medicine should be encouraged to learnthe principles and technique in administering penile block.

Northern Ireland and ‘The Troubles’, outlining an innovative approach to nursing/midwifery student teaching and module evaluation

This discussion paper outlines an approach to developing and evaluating an educative programme primarily delivered by lay `citizen trainers’ in educating student nurses, and student midwives to the impact of and experience of extended and extensive civil unrest within their communities (`the Troubles’ ). This is drawn from experience within the Northern Ireland `Troubles’ and all of the citizen trainers were directly affected physically/psychologically. The programme was intended to both educate but primarily to help facilitate student nurses and student midwives to better understanding to experience and context and to more effective care delivery to those affected by/damaged by `the Troubles’. Evaluation of the teaching and learning by the students was significantly positive.

Measurement of intraocular pressure with pressure phosphene tonometry in children.

PURPOSE: To study the accuracy and acceptability of intraocular pressure (IOP) measurement by the pressure phosphene tonometer, non-contact tonometer, and Goldmann tonometer in children. METHODS: Fifty children (5 to 14 years old) participated in this prospective comparative study. IOP was measured with the pressure phosphene tonometer, non-contact tonometer, and Goldmann tonometer by three different examiners who were masked to the results. The children were also asked to grade the degree of discomfort from 0 to 5 (0 = no discomfort; 5 = most discomfort). RESULTS: The mean IOPs measured by the Goldmann tonometer, pressure phosphene tonometer, and non-contact tonometer were 15.9 mm Hg (standard deviation [SD]: = 5.5 mm Hg; range: 10 to 36 mm Hg), 16.0 mm Hg (SD: 2.9 mm Hg; range: 12 to 25 mm Hg), and 15.7 mm Hg (SD = 5.1 mm Hg; range: 8 to 32 mm Hg), respectively (P = .722). The mean difference between pressure phosphene tonometer and Goldmann tonometer readings was 2.9 mm Hg and that between non-contact tonometer and Goldmann tonometer readings was 2.1 mm Hg. The 95% confidence interval of the mean difference between pressure phosphene tonometer and Goldmann tonometer readings was -1.07 and 1.19, and that between non-contact tonometer and Goldmann tonometer readings was -1.07 and 0.53. The mean discomfort ratings for the pressure phosphene tonometer, non-contact tonometer, and Goldmann tonometer were 0.6, 2.0, and 2.3, respectively (P < .001). CONCLUSION: Although the pressure phosphene tonometer was less accurate than the non-contact tonometer compared with Goldmann tonometer, it gave a reasonably close estimate and had a high specificity of raised IOP. In addition, measurement by the pressure phosphene tonometer is most acceptable to children. The pressure phosphene tonometer can be considered as an alternative method of IOP measurement in children.

Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review

BACKGROUND: Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents.

OBJECTIVES: To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs.

DATA SOURCES: We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014.

METHODS: Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis.

RESULTS: Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001).

LIMITATIONS: Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors.

CONCLUSIONS: Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine.

STUDY REGISTRATION: This study is registered as PROSPERO CRD42014014101.

FUNDING: The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

Structural and Functional Lung Impairment in Adult Survivors of Bronchopulmonary Dysplasia

RATIONALE: As more preterm infants recover from severe bronchopulmonary dysplasia (BPD), it is critical to understand the clinical consequences of this condition on the lung health of adult survivors.

OBJECTIVES: To assess structural and functional lung parameters in young adult BPD survivors and preterm and term controls Methods: Young adult survivors of BPD (mean age 24) underwent spirometry, lung volumes, transfer factor, lung clearance index and fractional exhaled nitric oxide measurements together with high-resolution chest tomographic (CT) imaging and cardiopulmonary exercise testing.

MEASUREMENTS AND MAIN RESULTS: 25 adult BPD survivors, (mean ± SD gestational age 26.8 ± 2.3 weeks; birth weight 866 ± 255 g), 24 adult prematurely born non-BPD controls (gestational age 30.6 ± 1.9 weeks; birth weight 1234 ± 207 g) and 25 adult term birth control subjects (gestational age 38.5 ± 0.9 weeks; and birth weight 3569 ± 2979 g) were studied. BPD subjects were more likely to be wakened by cough (OR 9.7, 95% CI: 1.8 to 52.6), p<0.01), wheeze and breathlessness (OR 12.2, 95%CI: 1.3 to 112), p<0.05) than term controls after adjusting for sex and current smoking. Preterm subjects had greater airways obstruction than term subjects. BPD subjects had significantly lower values for FEV1 and FEF25-75 (% predicted and z scores) than term controls (both p<0.001). Although non-BPD subjects also had lower spirometric values than term controls, none of the differences reached statistical significance. More BPD subjects (25%) had fixed airflow obstruction than non-BPD (12.5%) and term (0%) subjects (p=0.004). Both BPD and non-BPD subjects had significantly greater impairment in gas transfer (KCO % predicted) than term subjects (both p<0.05). Eighteen (37%) preterm participants were classified as small for gestational age (birth weight < 10th percentile for gestational age). These subjects had significantly greater impairment in FEV1 (% predicted and z scores) than those born appropriate for gestational age. BPD survivors had significantly more severe radiographic structural lung impairment than non-BPD subjects. Both preterm groups had impaired exercise capacity compared to term controls. There was a trend for greater limitation and leg discomfort in BPD survivors.

CONCLUSIONS: Adult preterm birth survivors, especially those who developed BPD, continue to experience respiratory symptoms and exhibit clinically important levels of pulmonary impairment.

Evaluation of passive ventilation provision in domestic housing retrofit

Increasing energy efficiency in the residential sector, while maintaining adequate home ventilation for health and well-being, is proving to be a challenge. This study assesses the efficacy of passive ventilation strategies designed to comply with building regulations and imposed after housing energy-efficiency retrofits. In particular, it focuses on the provision of ventilation using background through-wall vents, which remains a common strategy in a number of European countries including Ireland and the UK, where vent sizes, related to floor area, are stipulated in building regulations. A collective of social housing, with background through-wall vents installed post thermal retrofit, is taken as a case study. These homes are modelled to interrogate the impact of the passive ventilation strategy on house air exchange rate and thermal heating energy loads. The reaction of occupants to through-wall vent installation is decidedly negative and many block vents to limit thermal discomfort and heat loss. Simulation studies show significant external air ingress through vents. A wide range of effective air change rates are observed when vents are sized without reference to building airtightness, and significant energy penalties result for the leakier homes. This study evaluates the provision of passive through-wall ventilation as part of a retrofit programme and shows it to have a number of drawbacks that may impact on the health of the building and its occupants and ultimately be at odds with the aims of achieving energy efficiency in the residential sector.