The incidence and predictors of lower limb split skin graft failure and primary closure dehiscence in day case surgical patients

This project was an observational study of outpatients following lower limb surgical procedures for removal of skin cancers. Findings highlight a previously unreported high surgical site failure rate. Results also identified four potential risk factors (increasing age, presence of leg pain, split skin graft and haematoma) which negatively impact on surgical site healing in this population.

Incidence and predictors of lower limb split-skin graft failure and primary closure dehiscence in day-case surgical patients

BACKGROUND After general surgery, the lower limb experiences some of the highest complication rates. However, little is known about contributing factors to surgical site failure in the lower limb dermatological surgery population. OBJECTIVE To determine the incidence of lower limb surgical site failure and to explore the predictors that contribute to surgical site failure. METHODS A prospective observational study design was used to collect data from 73 participants, from July 2010, to March 2012. Incidence was determined as a percentage of surgical site failure from the total population. Predictors were determined by the use of a binary logistic regression model. RESULTS The surgical site failure rate was 53.4%. Split-skin grafting had a higher failure rate than primary closures, 66% versus 26.1%. Predictors of lower limb surgical site failure were identified as increasing age (p = .04) and the presence of postoperative hematoma (p = .01), with all patients who developed surgical site infection experiencing surgical site failure (p = .01). CONCLUSION Findings from this study confirmed that the lower limb is at high risk of surgical site failure. Two predictors of surgical site failure from this cohort were determined. However, to understand this phenomenon and make recommendations to assist and reduce surgical site complications, further research in this field is required.

Postprocedural effects of gastrointestinal endoscopy performed as a day case procedure in children : implications for patient and family education

A prospective design that included a survey tool, nursing care records, and telephone interview was used to determine postprocedural effects experienced by children and families following gastrointestinal endoscopy performed as a day procedure. One hundred twenty-one children attending a pediatric gastroenterology unit for endoscopy under general anesthesia participated in the study. Physical symptoms, day care/school attendance, behavioral issues, and economic factors in the 72 hours post procedure were identified. Over half the children (n = 69, 57%) experienced pain in the hospital post procedure. Pain was reported by 73 children (60%) at home on the day of the procedure, by 55 children (45%) on Day 1 post procedure, and by 37 children (31%) on Day 2 post procedure. The throat was the most common site of pain. Nausea or vomiting was experienced by 37 children (31%) at some time following their procedure but was not associated with procedure type, age, or fasting time. Over half the children (n = 53, 51%) who usually attended day care or school did not attend the day following their procedure. Twenty-four parents (40%) who would normally have worked on the day after the procedure did not attend employment. These findings have been used to improve the preprocedural information and discharge management of patients treated in a pediatric gastroenterology ambulatory setting. © The Society of Gastroenterology Nurses & Associates 2007. All Rights Reserved.

Day case stapled haemorrhoidopexy for prolapsing haemorrhoids

Objective Conventional surgical management of prolapsing haemorrhoids is by excisional haemorrhoidectomy. Postoperative pain has restricted the application of such procedures in the day case setting. These operations remain associated with a period of restricted activity. The use of circular stapling devices as an alternative to the excisional approach in the management of haemorrhoids has been described. This study reports our experience of stapled haemorrhoidopexy as a day case procedure.

Methods Patients with third or fourth degree haemorrhoids were eligible for the procedure. Patients were considered suitable candidates for day case surgery based on conventional parameters. Symptoms were assessed using a previously validated symptom severity rating score. Stapled haemorrhoiclopexy was carried out using a circular stapling device. Pain scores were obtained prior to discharge. Patients were admitted if pain was uncontrolled despite oral analgesia. Symptoms were re-scored at six-week follow-up.

Results Over a 70-month period 168 consecutive stapled haemorrhoidopexies were performed or directly supervised by one consultant colorectal surgeon. One hundred and ten (65%) patients were considered appropriate candidates for day case surgery by conventional criteria. Ninety-six (87.3%) patients successfully underwent stapled haemorrhoidopexyon a day case basis. Fourteen (12.7%) patients required admission on the day of surgery (5 for early Postoperative bleeding, 4 for pain necessitating continuing opiate analgesia, two for urinary retention and three for surgery performed late in the day). Six (5%) patients were re-admitted postoperatively; four for pain relief and two because of urinary retention. Of the day case patients, 91 (82.7%) and 56 (50.9%) had been seen for 6 week and 6 month review, respectively, at the time of analysis. Symptom scores were 6 (pre-operatively) vs 0 (postoperatively) (P <0.01). 76/91 (83.5%) patients reviewed at 6/52 were asymptomatic.

Conclusion Stapled haemorrhoidopexy is a safe and effective procedure that can be carried out on selected patients on a day case basis. Complications are of a similar nature to excisional haemorrhoidectomy.

Precipitation distributions for explicit versus parameterized convection in a large-domain high-resolution tropical case study

Global climate and weather models tend to produce rainfall that is too light and too regular over the tropical ocean. This is likely because of convective parametrizations, but the problem is not well understood. Here, distributions of precipitation rates are analyzed for high-resolution UK Met Office Unified Model simulations of a 10 day case study over a large tropical domain (∼20°S–20°N and 42°E–180°E). Simulations with 12 km grid length and parametrized convection have too many occurrences of light rain and too few of heavier rain when interpolated onto a 1° grid and compared with Tropical Rainfall Measuring Mission (TRMM) data. In fact, this version of the model appears to have a preferred scale of rainfall around 0.4 mm h−1 (10 mm day−1), unlike observations of tropical rainfall. On the other hand, 4 km grid length simulations with explicit convection produce distributions much more similar to TRMM observations. The apparent preferred scale at lighter rain rates seems to be a feature of the convective parametrization rather than the coarse resolution, as demonstrated by results from 12 km simulations with explicit convection and 40 km simulations with parametrized convection. In fact, coarser resolution models with explicit convection tend to have even more heavy rain than observed. Implications for models using convective parametrizations, including interactions of heating and moistening profiles with larger scales, are discussed. One important implication is that the explicit convection 4 km model has temperature and moisture tendencies that favour transitions in the convective regime. Also, the 12 km parametrized convection model produces a more stable temperature profile at its extreme high-precipitation range, which may reduce the chance of very heavy rainfall. Further study is needed to determine whether unrealistic precipitation distributions are due to some fundamental limitation of convective parametrizations or whether parametrizations can be improved, in order to better simulate these distributions.

The effects of explicit versus parameterized convection on the MJO in a large-domain high-resolution tropical case study. Part I: Characterization of large-scale organization and propagation

High-resolution simulations over a large tropical domain (∼20◦S–20◦N and 42◦E–180◦E) using both explicit and parameterized convection are analyzed and compared to observations during a 10-day case study of an active Madden-Julian Oscillation (MJO) event. The parameterized convection model simulations at both 40 km and 12 km grid spacing have a very weak MJO signal and little eastward propagation. A 4 km explicit convection simulation using Smagorinsky subgrid mixing in the vertical and horizontal dimensions exhibits the best MJO strength and propagation speed. 12 km explicit convection simulations also perform much better than the 12 km parameterized convection run, suggesting that the convection scheme, rather than horizontal resolution, is key for these MJO simulations. Interestingly, a 4 km explicit convection simulation using the conventional boundary layer scheme for vertical subgrid mixing (but still using Smagorinsky horizontal mixing) completely loses the large-scale MJO organization, showing that relatively high resolution with explicit convection does not guarantee a good MJO simulation. Models with a good MJO representation have a more realistic relationship between lower-free-tropospheric moisture and precipitation, supporting the idea that moisture-convection feedback is a key process for MJO propagation. There is also increased generation of available potential energy and conversion of that energy into kinetic energy in models with a more realistic MJO, which is related to larger zonal variance in convective heating and vertical velocity, larger zonal temperature variance around 200 hPa, and larger correlations between temperature and ascent (and between temperature and diabatic heating) between 500–400 hPa.

The effects of explicit versus parameterized convection on the MJO in a large-domain high-resolution tropical case study. Part II: Processes leading to differences in MJO development

High-resolution simulations over a large tropical domain (∼20◦S–20◦N and 42◦E–180◦E) using both explicit and parameterized convection are analyzed and compared during a 10-day case study of an active Madden-Julian Oscillation (MJO) event. In Part II, the moisture budgets and moist entropy budgets are analyzed. Vertical subgrid diabatic heating profiles and vertical velocity profiles are also compared; these are related to the horizontal and vertical advective components of the moist entropy budget which contribute to gross moist stability, GMS, and normalized GMS (NGMS). The 4-km model with explicit convection and good MJO performance has a vertical heating structure that increases with height in the lower troposphere in regions of strong convection (like observations), whereas the 12-km model with parameterized convection and a poor MJO does not show this relationship. The 4-km explicit convection model also has a more top-heavy heating profile for the troposphere as a whole near and to the west of the active MJO-related convection, unlike the 12-km parameterized convection model. The dependence of entropy advection components on moisture convergence is fairly weak in all models, and differences between models are not always related to MJO performance, making comparisons to previous work somewhat inconclusive. However, models with relatively good MJO strength and propagation have a slightly larger increase of the vertical advective component with increasing moisture convergence, and their NGMS vertical terms have more variability in time and longitude, with total NGMS that is comparatively larger to the west and smaller to the east.

Feasibility and safety of same-day home discharge after radiofrequency catheter ablation

Interventional cardiology in a day-case setting might reduce logistic constraints on hospital resources. However, in contrast with coronary angioplasty, few data support the feasibility and safety of radiofrequency catheter ablation (RCA). The aim of this prospective, multicenter cohort study was to evaluate the feasibility and safety of RCA in 1,342 patients (814 men; mean age 57 +/- 17 years) considered eligible for ambulatory RCA, according to specific set of criteria, for common atrial flutter (n = 632), atrioventricular nodal reentrant tachycardia (n = 436), accessory pathways (n = 202), and atrial tachycardia (n = 72). Patients suitable for early discharge (4 to 6 hours after uncomplicated RCA) were scheduled for 1-month follow-up. Predictive factors for delayed complications were studied by multivariate analysis. Of the 1,342 enrolled patients, 1,270 (94.6%) were discharged the same day and followed for 1 month; no deaths occurred, and the readmission rate was 0.79% (95% confidence interval 0.30% to 1.27%). Six patients had significant puncture complications, 2 presented with symptomatic delayed pulmonary embolism, and 2 had new onset of poorly tolerated atrial flutter. None of these complications was life threatening. Multivariate analysis did not identify any significant independent predictors for delayed complications. In conclusion, these data suggest that same-day discharge after uncomplicated RCA for routine supraventricular arrhythmias is safe and may be applicable in clinical practice. This approach is known to be associated with significant patient satisfaction and cost savings and can be considered a first-line option in most patients who undergo routine ablation procedures.

Influences of deep convective cloud systems on tropospheric trace gases and photochemistry over the tropical West Pacific

A numerical model for studying the influences of deep convective cloud systems on photochemistry was developed based on a non-hydrostatic meteorological model and chemistry from a global chemistry transport model. The transport of trace gases, the scavenging of soluble trace gases, and the influences of lightning produced nitrogen oxides (NOx=NO+NO2) on the local ozone-related photochemistry were investigated in a multi-day case study for an oceanic region located in the tropical western Pacific. Model runs considering influences of large scale flows, previously neglected in multi-day cloud resolving and single column model studies of tracer transport, yielded that the influence of the mesoscale subsidence (between clouds) on trace gas transport was considerably overestimated in these studies. The simulated vertical transport and scavenging of highly soluble tracers were found to depend on the initial profiles, reconciling contrasting results from two previous studies. Influences of the modeled uptake of trace gases by hydrometeors in the liquid and the ice phase were studied in some detail for a small number of atmospheric trace gases and novel aspects concerning the role of the retention coefficient (i.e. the fraction of a dissolved trace gas that is retained in the ice phase upon freezing) on the vertical transport of highly soluble gases were illuminated. Including lightning NOx production inside a 500 km 2-D model domain was found to be important for the NOx budget and caused small to moderate changes in the domain averaged ozone concentrations. A number of sensitivity studies yielded that the fraction of lightning associated NOx which was lost through photochemical reactions in the vicinity of the lightning source was considerable, but strongly depended on assumptions about the magnitude and the altitude of the lightning NOx source. In contrast to a suggestion from an earlier study, it was argued that the near zero upper tropospheric ozone mixing ratios which were observed close to the study region were most probably not caused by the formation of NO associated with lightning. Instead, it was argued in agreement with suggestions from other studies that the deep convective transport of ozone-poor air masses from the relatively unpolluted marine boundary layer, which have most likely been advected horizontally over relatively large distances (both before and after encountering deep convection) probably played a role. In particular, it was suggested that the ozone profiles observed during CEPEX (Central Equatorial Pacific Experiment) were strongly influenced by the deep convection and the larger scale flow which are associated with the intra-seasonal oscillation.

Reduced between-hospital variation in short term survival after acute myocardial infarction: the result of improved cardiac care?

Objectives: To re-examine interhospital variation in 30 day survival after acute myocardial infarction ( AMI) 10 years on to see whether the appointment of new cardiologists and their involvement in emergency care has improved outcome after AMI. Design: Retrospective cohort study. Setting: Acute hospitals in Scotland. Participants: 61 484 patients with a first AMI over two time periods: 1988 - 1991; and 1998 - 2001. Main outcome measures: 30 day survival. Results: Between 1988 and 1991, median 30 day survival was 79.2% ( interhospital range 72.1 - 85.1%). The difference between highest and lowest was 13.0 percentage points ( age and sex adjusted, 12.1 percentage points). Between 1998 and 2001, median survival rose to 81.6% ( and range decreased to 78.0 - 85.6%) with a difference of 7.6 ( adjusted 8.8) percentage points. Admission hospital was an independent predictor of outcome at 30 days during the two time periods ( p< 0.001). Over the period 1988 - 1991, the odds ratio for death ranged, between hospitals, from 0.71 ( 95% confidence interval ( CI) 0.58 to 0.88) to 1.50 ( 95% CI 1.19 to 1.89) and for the period 1998 - 2001 from 0.82 ( 95% CI 0.60 to 1.13) to 1.46 ( 95% CI 1.07 to 1.99). The adjusted risk of death was significantly higher than average in nine of 26 hospitals between 1988 and 1991 but in only two hospitals between 1998 and 2001. Conclusions: The average 30 day case fatality rate after admission with an AMI has fallen substantially over the past 10 years in Scotland. Between-hospital variation is also considerably less notable because of better survival in the previously poorly performing hospitals. This suggests that the greater involvement of cardiologists in the management of AMI has paid dividends.

May the contact lens force be with you

FULL TEXT: Like many people one of my favourite pastimes over the holiday season is to watch the great movies that are offered on the television channels and new releases in the movie theatres or catching up on those DVDs that you have been wanting to watch all year. Recently we had the new ‘Star Wars’ movie, ‘The Force Awakens’, which is reckoned to become the highest grossing movie of all time, and the latest offering from James Bond, ‘Spectre’ (which included, for the car aficionados amongst you, the gorgeous new Aston Martin DB10). It is always amusing to see how vision correction or eye injury is dealt with by movie makers. Spy movies and science fiction movies have a freehand to design aliens with multiples eyes on stalks or retina scanning door locks or goggles that can see through walls. Eye surgery is usually shown in some kind of day case simplified laser treatment that gives instant results, apart from the great scene in the original ‘Terminator’ movie where Arnold Schwarzenegger's android character encounters an injury to one eye and then proceeds to remove the humanoid covering to this mechanical eye over a bathroom sink. I suppose it is much more difficult to try and include contact lenses in such movies. Although you may recall the film ‘Charlie's Angels’, which did have a scene where one of the Angels wore a contact lens that had a retinal image imprinted on it so she could by-pass a retinal scan door lock and an Eddy Murphy spy movie ‘I-Spy’, where he wore contact lenses that had electronic gadgetry that allowed whatever he was looking at to be beamed back to someone else, a kind of remote video camera device. Maybe we aren’t quite there in terms of devices available but these things are probably not the behest of science fiction anymore as the technology does exist to put these things together. The technology to incorporate electronics into contact lenses is being developed and I am sure we will be reporting on it in the near future. In the meantime we can continue to enjoy the unrealistic scenes of eye swapping as in the film ‘Minority Report’ (with Tom Cruise). Much more closely to home, than in a galaxy far far away, in this issue you can find articles on topics much nearer to the closer future. More and more optometrists in the UK are becoming registered for therapeutic work as independent prescribers and the number is likely to rise in the near future. These practitioners will be interested in the review paper by Michael Doughty, who is a member of the CLAE editorial panel (soon to be renamed the Jedi Council!), on prescribing drugs as part of the management of chronic meibomian gland dysfunction. Contact lenses play an active role in myopia control and orthokeratology has been used not only to help provide refractive correction but also in the retardation of myopia. In this issue there are three articles related to this topic. Firstly, an excellent paper looking at the link between higher spherical equivalent refractive errors and the association with slower axial elongation. Secondly, a paper that discusses the effectiveness and safety of overnight orthokeratology with high-permeability lens material. Finally, a paper that looks at the stabilisation of early adult-onset myopia. Whilst we are always eager for new and exciting developments in contact lenses and related instrumentation in this issue of CLAE there is a demonstration of a novel and practical use of a smartphone to assisted anterior segment imaging and suggestions of this may be used in telemedicine. It is not hard to imagine someone taking an image remotely and transmitting that back to a central diagnostic centre with the relevant expertise housed in one place where the information can be interpreted and instruction given back to the remote site. Back to ‘Star Wars’ and you will recall in the film ‘The Phantom Menace’ when Qui-Gon Jinn first meets Anakin Skywalker on Tatooine he takes a sample of his blood and sends a scan of it back to Obi-Wan Kenobi to send for analysis and they find that the boy has the highest midichlorian count ever seen. On behalf of the CLAE Editorial board (or Jedi Council) and the BCLA Council (the Senate of the Republic) we wish for you a great 2016 and ‘may the contact lens force be with you’. Or let me put that another way ‘the CLAE Editorial Board and BCLA Council, on behalf of, a great 2016, we wish for you!’

Growing up in Affiliation with a Religious Community : A Case Study of Seventh-day Adventist Youth in Finland

This study investigates how the religious community as a socialization context affects the development of young people's religious identity and values, using Finnish Seventh-day Adventism as a context for the case study. The research problem is investigated through the following questions: (1) What aspects support the intergenerational transmission of values and tradition in religious home education? (2) What is the role of social capital and the social networks of the religious community in the religious socialization process? (3) How does the religious composition of the peer group at school (e.g., a denominational school in comparison to a mainstream school) affect these young people s social relations and choices and their religious identity (as challenged versus as reinforced by values at school)? And (4) How do the young people studied negotiate their religious values and religious membership in the diverse social contexts of the society at large? The mixed method study includes both quantitative and qualitative data sets (3 surveys: n=106 young adults, n=100 teenagers, n=55 parents; 2 sets of interviews: n=10 young adults and n=10 teenagers; and fieldwork data from youth summer camps). The results indicate that, in religious home education, the relationship between parents and children, the parental example of a personally meaningful way of life, and encouraging critical thinking in order for young people to make personalized value choices were important factors in socialization. Overall, positive experiences of the religion and the religious community were crucial in providing direction for later choices of values and affiliations. Education that was experienced as either too severe or too permissive was not regarded as a positive influence for accepting similar values and lifestyle choices to those of the parents. Furthermore, the religious community had an important influence on these young people s religious socialization in terms of the commitment to denominational values and lifestyle and in providing them with religious identity and rooting them in the social network of the denomination. The network of the religious community generated important social resources, or social capital, for both the youth and their families, involving both tangible and intangible benefits, and bridging and bonding effects. However, the study also illustrates the sometimes difficult negotiations the youth face in navigating between differentiation and belonging when there is a tension between the values of a minority group and the larger society, and one wants to and does belong to both. It also demonstrates the variety within both the majority and the minority communities in society, as well as the many different ways one can find a personally meaningful way of being an Adventist. In the light of the previous literature about socialization-in-context in an increasingly pluralistic society, the findings were examined at four levels: individual, family, community and societal. These were seen as both a nested structure and as constructing a funnel in which each broader level directs the influences that reach the narrower ones. The societal setting directs the position and operation of religious communities, families and individuals, and the influences that reach the developing children and young people are in many ways directed by societal, communal and family characteristics. These levels are by nature constantly changing, as well as being constructed of different parts, like the pieces of a jigsaw puzzle, each of which alters in significance: for some negotiations on values and memberships the parental influence may be greater, whereas for others the peer group influences are. Although agency does remain somewhat connected to others, the growing youth are gradually able to take more responsibility for their own choices and their agency plays a crucial role in the process of choosing values and group memberships. Keywords: youth, community, Adventism, socialization, values, identity negotiations

The case of negative day-ahead electricity prices

In recent years, Germany has significantly increased its share of electricity produced from renewable sources, which is mainly due to the Renewable Energy Act (EEG). The EEG substantially impacts the dynamics of intra-day electricity prices by increasing the likelihood of negative prices. In this paper, we present a non-Gaussian process to model German intra-day electricity prices and propose an estimation procedure for this model. Most importantly, our model is able to generate extreme positive and negative spikes. A simulation study demonstrates the ability of our model to capture the characteristics of the data.