The Operating Theatre Journal Digital Edition November 2018

£2.00
November 2018 Issue No. 338 ISSN 1747-728X
The Leading Independent Journal For ALL Operating Theatre Staff

“What bugs you!?”
In March, we reached out to a number of hospitals to ask for their problems. Our question was: “What is
irritating you in surgery for women’s health that you wished you had a solution for?”
Mr Bruce Ramsay and his team at Peterborough City Hospital responded to tell us about their problem with gas
cylinders during their laparoscopy procedures. A few weeks later, they could test out a solution, and have now
proceeded to purchase six SplitFit Connectors for their gas bottles in theatres. Here is what happened:
JUNE: What was the problem you had in theatre?
Mr Ramsay: During laparoscopic surgery the CO2
cylinder will sometimes run out of gas to keep the
patients’ abdomen inflated.
JUNE: What does that mean? How does it impact
surgery?
Mr Ramsay: When we have to switch bottles, it takes a
little while for the swap over. During that time the
abdomen deflates, and then we have to wait for it to
distend again when the new gas bottle is connected.
JUNE: What is the associated risk?
Mr Ramsay: There is always a risk in not having visibility
during surgery, and ideally as a surgeon, you want to be
in control of your surgical field during the entire
operation.
JUNE: How long does it take to change over the gas
tubes and to reinflate the abdomen?
Mr Ramsay: A couple of minutes usually. Sometimes
longer if there is a connection problem or when we have
inexperienced staff.
JUNE: What if there is a bleed just when this happens?
Mr Ramsay: That’s our concern. If we don’t have visibility
we can’t identify it and we can’t fix it. As we strive to
make all aspects of surgery safer and more efficient and
to eliminate all possible risks, this is a step we can
influence, now that we have a solution.
JUNE: Will this save time during the operation?
Mr Bruce Ramsay: Yes, as the switch over is done in a matter of
seconds and then the cylinders can be swapped by staff at the end of
the procedure.
SplitFit installed
PHOTO COURTESY OF MR BRUCE RAMSAY,
PETERBOROUGH CITY HOSPITAL
Ordering details:
Code: JM7-510-50
Cost: £1299
Delivery: Next day
order@junemedical.com
JUNE: Have you found any other solutions to this issue?
Mr Bruce Ramsay: There was no solution available direct from stack manufacturers when we asked, hence
sourcing the SplitFit connector.
JUNE MEDICAL Ltd, Innov8, Queen Alexandra Road, High Wycombe, Buckinghamshire, HP11 2GZ
T.+44 1628 330010 W.junemedical.com Registered in England and Wales. Company Reg no.08612384

November 2018 Issue No. 338 ISSN 1747-728X
The Leading Independent Journal For ALL Operating Theatre Staff
NHS managers need to take back seat
for much-needed innovations to spread
Managers need to be a ‘back seat driver’ and share leadership if much-needed and promising innovations
are going to spread across the NHS, new research suggests.
Billions of pounds are spent annually on R&D in the NHS - the National Institute for Health Research has
an annual budget of £1 billion alone - and yet spreading innovations across hospital trusts is notoriously
problematic and poor.
Graeme Currie and Dimitrios Spyridonidis, of Warwick Business School, followed the progress of
12 innovations as they were attempted to be spread across trusts over a three-year period, which
encompassed 210 interviews and 56 hours of observation.
They found one innovation dealing with chronic obstructive pulmonary disorder (COPD) to be the stand out
performer as it successfully spread to 15 other healthcare providers, while others went nowhere.
Professor Currie said: “It was a workforce innovation, where a team combining nurses, community nurses,
and doctors was put together and through a programme of care, education around lifestyle and monitoring
they were able to keep long-term sufferers of respiratory conditions under control and out of A&E and so
saving the trusts thousands of pounds, while improving patients’ health.
“There were other great innovations we looked at involving HIV care, diabetes and more, but they did
not spread as successfully as this COPD innovation. That was because they did not have the same shared
leadership model as the COPD innovation, either managers put too much pressure on doctors with
performance or financial targets, or those innovations initiated by doctors simply ran out of money.
“But this COPD innovation saw managers, nurses and doctors working in concert. Managers gave the
mandate to innovate and provide the resource, but were then like a back seat driver. They understood
doctors have the power and expert knowledge, while nurses deliver the care so understand the operational
context.”
Dr Spyridonidis said: “This shared leadership model with innovation could be used as a blueprint across the
NHS in getting evidence-based innovations actually into practice across the whole healthcare system.
“There is plenty of innovation going on in the NHS, the big problem is diffusing it and that is an
organisational and management problem. This shared leadership model provides an answer.”
At the hospital in North West London studied, managers outlined the problem with COPD and called for bids
for a pot of money to work on solutions. The winning bid from a group of doctors was then given a trial and
evaluation period. It saw managers then taking a back seat as doctors worked with nurses in the hospital
and community in putting a package of care together.
To help it spread to other hospitals in the region managers put in structures and organised meetings for
doctors to meet with commissioners and peers to reveal evidence of the successful innovation.
One doctor said: “I walked into the workshop meeting and they [medical leads of the COPD innovation]
are advising us about how we can implement the innovation and asking us how can they help. Doctors
promoted innovation to others, and with greater force, through building networks and creating momentum
for diffusion among others in their profession.”
Nurses in each hospital would then takeover leadership of the innovation by adapting it to their context
and environment.
As one manager said: “We cede responsibility for innovation to medical leaders, but provide support for
their projects, specifically through supporting leadership development for innovation. The result is sharing
of leadership extending to many, beyond senior doctors with junior doctors now emerging as champions for
innovation.”
Managers were reliant upon doctors to influence commissioners to release extra resource to help spread
the innovation. As a doctor said: “This could be the template for lots of other innovation attempts.”
Professor Currie added: “The configuration of shared leadership was one in which doctors were preeminent
influencers of innovation diffusion, nurses had enhanced their leadership influence through
engagement and adaption activity, and managers had ceded leadership to doctors albeit the former
continued to influence innovation diffusion in the background.
“It is a template that should be adopted more widely to get innovations properly diffused.”
Inside this issue
Why poor quality surgical
instruments put patients at
risk
Find out more 02921 680068 • e-mail admin@lawrand.com Issue 338 November 2018 3
P4
Disheartening to see many
doctors suffering from bullying
Partnering with industry to
improve the future of health
for patients
P5
P8
Perioperative practitioners –
driving forward their scope of
practice?
Defibrillation for sudden
cardiac death
Basophils - underestimated
players in lung development
LIFE, LIONS AND
LAPAROSCOPIC SURGERY –
A MEDICAL ODYSSEY FROM
CAMBRIDGE TO MOUNT
KILIMANJARO
P9
P10
P10
The Sound Doctor raises
awareness of COPD ahead of
condition’s national month
Accurate evaluation of
chondral injuries by near
infrared spectroscopy
P11
P12
P12
New online registration
tool could help increase the
numbers of non-directed
altruistic living organ donors
Scientists uncover why
knee joint injury leads to
osteoarthritis
P13
P13
NOL® Monitoring Technology
for Optimized Pain Control
P14
Gross negligence
manslaughter vs involuntary
culpable homicide
P14

Why poor quality
surgical instruments
put patients at risk
Fears that contaminated surgical instruments are causing unnecessary illness and deaths because of
the risk of infection continue to hit the headlines.
From Alzheimer’s to HIV, Hepatitis
B or C and many more dangerous
diseases, there seems to be a
steady stream of stories about
how patients’ health has been put
at risk.
What is not often mentioned in
conjunction with these stories
however, is the fact that poor
quality surgical instruments are
often to blame for poor standards
of infection control.
What’s more, despite a BBC
documentary “Surgery’s Dirty
Secrets” revealing several
years ago that large numbers of
surgical tools used in the NHS
failed to meet quality standards,
the problem of poor quality
instruments is still rife.
In fact, Tom Brophy, a lead
technologist with Barts Health
NHS Trust went on record at the
time to say that about 20% of all
the instruments that he received
were rejected because of flaws
that could put patient’s health at
risk.
So why do poor quality surgical
instruments pose a risk?
Poorly manufactured surgical
instruments can risk patient
health for a number of reasons:
• Micro-punctures in surgeons’
gloves
Low quality surgical instruments
are often machine-made and
finished, leaving metal fragments
and sharp burs that can lacerate
surgical gloves.
As these punctures can be
miniscule, they can easily go
undetected during a surgical
procedure, creating an easy
pathway for infection to be
transferred to the patient.
• Defects that are invisible to
the naked eye
In addition to revealing sharp burs
and microscopic shards of steel,
an inspection of a poor-quality
instrument under a microscope
will often reveal numerous other
defects that can pose a risk to
patients.
This is because by using low-grade
steel, such instruments can easily
become corroded or pitted and
even develop hairline fractures.
This means that whilst an
instrument might seem perfectly
clean to the naked eye, a look
under a microscope can reveal
numerous areas that could be
harbouring dangerous bacteria
and viruses.
• Unclean manufacturing
facilities
Although Swiss craftsmanship and
German-quality stainless steel
may come to mind when one
thinks of surgical instruments,
two-thirds of the world’s
instruments are actually made in
Pakistan.
While some of these
manufacturers adhere to high
standards of manufacture, others
have been found to operate in
dust-filled environments near to
open sewers, piling newly made
instruments on the floor and
failing even to carry out a visual
inspection with a magnifying glass
before marking their wares with a
CE quality stamp.
Clearly this then begs the
question just how clean these
brand-new instruments are by the
time they get into the hands of
our UK surgeons.
• Low grade materials
It is clear to see why both UK
surgeons and NHS procurement
teams would want to avoid poor
quality instruments that pose such
risks of infection and harm, even
when the pricing can differ so
significantly between high-quality
and poor-quality instruments.
Article author Michael Ray,
Area Account Manager, Cairn
Technology Ltd.
Of course, German stainless
steel is recognised as the very
best material for making surgical
instruments, but in a time of
ongoing budgetary pressures on
the NHS, surely it makes sense
to buy less expensive ‘German’
instruments than recognised
brands?
However, due diligence is needed
here as well, as the ‘Dirty Secrets’
documentary also revealed
Pakistani representatives offering
to sell tools made with Pakistani
and French steel that are stamped
“Made in Germany”.
The result is that hospitals may
still end up paying a lot for
substandard instruments that
pose a risk to hygiene and health.
• Design limitations that affect
cleanliness
Another issue with poorly
manufactured
surgical
instruments is that they have not
been designed to be dismantled
for cleaning and inspection.
As infection is harder to eradicate
around instrument joints, being
able to fully separate parts can
significantly reduce the risk of
cleaned instruments continuing
to harbour germs.
Looking for high-quality
surgical instruments?
Congratulations, reading the extended OTJ
You can contact the Cairn
instrument team on 0845 226 0185
to discuss individual instruments,
recommended instrument sets or
to arrange for a demonstration of
specific instruments.
When responding to articles please quote ‘OTJ’
The next issue copy deadline, Friday 23rd November 2018
All enquiries: To the editorial team, The OTJ Lawrand Ltd, PO Box 51, Pontyclun, CF72 9YY
Tel: 02921 680068 Email: admin@lawrand.com Website: www.lawrand.com
The Operating Theatre Journal is published twelve times per year. Available in electronic format from the website, www.otjonline.com
and in hard copy to hospitals throughout the United Kingdom. Personal copies are available by nominal subscription.
Neither the Editor or Directors of Lawrand Ltd are in any way responsible for the statements made or views expressed by the contributors.
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at the PO Box address above. No part of this journal may be reproduced without prior permission from Lawrand Ltd. © 2018
Operating Theatre Journal is printed on paper sourced from Forest Stewardship Council (FSC) approved paper mills and is printed with vegetable based inks. All paper and ink waste is recycled.
Journal Printers: The Warwick Printing Co Ltd, Caswell Road, Leamington Spa, Warwickshire. CV31 1QD
4 THE OPERATING THEATRE JOURNAL www.otjonline.com

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Enthermics ivNow® Fluid Warmers
Available From Central Medical Supplies
Updated Enthermics ivNow® fluid warming products, with new features, are now
available from Central Medical Supplies Ltd (CMS). Enthermics is a pioneering
company in the patient warming arena and CMS has been the UK distributor of
Enthermics warming equipment for over fifteen years.
Enthermics ivNow® modular fluid warmers warm fluids when and where they are
needed. Products in the ivNow® range include ivNow-1, ivNow-2 and ivNow-3,
which have capacity for one, two and three bags of fluid respectively. Individual
units can be combined in any configuration and, as the units are now modular, they
can be added to or removed as required rather than being a fixed unit.
Convenient and easy to use, ivNow® fluid warmers quickly heat and maintain safe
temperatures of intravenous and irrigation fluids, saving both space and staff
time. ivNow® fluid warmers record each bag’s warming time, to increase safety,
comply with regulations and reduce waste. The system monitors how long a bag
has been warming for and will alarm if the fourteen day time limit is reached. Using
ivNow®, a one litre bag of fluid can be warmed
in approximately twenty five minutes, while a
three litre bag can be warmed in around forty
five minutes.
ivNow® can be mounted on pedestal stands,
heavy duty mobile equipment pole stands and
mast arms or anaesthesia trolleys. They can
also be hung on walls using the back plate
provided and additional mounting brackets.
A new feature of ivNow® is that it can take a
three litre bag of fluid without the need for a
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For more information on the Enthermics ivNow®
fluid warmers contact Tracey Pavier-Grant,
Sales Director at Central Medical Supplies, on
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co.uk. Further details of the Enthermics range
can be found at www.centralmedical.co.uk
When responding to articles please quote ‘OTJ’
Disheartening to see
many doctors suffering
from bullying, says NHS
Employers in response to
BMA report
Responding to the BMA report, Bullying and harassment:
how to address it and create a supportive and inclusive
culture, Paul Wallace, director of employment relations
and reward at NHS Employers, said:
“It is disheartening to see that so many UK doctors
suffer from bullying, undermining and harassment.
This kind of behaviour in the NHS or any workplace is
completely unacceptable, and we will continue to work
with employers to make sure doctors feel supported to
speak up, if they or their colleagues face mistreatment
at work.
“Our hardworking colleagues do great work under
extreme pressure, and it is understandable that it may
affect their mood, but it is not fair that this pressure
should be compounded by bad behaviour. It is paramount
that all NHS organisations, national and local, address
and reduce bullying and create a supportive environment
for doctors and all staff. We are glad to see the BMA is
offering solutions in this report.”
Further information:
NHS Employers’ work on tackling bullying is led through
the National Social Partnership Forum and Workforce
Issues Group. We support and recognise the importance
of doing this in partnership; change is much easier to
effect when staff and employers co-operate with each
other. Visit our website for more information - http://
www.nhsemployers.org/your-workforce/retain-andimprove/staff-experience/tackling-bullying-in-the-nhs
Find out more 02921 680068 • e-mail admin@lawrand.com Issue 338 November 2018 5

Nurse Led Clinics - Preoperative Assessment
(2 Day Programme)
Thursday 20th – Friday 21st May 2019
These study days are aimed at nurses and other health care
professionals with an interest in preoperative assessment.
They will allow participants to update and enhance their knowledge
within the speciality of preoperative assessment, covering a wide
range of clinical and organisational topics facilitated by specialist
nurses and consultant anaesthetists.
The Royal Marsden Education and Conference Centre
Stewart’s Grove, London, SW3 6JJ
For further information and to book your place please visit
www.royalmarsden.nhs.uk/studydays
Did YOU know you can read and download
the larger, digital version of The Operating
Theatre Journal for FREE every month?
Simply register at the top right hand corner
of www.otjonline.com and you’ll receive
a notification every time the next issue is
available.
The simple way to stay up to date!
New Kanmed Warming Cabinet And
WarmCloud Available From CMS
The new Kanmed Desk Top
Warming Cabinet is now available
from Central Medical Supplies
(CMS), along with the unique
updated Kanmed WarmCloud.
CMS is the sole UK distributor
for Swedish medical patient
warming specialist, Kanmed.
The two companies have been in
partnership for 30 years.
The Desk Top Warming Cabinet
is a new product in the Kanmed
range. There are two version of
the cabinet; one for infusions
and gels, which is pre-set to a
maximum temperature of 42°C,
and one for blankets and towels that has a pre-set maximum temperature
of 70°C. The Cabinet comes with electronic temperature regulation,
along with a high temperature alarm. It also has a mechanical over
temperature relay and a built-in safety thermostat inside the heating
element, as extra safety precautions.
The benefits of the Kanmed Desk Top Warming Cabinet include very low
running and maintenance costs, along with low energy consumption.
The Cabinet is quiet while running and easy to clean.
Kanmed WarmCloud is a patient
warming system with built in
pressure sore prevention. This
unique system ensures patients
stay warm during surgery, while
at the same time reducing the
risk of pressure sores.
The Kanmed WarmCloud system
consists of a single-use warm
air mattress, a main unit and
an optional remote control for
operating the system.
The warm air mattress, which
is placed under the patient,
lifts the patient creating a soft,
comfortable and temperaturecontrolled
environment. The
system quickly makes a cold, hard
operating table comfortable for
the patient, which helps them
to relax. It also reduces the risk
of pressure sores, particularly
during very long procedures.
As the mattress is under the
patient this gives surgeons easy
access to surgical sites.
Efficient patient warming and effective pressure sore prevention
save hospital trusts time and money. Warming the patient shortens
postoperative time in hospital, as hypothermia-induced complications
are eliminated. Maintaining normothermia can help reduce surgical
site infections, enhance clinical outcomes, comply with regulatory
guidelines, improve patient safety and aid recovery. Approximately 12
per cent to 25 per cent of patients with a hospital acquired pressure
ulcer develop them during surgical procedures. Studies reveal that one
in twelve patients undergoing surgical procedures lasting more than
three hours will develop postoperative pressure ulcers within four days.
Pressure ulcers produce needless pain and suffering for patients. They
have a negative impact on a patient’s quality of life and can sometimes
last for months at a time. Central Medical Supplies (CMS) is committed
to assisting healthcare professionals in keeping patents at a healthy
temperature and reducing pressure sores.
For more information on the Kanmed Desk Top Warming Cabinet, along
with the Kanmed WarmCloud, contact Tracey Pavier-Grant,
Sales Director at Central Medical Supplies
Tel: 01538 392 596,
email: tracey@centralmedical.co.uk or
visit: www.centralmedical.co.uk
When responding to articles please quote ‘OTJ’
6 THE OPERATING THEATRE JOURNAL www.otjonline.com

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Find out more 02921 680068 • e-mail admin@lawrand.com Issue 338 November 2018 7

The Association for Perioperative Practice (AfPP) delivers Clinical
workshop session on the WHO Checklist at the Leeds Teaching
Hospital NHS Trust Program event Theatres and Anaesthesia
Conference 2018 on ‘Patient Centered Care’.
AfPP recently attended the Theatres and Anaesthesia Conference 2018,
on Patient Centered Care, held in Leeds on Saturday 13 October. The day
started with opening remarks from Dr Moira O`Meara, Clinical Director
and Joan Ingram, Head of Nursing, Theatres and Anaesthesia. Followed
by Professor Giles Toogood on Transplant Surgery and an emotive talk
from Pete McKee about the patient experience.
The day consisted of ‘Breakout Sessions’ which included improving
experience by learning from others, improving the patient experience,
talking about enhanced recovery – a very topical area in perioperative
practice as part of the patient’s journey.
Sessions also included improvement and innovation with examples from
theatre, patient experience and engagement, involving patients in their
care which is a key aspect for operating theatres to consider. Along
with sessions on advanced roles in theatres and anaesthesia, which are
increasing in practice as boundaries are constantly being challenged,
driven by need and changes to practice; staff health and wellbeing
being important drivers in creating a healthier work culture / life
balance, which is not always easy in practice. The day’s sessions were
all supported by clinical workshops from exhibitors, and specialists.
AfPP supported perioperative practitioners by delivering a clinical
workshop session on the WHO checklist “5 Steps to Safer Surgery”,
by Lindsay Keeley, AfPP Patient Safety and Quality Lead, as well as
exhibiting at the event.
Lindsay Keely commented; “The aim of the AfPP session was to give an
overview of the WHO checklist “5 Steps to Safer Surgery” and where
we are now in practice, with key areas on guidance, how to implement
and maintain standards to reduce ‘Never Events’. The WHO checklist
“5 Steps to Safer Surgery” has now been around for ten years. It is
mandated, and ignorance is not acceptable as we are all accountable
as practitioners.
Issues in practice were raised and discussed along with modifications
to checklists, communication, implementing whole team training,
discussions around mandating ‘Human Factors’ training and how to
embed into practice, barriers and challenges to practice and how these
can be overcome.
The day was well attended by delegates, mainly from Leeds Teaching
Hospital as well as other trusts and hospitals. Speaking with delegates
at the AfPP stand enabled them to discuss the day further along with
the breakout sessions which they found very informative.”
8 THE OPERATING THEATRE JOURNAL www.otjonline.com
When responding to articles please quote ‘OTJ’
Partnering with industry to improve the future of health for patients
In the 70th year of the NHS, there is increasing pressure on hospitals to find ways to tackle the challenges our health service
faces without increasing costs. Lucy Morrisey, Deputy Director: Strategy, at Barts Health NHS Trust, shares her views.
Like most NHS Trusts, we are always on the lookout for ways to improve
productivity and patient outcomes without driving higher costs.
When our orthopaedic product tender came up for renewal, we saw the
opportunity to do things differently. We wanted to find a solution that
supported our mission to transform the service provided to patients
and improve pathways to care through innovation.
In short, we set out to find an external partner that would help us do
a number of things:
• Improve patient outcomes whilst reducing length of stay
• Release capacity in our orthopaedic theatres
• Increase the Trust’s income by improving patient throughput (driven
by the release in capacity)
• Optimise the patient pathway through standardising clinical best
practice and reducing process variation
The Johnson & Johnson Medical Devices Companies (JJMDC)
CareAdvantage approach, a value-based offering, was clearly aligned
to our needs as a Trust.
A dedicated team was put on site to work with us and, following an
extensive diagnostic exercise to identify areas of improvement, a
number of plans and ways of working were put in place to help us meet
our objectives.
Thanks to the partnership, we moved to standardised products across
three large sites, introduced consistent clinical best practice and
reduced process variation; which in turn has reduced length of stay
and released bed capacity. Initial results show the team to be on track
in delivering 1,500 bed days and a 12% increase in theatre utilisation.
We have also implemented a range of initiatives to support and inform our
patients, with effective messaging and expectation setting. This ranged
from refreshing our patient literature, to developing an engagement
app which provides a digital approach to patient engagement.
The creation of ‘super-lists’ to optimise theatres by increasing the
number of patients on lists has enabled us to treat five patients per day
instead of the previous three, giving more patients access to care and
driving increased income for the Trust.
These are fantastic results and there are multiple ways that the project
has demonstrated additional value to the Trust. The value created
by team working, learning from the external support team, bringing
an industry voice to our working practices has in itself been hugely
beneficial. In addition, the collaboration of teams across the board – be
it in theatres or on the ward – has enabled our front-line staff to work
together to solve problems and improve patient outcomes.
A real sign of the partnership’s success is how the practices
implemented within the orthopaedic theatres have been expanded to
other theatres outside the project scope. The whole project has been a
collective effort across multiple professions at various levels across the
organisation, working together and sharing successes. The possibilities
that collaboration between the NHS and industry holds make it an
exciting era for us. At a time when we need seamless, integrated
working more than ever, I believe partnership is a key element to
the successful future of both our healthcare system and delivering on
patient expectations.
www.OperatingTheatreJobs.com
A one-stop resource for ALL your theatre related Career opportunities
View the latest vacancies online !

Perioperative practitioners – driving forward
their scope of practice?
Are there limits to the scope of the perioperative practitioner’s
professional practice in today’s surgical teams? That was the key
question for debate at this year’s annual Faculty of Perioperative Care
conference that took place in Birmingham on 3 November, where over
80 delegates were already signed up and one of the two courses on
offer was already full.
The Faculty of Perioperative Care (FPC) Lead Charlie Auld and Royal
College of Surgeons of Edinburgh (RCSEd) Council Member said that with
the Government decision to regulate physician associates and assistants
in anaesthesia “there will be further development in legislation for
surgical care practitioners that is likely to lead to statutory regulation
in the near future, so it is important for perioperative practitioners to
push the boundaries of their scope of practice.
“A surgical care practitioner (SCP), for example, can lead ward rounds
and undertake advanced roles in surgery. Perioperative practitioners
are developing the skills and knowledge that will ensure they can work
alongside junior doctors in clinics and theatres,” Charlie Auld explained.
“That’s why this year’s annual conference was focused on their scope
of practice, how we can build on this, work better as a team and
progress levels of competency. How good medical practice applies to
the extended surgical team is key because perioperative practitioners
are working towards a medical model of care, and the General Medical
Council (GMC) is likely to be their regulator in the future,” he added.
This was echoed by session chair John Stirling, a senior nurse and Lead
for the NORS Workforce Transformation Project and first MFPCEd:
“Increasingly, surgical teams in the operating theatres, clinics and wards
do not adhere to the traditional medical model with more and more
highly specialised clinical practitioners from a nursing or allied health
professional (AHP) background augmenting the medical workforce.”
He stressed the importance of “maintaining a safe environment for
staff and patients that all team members are aware of each other’s
competencies and limitations to practice. We should all embrace the
drive towards statutory regulation and engage with the debate so we
can all be involved in shaping the surgical teams of the future”.
Central to the effectiveness of surgical teams is the impact that bullying
and harassment can have not only on the NHS workforce but on patient
care. As John Stirling says “many of us who have worked within surgical
teams over the years will have witnessed the consequences of negative
behaviours on both staff and patients, which takes many forms and can
affect all members of the multidisciplinary surgical team”.
Speaker Alice Hartley, senior trainee in urology and chair of the RCSEd
campaign to tackle undermining and bullying #LetsRemoveIt, agreed:
“As a surgeon you have to lead, but as the surgical team changes
all members have to take responsibility to challenge bullying and
harassment. That’s why we must have a multidisciplinary approach
to remove this from the working environment and promote the
development and maintenance of teams that foster a supportive and
respectful culture.”
The FPC, set up by the RCSEd in 2016, provides the education, training
and support for advanced perioperative practitioners who are key
members of today’s surgical team. Perioperative practitioners are a
flexible but permanent part of the surgical team, while junior doctors
move between training jobs. Research shows that this continuity and
more holistic approach has improved patient care.
For the first time the Faculty is offering delegates the opportunity to
attend professional development courses the day before the annual
conference took place (2 November 2018): “I am delighted we were
able to offer bespoke courses in cardiothoracic surgery and leadership
and development for perioperative practitioners to attend - free as
a conference delegate or at a discounted rate. And, I was even more
delighted to say that the leadership and development course wass
already full!” Charlie Auld said.
“RCSEd supports the whole surgical team and the role of perioperative
practitioners because it is increasingly a key element in the health
service providing safe patient care, working in partnership with the
surgical team,” Charlie Auld explained.
About The Royal College of Surgeons of Edinburgh Faculty of
Perioperative Care
The Royal College of Surgeons of Edinburgh (RCSEd) established
the Faculty of Perioperative Care in recognition of the evolving and
increasingly important role that Surgical Care Practitioners (SCPs) and
Surgical First Assistants (SFAs) play as part of the wider surgical team
in delivering safe, surgical care to patients. The Faculty is available to
all perioperative practitioners in the UK, including trainees, such as:
Surgical Care Practitioners; Surgical First Assistants; and all those with
similar titles involved in the delivery of high-quality surgical care.
The Faculty has been established to recognise the increasingly
important role played by all these individuals and offers many benefits
to its membership. RCSEd has an international reputation for delivering
education, training and setting of standards.
Find the Faculty of Perioperative Care website here https://fpc.rcsed.
ac.uk/ on Twitter https://twitter.com/RCSEdFPC and on Facebook
https://www.facebook.com/rcsedperioperative/
About The Royal College of Surgeons of Edinburgh
RCSEd (www.rcsed.ac.uk) was first incorporated as the Barber Surgeons
of Edinburgh in 1505, and is one of the oldest surgical corporations
in the world with a membership of over 23,000 professionals in over
100 countries worldwide. The College promotes the highest standards
of surgical and dental practice through its interest in education,
training and examinations, its liaison with external medical bodies and
representation of the modern surgical and dental workforce. It is also
home to the UK’s only Faculty of Surgical Trainers, open to all those
with an interest in surgical training regardless of College affiliation.
Find RCSEd on Twitter www.twitter.com/RCSEd and on Facebook www.
facebook.com/rcsed
The College is based at Nicolson Street, Edinburgh, EH8 9DW and can
be reached on (0)131 527 1600 or mail@rcsed.ac.uk. In March 2014, a
new base opened in Birmingham, catering to the 80% of the College’s
UK membership who are based in England and Wales.
We are pleased to accept
clinical articles for publication
within the pages of
The Operating Theatre Journal
Please send for the attention of the
Editor at:
admin@lawrand.com
Find out more 02921 680068 • e-mail admin@lawrand.com Issue 338 November 2018 9

Defibrillation for
sudden cardiac death:
it all comes down to the
programming
Sudden cardiac death is a common cause of death in patients with
congenital or acquired heart disease. An implanted cardiac defibrillator
(ICD) can effectively put a stop to any underlying cardiac arrhythmia.
In a long-term observational study involving 1,500 patients, researchers
from MedUni Vienna’s Department of Medicine II (Division of
Cardiology) have now shown that the programming selected for the
implanted defibrillators (ICDs) plays a major role. It was found that the
most “defensive” possible procedure is safe and, at the same time,
significantly reduces inappropriate therapy.
People with implanted cardiac defibrillators (ICDs) are carrying a form
of life insurance in their chests. This is only meant to be activated if
their hearts lose their rhythm to such a degree that their lives are in
acute danger: this primarily concerns ventricular tachycardia or atrial
fibrillation. Depending upon the situation, the ICD emits a painless pulse
or immediately gives a (painful) electric shock until normal cardiac
rhythm has been restored. “Unfortunately, in some patients, this
therapy overshoots the mark. This results in premature or unnecessary
shocks with the associated detriment to quality-of-life,” says study
author Achim L. Burger from MedUni Vienna’s Division of Cardiology.
“In this study we compared customised ICD programming, standard
programming and programming with extended detection times,”
explains Burger. “Our department has used the extended detection
time (the time before the ICD kicks in) since 2010 and this gives the
heart a chance to regain its rhythm spontaneously,” adds study author
Thomas Pezawas from the Medical University of Vienna’s Division of
Cardiology.
Compared with standardised programming, programming with extended
detection times could reduce the number of unnecessary ICD shocks
by 29%. Furthermore, the recent study showed that this procedure
is equally appropriate for all patients, irrespective of their gender,
underlying disease or type of device.
“We can refer to excellent results accompanied by very high levels
of patient safety. Previously published annual rates for the number
of unnecessary ICD shocks were between 5.1 and 7.9%. We are now
aiming for 3.7%, which will be a top international value,” says principal
investigator Thomas Pezawas, summarising the results, which have now
been published in “Circulation J”.
Long-standing centre of excellence for defibrillators
These results will also be important for other defibrillator centres,
since the data available in this field was previously very thin. These new
findings should also encourage other centres to adopt a less aggressive
programming strategy, say the MedUni Vienna experts: with the aim
of achieving excellent protection from sudden cardiac death while
reducing the number of inappropriate shocks. The recommendation
made by the study authors to allow the ICD to “observe” for slightly
longer (a matter of seconds) before reacting, could drive a paradigm
shift in treatment.
The present publication was produced at MedUni Vienna (Division of
Cardiology, principal investigator Thomas Pezawas). The Department is
a centre of excellence for implantable devices with more than 25 years’
experience of using ICDs.
Service: Circulation J
Defensive Implantable Cardioverter-Defibrillator Programming Is Safe
and Reduces Inappropriate Therapy – Comparison of 3 Programming
Strategies in 1,471 Patients. Burger AL, Stojkovic S, Schmidinger H, Ristl
R, Pezawas T. Circulation J. 2018 Sep 29.
doi: 10.1253/circj.CJ-18-0611.
Basophils - underestimated
players in lung development
The adult lung consists of different, highly specialized cell types that
are protected by a variety of immune cells. How these immune cells
migrate to the lungs during development and after birth, and how
these cells influence each other, is poorly understood. Using advanced
single cell sequencing methods, researchers of the Weizmann Institute
of Science in Israel, the CeMM and the Medical University in Vienna
discovered a hitherto unknown, fundamental mechanism: so-called
basophils, immune cells mainly known in the context of allergy, play
a crucial role in the development of macrophages in the lung. The
study, published in Cell, could open new clinical strategies to fight lung
diseases.
Lungs are vital organs required for the uptake of oxygen in exchange for
carbon dioxide. However, the enormous complexity of the respiratory
organ is often underestimated and deserves a closer look: A broad
range of specialized cells work closely together to ensure the proper
functioning of the lung and provide the vital gas exchange. Among those
cells are various immune cells, which keep invading microorganisms in
check while at the same time preventing harmful inflammation.
The development and maturation of this complex organ during the
embryonal stages and after birth was largely unknown. In the latest
issue of Cell (DOI: 10.1016/j.cell.2018.09.009), scientists from Israel
and Austria made an important contribution to the understanding
of the pulmonary immune-development using a combination of high
throughput single-cell RNA sequencing, functional assays and cuttingedge
microscopy methods. The research group of Ido Amit from the
Weizmann Institute of Science, together with the teams of Sylvia
Knapp at the CeMM Research Center for Molecular Medicine of the
Austrian Academy of Sciences and the Department of Medicine I of the
Medical University Vienna and Tibor Harkany at the Center for Brain
Research of the Medical University of Vienna could establish the first
comprehensive map of lung cell types and their inter-lineage crosstalk
during development.
An unexpected finding: basophils, immune cells that were hitherto
held responsible for allergic reactions, reside in lungs where they
develop into a special subtype that produces crucial growth factors
and cytokines. These cells are different from previously described
basophils that circulate in the blood, and their role in development
and homeostasis, specifically in the lungs, was never reported before.
“We were able to show that the development of the lung proceeds in
several waves, and that lung resident basophils are important players,”
Anna-Dorothea Gorki, CeMM/MedUni Vienna PhD student and co-first
author of the study, explains. “Basophils broadly interact with other
cell types of the lung, especially macrophages. Molecular signals,
emitted by basophils, assist in the maturation of macrophages into their
lung-specific phenotype, the so called alveolar macrophage.”
“This discovery is very interesting, even from a medical point of
view,” Sylvia Knapp, Principal Investigator at CeMM and Professor at
the Medical University Vienna, adds. “The unique signals of basophils
and their impact on macrophages suggest they may play a role in lung
diseases and might therefore expose and potential target for novel
immunotherapies.”
Cell
Lung single cell signaling interaction map reveals basophil role in
macrophage“
Merav Cohen, Amir Giladi, Anna-Dorothea Gorki, Dikla Gelbard Solodkin,
Mor Zada, Anastasiya Hladik, Andras Miklosi, Tomer-Meir Salame, Keren
Bahar Halpern, Eyal David, Shalev Itzkovitz, Tibor Harkany, Sylvia
Knapp, Ido Amit; erschienen in der Zeitschrift Cell am 11.10.2018. DOI:
10.1016/j.cell.2018.09.009
10 THE OPERATING THEATRE JOURNAL www.otjonline.com

LIFE, LIONS AND LAPAROSCOPIC SURGERY – A MEDICAL
ODYSSEY FROM CAMBRIDGE TO MOUNT KILIMANJARO
Once in a lifetime, a chance may come along to be involved in something
amazing. That chance presented itself to award-winning engineer
Colin Dobbyne, the founder of Cambridge-based product development
consultancy Big Blue Solutions, when he was invited to be part of a
project to introduce laparoscopic surgery to Tanzania and across East
Africa.
It all started in Hexham…
The story starts ten years ago in Hexham, when a team from
Northumbria Healthcare NHS Foundation Trust approached Colin with
a challenging proposal – could he design an audiovisual tele-mentoring
link that would allow their surgeons to communicate, with surgical video
and in real time, with their counterparts at the Kilimanjaro Christian
Medical Centre (KCMC), a large referral hospital in Northern Tanzania
that serves an astonishing 15 million people. The link would have to
be affordable, sustainable and work over the meagre Internet service
available in the region at that time, other methods, like satellite links,
being prohibitively expensive.
Why laparoscopic surgery?
Laparoscopic or “keyhole” surgery delivers cheaper, more efficient,
procedures, with shorter hospital stays and a greatly reduced risk of
post-operative infection. In a country like Tanzania, where money is
tight and patients, who may be the sole breadwinner or carer, struggle
to be away from their family for long periods of time, the benefits it
offers are huge.
Setting up the Link
An ambitious plan
KCMC had a team of surgeons desperate to develop their laparoscopic
skills and improve the treatment they could offer patients. However, it
was virtually impossible for the Tanzanian government to fund overseas
training, and the occasional visits from foreign surgeons only went so
far.
This project was set to change everything. The ambitious plan to train
and mentor African surgeons in minimally invasive techniques on live
cases during surgery would mean the hospitals no longer had to rely on
sporadic help from overseas volunteers but could take full ownership of
the surgery they carried out, directly benefitting thousands of patients
each year.
At first, the project seemed to present an insurmountable challenge - it
would take software that didn’t yet exist, running on a bandwidth that
may not available, set up in a hospital with as yet unknown technical
resources, but “the link”, as it came to be known, could be done.
Would be done. Next stop – Tanzania!
Surgery in progress
“The Link – An Adventure in Africa from the Inside Out”
The story of the project is now available from Amazon http://amzn.
eu/d/cuVATGv. It not only tells the full story of the link, from conception
to installation, but also creates an evocative picture of KCMC and life
in Tanzania, where day-to-day existence can be cruel and challenging
but the beauty of the people and their country always shines through.
Meet the book’s characters through Colin’s eyes – the spice girl whose
temper is as hot as her goods; the hospital patient who is not all that
he seems; and Dr Ali – a man with plan.
A selection of images from the project can be seen at,
www.dobbyne.com.
Further Information:
Colin Dobbyne
+44 (0) 7966 402359
Are You Linkedin ?
Join our Group
The Operating Theatre Journal
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When responding please quote ‘OTJ’
Find out more 02921 680068 • e-mail admin@lawrand.com Issue 338 November 2018 11

Accurate evaluation of chondral
injuries by near infrared
spectroscopy
Osteoarthritis is a disabling disease characterised by joint pain and restricted
mobility, affecting especially the elderly. The disease generally progresses
slowly, even over decades. Post-traumatic osteoarthritis, however, affects
people of all ages and is initiated by joint trauma, for example, as a result of
falling. The disease is most prevalent in articulating joints, such as the knee.
The Sound Doctor raises awareness of
COPD ahead of condition’s national month
Although no cure currently exists for osteoarthritis, early detection of cartilage
lesions could enable halting the disease progression by pharmacological or
surgical means. Conventionally, joint health is diagnosed based on patients’
symptoms, joint mobility and, if required, with x-ray and magnetic resonance
imaging. Based on these examinations, joint repair surgery may be performed
during arthroscopy. The decision on the optimal treatment option is made during
the surgery, in which the joint health is evaluated visually and by palpating the
cartilage surface with a metallic hook. These techniques are subjective and
dependent on surgeons’ experience and can, therefore, influence the treatment
outcome.
Health educators, The Sound Doctor, are raising awareness of Chronic
Obstructive Pulmonary Disease (COPD) and providing tools to manage
the condition ahead of November’s National COPD Month – which
includes World COPD Awareness Day on November 21st, 2018.
COPD affects millions of people in the UK. It is a condition of the lungs,
making it hard to push air out, due to a narrowing of the airways. COPD
usually develops because of long term damage to lungs from breathing
in a harmful substance. Usually this is cigarette smoke, but could be
smoke from other sources, or air pollution.
COPD Awareness Month aims to increase public understanding of this
condition, and is especially important since many people who have it
don’t realise they’re living with the condition.
NICE, the National Institute for Care and Excellence guidelines, say it is
estimated that 3 million people in the UK have COPD but only just over
1million are diagnosed.
More people get it as they age, and most people aren’t diagnosed until
they are in their 50’s. It isn’t curable, but you can live well with COPD
if you look after yourself properly.
As well as making people more aware of the condition, the organisation
is keen to provide people who have COPD, and their families, with the
tools they need to stay out of hospital and avoid exacerbations or flare
ups where possible.
The Sound Doctor has a large library of films to give people a better
understanding of this disease, whether they have just been diagnosed
or have lived with the condition for many years.
Rosie Runciman, co-founder of The Sound Doctor, said: “Our mission is
to empower people to manage their own health conditions. So we’re
especially pleased to be raising awareness of COPD during the national
awareness month. By providing patients with detailed, accessible and
easily comprehendible online information, the overall management of
their illness becomes more effective and efficient.”
Professor Mike Morgan, Respiratory National Clinical Lead and Vice
President of the British Lung Foundation, says: “Like many of the best
uses of technology, The Sound Doctor is both simple and effective. It
gives patients easy access to practical information so they can better
understand and manage their own health conditions.”
Between three and five minutes long, the films are full of accessible,
easily understandable information for those who are interested in
learning how to maintain and improve their health and well-being.
There is plenty of practical advice on how to recognise and reduce
the risk of exacerbations, how to cope with breathlessness and use an
inhaler effectively, plus how to get the most out of life generally.
As well as COPD, other film libraries created by The Sound Doctor
include diabetes, heart failure, back pain, dementia and weight
management surgery.
For more information about The Sound Doctor, visit:
https://www.thesounddoctor.org/
For more information about World COPD Day, visit:
https://www.blf.org.uk/copdday
When responding to articles please quote ‘OTJ’
The Novel arthroscopic probe
An arthroscopic near infrared spectroscopic probe for evaluation of articular
cartilage and subchondral bone structure and composition was developed as
part of a PhD thesis at the University of Eastern Finland. The probe enables
enhanced detection of cartilage injuries, as well as evaluation of the integrity
of the surrounding tissue. The availability of comprehensive information on the
health of joint tissues could substantially enhance the treatment outcome of
arthroscopic intervention.
Previously, the near infrared spectroscopy technique has been utilised in, for
example, evaluation of grain quality, but its clinical applications are still rare.
However, clinical application of the technique is now possible thanks to better
availability of computational power along with state-of-the-art mathematical
modelling methods, such as neural networks. With these methods, the
relationship between the absorption of near infrared light and tissue properties
can be determined. This enables reliable determination of articular cartilage
stiffness and subchondral bone mineral density — changes in these tissue
properties are prognostic indicators of osteoarthritis.
Since near infrared spectroscopy is not optimal for imaging of tissues,
arthroscopically applicable imaging techniques, such as optical coherence
tomography and ultrasound imaging, were also used in the study. These
techniques have been previously applied in intravascular imaging via specialized 1
mm diameter catheters, which are therefore well-suited for imaging narrow joint
cavities. The study compared the reliability of these techniques for evaluation of
chondral injuries with that of conventional arthroscopic evaluation.
“Optical coherence tomography was superior to conventional arthroscopy
and ultrasound imaging. In contrast to conventional arthroscopic evaluation,
optical coherence tomography and ultrasound imaging provide information on
inner structures of cartilage and enable, for example, detection of cartilage
detachment from subchondral bone,” Researcher Jaakko Sarin from the
University of Eastern Finland explains.
The doctoral dissertation, entitled Evaluation of chondral injuries using near
infrared spectroscopy, is available for download at http://epublications.uef.fi/
pub/urn_isbn_978-952-61-2910-5/urn_isbn_978-952-61-2910-5.pdf
The findings were originally reported in Osteoarthritis and Cartilage, Annals of
Biomedical Engineering, and Scientific Reports.
Open access article:
Arthroscopic near infrared spectroscopy enables simultaneous quantitative evaluation of
articular cartilage and subchondral bone in vivo. Jaakko K. Sarin, Nikae C. R. te Moller,Irina
A. D. Mancini, Harold Brommer, Jetze Visser, Jos Malda, P. René van Weeren, Isaac O. Afara &
Juha Töyräs. Scientific Reports, volume 8, Article number: 13409 (2018).
https://doi.org/10.1038/s41598-018-31670-5
When responding to articles please quote ‘OTJ’
12 THE OPERATING THEATRE JOURNAL www.otjonline.com

New online registration tool could help increase the
numbers of non-directed altruistic living organ donors
With the number of non-directed
altruistic donations plateauing
over the last five years, it’s hoped
a new online tool will help make
the process easier for those who
want to save the life of a stranger.
NHS Blood and Transplant
have produced a simple online
expression of interest form to
streamline the referral process
for non-directed altruistic
living donation and to improve
everyone’s experience.
53-year-old Kate Bullion, a
carer from Lowestoft in Suffolk,
decided to donate a kidney
anonymously to a stranger, but
was told she was too overweight.
Determined to make a difference,
Kate lost an incredible six and a
half stone to eventually make the
donation possible.
“I gained as much as I gave with
the donation,” said Kate.
“The weight loss made me so
much healthier and I felt that it
was important to give someone
a chance at a better life. Most of
my family were against me doing
it at first, but I wanted to do it.
I don’t need two kidneys and to
me it felt like I was passing on
something I didn’t need, just like
giving clothes to charity.”
Kate adds: “My recovery took
about six months, but if I could
I would be prepared to do it all
again. It felt right to give someone
hope and a chance at a better life.
I have been able to live a normal
life and it felt important to help
someone else do the same.”
In 2017/18 there were 940 adult
living donor kidney transplants
performed in the UK* - 123 of
those were paired or pooled**
and 85 were altruistic donor
transplants – given voluntarily to
a stranger. The new form offers a
simple way for those who want to
express their interest in donating
a kidney or part of their liver to a
stranger to contact their nearest
transplant centre.
For suitable patients,
transplantation is normally the
best treatment for end stage
kidney disease compared with
dialysis. A transplant from a living
kidney donor is often the best
chance of a successful transplant.
Living kidney transplants have
been performed in the UK since
1960 and there are currently 6,119
people on the transplant waiting
list, including 4,828 people
waiting for a kidney.***
Lisa Burnapp, Lead Nurse for
Living Donation at NHS Blood and
Transplant, said:
“Our aim is to ensure that all
donors have the best possible
experience and that no donation
opportunity is lost. Inspired
by discussions with the ‘Give
a Kidney’ charity, the online
expression of interest form is
for people who do not have a
recipient in mind, but simply want
to transform a life by donating an
organ to someone in need.
“Non-directed altruistic kidney
donors are game-changers for
patients waiting for a transplant.
By donating their kidneys into the
UK Living Kidney Sharing Scheme,
they trigger a chain of up to 2 or 3
kidney transplants and everyone
gains. More patients and their
families benefit from a successful
transplant and more organs
are available for every patient
waiting.”
The number of altruistic
donations has plateaued over the
last five years, so it’s hoped that
making the whole process easier
will encourage more people to
consider donating a kidney or part
of their liver to someone they
don’t know.
The lack of increase in living
kidney donation is especially
concerning for black and Asian
patients waiting for a transplant.
Organs are matched by blood
group and tissue type and people
from the same ethnic background
are more likely to be a match.
However Black and Asian
families are less likely to agree
to deceased organ donation or
to donate anonymously as living
donors, which means black
and Asian kidney patients rely
disproportionately on living
donations from family members.
This is the first time an online
submission option for living
donation has been available and
is separate to the NHS Organ
Donor Register, which records the
wishes of those wanting to donate
organs after death.
For more information on living
donation and to access the
expression of interest form visit
https://www.organdonation.
nhs.uk/about-donation/livingdonation/
*https://nhsbtdbe.blob.core.
windows.net/umbraco-assetscorp/12257/nhsbt-living-donorkidney-transplantation-annualreport-2017-2018.pdf
**Paired/Pooled donation is when
donor and recipient pairs who are
incompatible by Human Leucocyte
Antigen (HLA) type or ABO blood
group and unable to donate directly,
one to the other, are registered
in a national scheme to achieve
compatible transplants with other
pairs. When two pairs are involved
it is called ‘paired’ donation; more
than two pairs are involved it’s
called ‘pooled’ donation. More
on the UK Living Kidney Sharing
Scheme can be found at https://
www.odt.nhs.uk/living-donation/
uk-living-kidney-sharing-scheme/
***As of 27 September 2018
Scientists uncover why knee joint injury leads to osteoarthritis
Knee joint injuries are typically related to sports, such as football,
rugby or ice hockey, but people often do not know that such injuries
may lead to joint inflammation and post-traumatic osteoarthritis. In
advanced post-traumatic osteoarthritis, joint cartilage breaks down
completely, causing severe joint pain, lack of mobility and even social
isolation. However, the mechanisms leading to osteoarthritis are
not known. Currently, it is not possible for a physician examining a
patient to predict future joint condition and possible development
of osteoarthritis. In the future, however, this may be possible, as a
new study from the University of Eastern Finland and Massachusetts
Institute of Technology now shows that articular cartilage degenerates
specifically around injury areas when the fluid flow velocity becomes
excessive. The findings were reported in Scientific Reports.
The study presents a new mechanobiological model for cartilage
degeneration by implementing tissue deformation and fluid flow as
mechanisms for cartilage breakdown when a normal dynamic loading,
such as walking, is applied to the joint. The results were compared to
experimentally observed degradation of articular cartilage. Ultimately,
the new model could be used to predict osteoarthritis in personal
medicine, to suggest optimal rehabilitation protocols, and to improve
the quality of life.
The researchers found that different mechanisms, such as fluid flow
and tissue deformation, can cause cartilage degradation after a knee
injury. The results obtained using the novel algorithm agreed well
with the experimentally observed proteoglycan content and cell
death in cartilage samples. According to the researchers, a numerical
analysis shows that both fluid flow and tissue deformation are plausible
mechanisms leading to osteoarthritis, but increased fluid flow from
cartilage seems to be better in line with the experiments.
“Our findings indicate that after an injury in the knee and subsequent
tissue loading, osteoarthritis is caused by easy leakage of proteoglycans
through the injury surface by high fluid outflow,” Early Stage Researcher
Gustavo A. Orozco from the University of Eastern Finland explains.
The findings are significant and could open up new avenues for the model
to be employed in the prediction of subject-specific progression of posttraumatic
osteoarthritis, and in the evaluation of the effect of clinical
interventions in the future. Specifically, the model could identify high
and low-risk lesions in the cartilage for osteoarthritis development and
suggest an optimal and individual rehabilitation protocol.
The study has received funding from the European Union’s Horizon 2020
research and innovation programme under the Marie Sklodowska-Curie
grant No 713645.
Original article:
Gustavo A. Orozco, Petri Tanska, Cristina Florea, Alan J. Grodzinsky & Rami K. Korhonen
A novel mechanobiological model can predict how physiologically relevant dynamic loading
causes proteoglycan loss in mechanically injured articular cartilage. Scientific Reports (2018).
DOI: 10.1038/s41598-018-33759-3.
The article is available for download at:https://www.nature.com/articles/s41598-018-33759-3
Find out more 02921 680068 • e-mail admin@lawrand.com Issue 338 November 2018 13

Medasense Announces Positive Results From Clinical Outcome Studies
Using the NOL® Monitoring Technology for Optimized Pain Control
The researchers concluded: “opioid administration based on NOL is
clinically relevant and improves patient outcome.”
Mrs. Galit Zuckerman-Stark, Medasense CEO and founder, said
today: “A growing body of evidence indicates that intraoperative
hypotension increases the risk of myocardial injury, acute kidney
injury, and mortality. The study demonstrates the importance of NOL
monitoring during surgery and its potential to reduce the probability of
postoperative complications.”
The leading study, investigating NOL-guided opioid administration,
demonstrated that using the NOL technology significantly reduced
opioid-consumption and improved hemodynamic stability in patients
undergoing major surgery
Medasense Biometrics Ltd., developer of innovative systems and
applications to objectively assess the physiological response to pain,
today announced positive results from several studies using the NOL®
monitoring technology. NOL technology helps clinicians optimize the
delivery of pain medication by assessing patient’s nociceptive (pain)
state in situations where patients are unable to communicate, especially
in critical care and surgery under general anaesthesia.
All studies evaluated the role of NOL (the nociception level index,
presenting the patients’ pain state on a scale of 0 to 100 on the PMD-200
monitor) to provide superior pain assessment for improved outcomes.
In the first study[1], Professor Albert Dahan and his team from Leiden
University Medical Centre (LUMC), aimed to investigate whether
NOL-guided administration of opioid analgesics during surgery versus
standard practice would affect opioid use and patient outcomes.
Awarded among the 10 Best Abstracts of Clinical Science, Prof. Dahan
presented the study results at the Anaesthesiology 2018 conference in
San Francisco, U.S.A.
The study included 80 patients who underwent elective major
surgery during remifentanil/propofol anaesthesia with NOL-guided
analgesia, versus standard of care. Current standard of care relies on
the discretion of the attending anaesthesiologist to administer opioids
based on changes in a patient’s heart rate and blood pressure. The
results showed that NOL-guided opioid administration led to 33% less
intraoperative opioids and 80% less hemodynamic hypotensive events.
In the second study[2], Professor Patricia Lavand’homme and
colleagues from the Université Catholique de Lovain in Belgium, sought
to assess the potential link between the intraoperative NOL values
and postoperative recovery after knee arthroplasty with Opioid-Free
Analgesia Protocol. Following an analysis of 75 adult patients, the
results, presented last September at the International Association for
the Study of Pain® (IASP) 2018 conference, showed that NOL correlated
with pain at mobilization on day 1 following surgery, and pain at
movement 3 months following surgery. The authors concluded “control
of intraoperative nociception (assessed by NOL) is important as it may
predict early and longer-term postoperative pain.”
Mrs. Zuckerman-Stark added: “The latest clinical evidence clearly
indicates the potential of our technology to improve patient care and
empower clinicians in this mission. We believe these results are just the
first marker of the potential benefit NOL technology holds, with many
others to come in the near future.”
For more information: http://www.medasense.com;
info@medasense.com
* PMD-200 and its NOL index are commercially available in Europe,
Canada, Australia and Israel. Not commercially available in the U.S.A.
Reference:
1. Nocicepion Level (NOL)-guided Analgesia: Influence on Opioid
Consumption and Hypotensive Events During Propofol/remifentanil
anesthesia. Albert Dahan. Fleur S. Meijer, Suzanne Broens, Monique
van Velzen, Christian Martini. “Best of Abstracts: Clinical Science”, ASA
Annual Meeting 2018, SF, U.S.A.
2. Intraoperative nociception monitoring and postoperative recovery
after knee arthroplasty P. Lavand’homme, E. Thienpont, M.N. France.
The International Association for the Study of Pain®(IASP), 2018,
Boston, U.S.A.
Gross negligence manslaughter vs involuntary culpable homicide
Speaking recently at the President’s Leadership lecture at the Royal College of Physicians and Surgeons
of Glasgow, Advocate Neil Mackenzie, a specialist in the areas of professional negligence and industrial
disease, outlined the differences between gross negligence manslaughter and involuntary culpable
homicide legislation.
In the lecture, Neil MacKenzie said “Gross negligence manslaughter is an English crime while the law is
different in Scotland. The closest equivalent is ‘involuntary culpable homicide’, the starting point of the
assessment is whether a person’s actions were criminal. Cases involving Involuntary Culpable Homicide
have thus far been far removed from medical care. No doctor has been convicted of this crime in
Scotland.”
He continued that to be guilty of this crime, the Crown would require to prove, beyond reasonable doubt,
that a patient died because a doctor displayed an utter disregard for the consequences of an act, or a high
level of indifference to the consequences, so far as a patient is concerned.
In 2014, the Scottish Parliament consulted on a Bill to reform Culpable Homicide. While it proposed a
change to the law to include gross negligence culpable homicide, this related to organisations. Further
the consultation has not been acted on. The Scottish Law Commission has recently started a review of
Scottish homicide laws, which is likely to take 5 years. There is also the Independent Review of Gross
Negligence Manslaughter and Culpable Homicide commissioned by the General Medical Council, which is
due to report in 2019.
Mr Mackenzie’s view was that in Scotland, a doctor’s reflections may be recoverable by the courts. Whether they are admitted to evidence,
however, is likely to depend on whether they contain contemporaneous factual statements and whether it is fair in all the circumstances to do
so. He thought it reasonable to argue that the chilling effect and the potential harm to patients’ care by preventing reflective learning, of making
reflections admissible in court make it unfair to admit them in evidence.
A full recording of the lecture is available at https://www.youtube.com/watch?v=09SoKwHKd0g
14 THE OPERATING THEATRE JOURNAL www.otjonline.com

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