Networked information and clinical decision making: the experience of Birmingham Heartlands and Solihull National Health Service Trust (Teaching).

OBJECTIVES: The paper presents the findings of the evaluation of a pilot project to introduce networked information resources into clinical settings in a large NHS Trust and describes the subsequent developments of networked information within the Trust. DESIGN: The main purpose of the evaluation was to ascertain whether access to electronic journals and other resources via a networked system offered real benefits to clinical effectiveness. SETTING: Birmingham Heartlands and Solihull NHS Trust (Teaching). SUBJECTS: Medical and administrative staff at Birmingham and Solihull NHS Trust. RESULTS: The main conclusions of the evaluation were that: (1) appropriate location of terminals close to clinical areas is vital to ensure that best use is made of networked information resources; (2) rapid access to networked information services saves staff time and allows educational opportunities to be realized; (3) networked information resources enhance rather than replace existing information sources; (4) training and support are essential to maximizing the benefits of networked information services, and (5) such a network can support clinical decision making. CONCLUSIONS: With the development of clinical governance, the clinical network has assumed even greater importance within the Trust. Timely and easy access to clinical and educational information is crucial to the practice of evidence-based medicine which underpins high quality clinical care. The evaluation led to a number of recommendations which have since been used to develop the clinical network at Birmingham Heartlands and Solihull NHS Trust.

Venous drainage of free flaps following radical neck dissection.

Large tissue defects may occur following head and neck surgery. When combined with ipsilateral radical neck dissection the venous drainage of a free flap used to cover the defect may be compromised. Twelve patients having radical neck dissections underwent on-table venography to study the pattern of venous drainage of these flaps. The predominant drainage pattern is initially in a cephalic direction, then across the midline and finally in a caudal direction on the contralateral side of the neck. Venous drainage to the contralateral side of the neck may be a determinant of flap survival. In order to facilitate venous drainage following free flap procedures, patients should be positioned so that the contralateral internal jugular vein is not compressed. Drains should be placed caudal to the microvascular anastomoses in order to minimize interference with the cephalic direction of venous drainage. Any patient having a radical neck dissection requiring a central venous catheter should have it placed ipsilateral to the neck dissection. Thrombosis around a contralaterally placed cannula may significantly increase head and neck venous pressure.

Endoscopic transanal resection of rectal lesions: facilitation by adaptation of Lord's dilator.

A wide variety of techniques are available to remove lesions within the anal canal and rectum. Endoscopic transanal resection is a well tolerated procedure which achieves good palliation. Leakage of glycine from the rectum during the procedure can be problematic. To overcome this problem a Lord's dilator has been specially adapted to enable the passage of a urological resectoscope so preventing leakage of glycine during the procedure and improving operator acceptability. This technique of transanal resection with the adapted Lord's dilator provides a cheap and effective way of treating some rectal lesions largely utilizing existing equipment.

Is closure of the peritoneal layer necessary in the repair of midline surgical abdominal wounds?

This study describes a prospective randomized controlled trial to evaluate whether suture of the peritoneal layer is necessary as a separate step in the closure of midline abdominal surgical wounds. Consecutive patients undergoing abdominal operation--elective and emergency surgery--through a midline abdominal wound were randomized to have the peritoneal layer closed with continuous catgut, or to have this step omitted. The linea alba was closed with interrupted stainless steel sutures, and the skin approximated with staples. Patients were evaluated for wound sepsis, wound dehiscence, and subsequent incisional hernia development. Postoperative pain was assessed by a self-administered visual analogue score, and by measuring narcotic requirements. There was no significant difference in narcotic requirements, pain scores, or wound complications between the 2 groups. Single-layer closure of the abdominal wall is quicker, less costly, and theoretically safer than layered closure, and it is recommended that separate suture of the peritoneum be abandoned.

Duodenal obstruction following abdominal aortic reconstruction.

Four patients developed duodenal obstruction after 161 abdominal aortic reconstructions, an incidence (2.5%) rivaling that of graft infection and arterioenteric fistula. The diagnosis is easily confirmed by gastrointestinal contrast studies. Duodenal obstruction is usually caused by perigraft collagenous adhesions and is probably less likely to occur if the mobilized duodenum is not replaced directly over the aorta during resuture of the retroperitoneum. Undetected duodenal obstruction leads to rapid dehydration and electrolyte and caloric depletion.