Outcome of open abdominal management following military trauma.

BACKGROUND: Temporary abdominal closure (TAC) is increasingly common after military and civilian major trauma. Primary fascial closure cannot be achieved after TAC in 30 per cent of civilian patients; subsequent abdominal wall reconstruction carries significant morbidity. This retrospective review aimed to determine this morbidity in a UK military cohort. METHODS: A prospectively maintained database of all injured personnel from the Iraq and Afghanistan conflicts was searched from 1 January 2003 to 31 December 2014 for all patients who had undergone laparotomy in a deployed military medical treatment facility. This database, the patients' hospital notes and their primary care records were searched. RESULTS: Laparotomy was performed in a total of 155 patients who survived to be repatriated to the UK; records were available for 150 of these patients. Seventy-seven patients (51·3 per cent) had fascial closure at first laparotomy, and 73 (48·7 per cent) had a period of TAC. Of the 73 who had TAC, two died before closure and two had significant abdominal wall loss from blast injury and were excluded from analysis. Of the 69 remaining patients, 65 (94 per cent) were able to undergo delayed primary fascial closure. The median duration of follow-up from injury was 1257 (range 1-4677) days for the whole cohort. Nine (12 per cent) of the 73 patients who underwent TAC subsequently developed an incisional hernia, compared with ten (13 per cent) of the 77 patients whose abdomen was closed at the primary laparotomy (P = 1·000). CONCLUSION: Rates of delayed primary closure of abdominal fascia after temporary abdominal closure appear high. Subsequent rates of incisional hernia formation were similar in patients undergoing delayed primary closure and those who had closure at the primary laparotomy.

Breast lumps in service women.

INTRODUCTION: Breast cancer is uncommon in a young population but it does occur. 80% of breast cancer occurs after 50 yrs of age. This article uses current guidelines and evidence to advise military medical staff on how best to investigate and manage serving-age women presenting with breast symptoms. Male breast changes will be dealt with in a future article. DIFFERENTIAL DIAGNOSIS: Young females presenting with breast lumps are unlikely to have cancer. In order of frequency the causes are likely to be benign breast change; fibroadenoma; abscesses in 20-30 year olds; cysts in 30-40 year olds, and lastly cancer. The UK sees 48,000 new cases of breast cancer in women every year; breast cancer can also occur in men but is very rare. DIAGNOSIS AND MANAGEMENT: Management in the deployed, primary and secondary care settings are described. It may be reasonable in young women to wait and see if a lump resolves after the patient's next menstrual cycle before referring the patient. Once referred, current guidelines recommend that all patients are seen by a breast surgeon within two weeks. Within this group, a subgroup of patients with 'red-flag' lumps is identified who need to be referred urgently. The remaining patients have lumps that can be considered non-urgent: however, hospitals will still endeavour to see these patients within two weeks.. CONCLUSIONS: Breast cancer is more difficult to diagnose in the younger patient. In primary care, breast lumps are still simple to manage if the points in this article are followed. Anxious patients can be reassured that cancer is unlikely. However, cancer in this young age group is associated with worse outcomes than breast cancer in older patients.

Methods for siting emergency stomas in the absence of a stoma therapist.

INTRODUCTION: Stomas often have to be sited in emergencies by trainees who may have had little training in this. Emergency stomas and stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient's quality of life. Advice in the literature on how to best site stomas is conflicting. We compared two easy anatomical methods of siting stomas to sites chosen by a stoma therapist and looked at how this site was affected by the patients' body mass index (BMI). METHODS: Patients undergoing elective colorectal surgery were seen either pre or postoperatively. Each patient's BMI was recorded and the positions of three different potential stoma positions (site G: the gold standard, marked by a stoma therapist; site S: marked using a pair of scissors against the umbilicus; site H: halfway between the umbilicus and anterior superior iliac spine) were compared. RESULTS: The two fixed anatomical methods described (method S and method H) both gave poor results. The most common reason for poor siting was the proximity of a skin crease. There was a statistically significant correlation between the patient's BMI and the laterality of the gold standard site. CONCLUSIONS: The two simple anatomical methods described here do not provide a shortcut to effective siting. A more effective method may be calculating the laterality of the site using the patient's BMI, and then moving up/down to avoid a skin crease and improve the patient's view for changing the bag. This deserves further study.

Attendance at iron deficiency anaemia clinic: audit of outcomes 5 years on.

AIM: To determine the long-term outcomes of patients in whom no initial cause for their anaemia is established. METHOD: Six hundred and thirty-nine patients presenting to an iron deficiency anaemia pathway were prospectively entered onto a database. Initial assessment included haematological review, coeliac screen, oesophagogastroduodenoscopy and colonic imaging as per British Society of Gastroenterology guidelines. A 5-year audit of outcomes was undertaken using patient medical records and hospital laboratory databases. RESULTS: A diagnosis was found initially in 266 (42%) patients, with 124 (19%) having a gastrointestinal (GI) luminal neoplasm, 54 (8%) of which were malignant. Twelve patients had a nonluminal or non-GI malignancy. Eighty-eight (14%) had benign upper GI bleeding and 23 (4%) had coeliac disease. One hundred and forty-three (22%) did not have confirmed iron deficiency anaemia on review of haematinics. Complete records were available for 595 (93%) patients at 5 years. Of the 373 patients in whom a cause was not initially diagnosed, 6 (2%) were ultimately diagnosed with a GI luminal malignancy and 18 (5%) with a nonluminal or non-GI malignancy. There was no difference in the incidence of malignancies between those with or without confirmed iron deficiency. CONCLUSIONS: Most patients in whom no cause was found at initial investigation resolve on oral iron supplements. Patients with normal ferritin values had as high an incidence of GI malignancies as those with low values and should be investigated. In the over 50s if the anaemia remains after a course of iron further investigation is recommended as there is a significant incidence of both GI and non-GI pathology.

Audit of prescription of anti-malarial prophylaxis to patients admitted to Royal Centre for Defence Medicine (RCDM) following evacuation from Afghanistan.

INTRODUCTION: For most of the year Military personnel deployed to Afghanistan are required to take anti-malarial chemoprophylaxis (AMC). This audit aims to quantify how many personnel taking AMC in theatre have it continued at RCDM. METHOD: A database kept at RCDM was searched for details of all evacuated patients. Records of these patients were then searched to find out which had been admitted, how many had been taking AMC prior to admission and how many were prescribed it in hospital. RESULTS: During the study period 40 patients were evacuated to RCDM. 26 of these were admitted and had notes available and were therefore included in the study. 9 of these had been taking AMC prior to admission; of them, only 4 had been continued on AMC by the time they were admitted to RCDM. CONCLUSION: Insufficient numbers of patients taking AMC prior to admission have it continued as an inpatient. Awareness of this issue needs to be raised at all points of the medical evacuation chain.