Major cardiothoracic trauma: Eleven-year review of outcomes in the North West of England.

INTRODUCTION: Up to 15% of patients with cardiothoracic trauma require emergency surgery, and death can be prevented in a substantial proportion of this group. UK reports have emphasised the need for improvement in this field. We assessed major cardiothoracic trauma (MCT) outcomes in North West England over 11 years. METHODS: The database from the Trauma Audit and Research Network was used to retrieve data for all patients who had suffered MCT between 2000 and 2011 in North West England and the findings analysed. Trauma that led to thoracotomy/thoracoscopy or sternotomy was defined as MCT. RESULTS: A total of 146 patients were identified, and a considerable male predominance (88.4%) noted. A total of 54.1% had sustained penetrating cardiothoracic trauma. Also, 53.4% had been admitted to tertiary-care hospitals for trauma (TCHT) and 46.6% had been admitted to non-TCHT. Overall prevalence of mortality was 35.6%. No significant difference was found in mortality between TCHT vs non-TCHT. Prevalence of mortality was significantly higher in the subgroup of patients cared for exclusively in non-TCHT compared with patients transferred from non-TCHT to TCHT (41% vs 13.8%, p<0.05). CONCLUSIONS: No significant difference was demonstrated in length of stay in hospital/length of stay in the intensive treatment unit and prevalence of mortality between patients originally presenting in TCHT and those presenting in non-TCHT. However, patients transferred from non-TCHT to TCHT had a lower prevalence of mortality. These findings may constitute a valuable benchmark for comparison with results arising after introduction of trauma centres in the UK.

Preoperative fasting: current practice and areas for improvement.

Preoperative fasting aims to increase patient safety by reducing the risk of adverse events during general anaesthesia. However, prolonged fasting may be associated with dehydration, hypoglycaemia and electrolyte imbalance as well as patient discomfort. We aimed to examine compliance with the current best practice guidelines in a large surgical unit and to identify areas for improvement. Adult patients undergoing elective and emergency general, orthopaedic, gynaecology and vascular surgery procedures in the Royal Infirmary of Edinburgh were surveyed over a 3-month period commencing November 2011. A standardised questionnaire was used to collect information on the duration of preoperative fasting and the advice administered by medical and nursing staff. 292 patients were included. Median fast from solids was 13.5 h for elective patients (IQR 11.5-16) and 17.38 h for emergency patients (IQR 13.68-28.5 h). Similarly, the median fast from fluids was 9.36 h for elective patients (IQR 5.38-12.75 h) and 12.97 h for emergency patients (IQR 8.5-16.22 h). The instructions that elective patients received contributed to prolonged fasting times. The median fast for elective patients fully compliant with fasting advice would be 10 h for solids (IQR 8.75-12 h) and 6.25 h (IQR 3.83-9.25 h) for clear fluids. Elective patients fasted for longer than recommended confirming that clinical practice is slow to change. The use of universal fasting instructions and patient choice are factors that unnecessarily prolong preoperative fasting, which however appears to be multifactorial. Service improvement by abbreviation of the observed fasting periods will rely on targeted staff education and effective clinical communication by provision of written information for both elective and emergency surgical patients. The routine use of preoperative nutritional supplements may need to be re-examined when further evidence is available.

Does laparoscopic Heller's myotomy provide superior results compared to endoscopic dilatation for oesophageal achalasia?

A best evidence topic was written according to a structured protocol. In [patients with primary oesophageal achalasia] is [laparoscopic Heller Myotomy] superior to [endoscopic dilatation] with respect to [clinical outcomes]. In total 49 papers were found using the reported search, and eight of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that LHM is associated with improved post-operative symptoms and reduced clinical relapse rates compared to ED. Satisfactory clinical outcomes with ED often require repeat procedures performed over time and are associated with an increased risk of oesophageal perforation compared to LHM. One prospective randomized study showed no significant difference in post-operative outcomes between LHM and ED but this was limited by lack of standardization in the endoscopic dilatation procedure, limited reporting of complications and poor long-term follow up. Current evidence shows oesophageal perforation during LHM may be successfully managed intra-operatively but in ED usually requires further laparoscopic or open operative intervention. Fundoplication during LHM is associated with reduced incidence of post-operative gastro-oesophageal reflux disease. There is an increased risk of clinical relapse regardless of the treatment in patients with a sigmoid-shaped oesophagus or reduced oesophageal sphincter pressure assessed during pre-treatment manometry. Current studies are limited by study design, variations in operative technique and dilatation regimens, and limited follow up times. Further higher power studies matching patients for disease severity and surgical technique with longer follow up may enable greater understanding of differences in outcomes and improved patient selection for different treatment regimens.

An audit of the use of laser Doppler imaging (LDI) in the assessment of burns of intermediate depth.

This is the first report of an evaluation of the use of a laser Doppler imager (LDI) scanner in the assessment of burn depth in patients. It is based on a 6-month, prospective audit of 76 burns of intermediate depth. Clinical and LDI assessments of burn wound depth were recorded at 48-72 h post-injury. Histological confirmation of depth was obtained from those burns requiring surgery. A healing time of less than 21 days was taken as confirmation of the injury being an superficial dermal burn. The accuracy of LDI in the assessment of burn depth was 97%, compared with 60-80% for established clinical methods. This audit confirms that LDI is a very accurate measurement tool for the assessment of burn wound depth. We recommend that all burns of intermediate depth should be analysed in this way in order to ensure appropriate management of the burn, to avoid unnecessary surgery and to reduce hospital stay and costs.

Health informatics in the context of user ownership.

Of fundamental importance to the successful implementation of health information systems is the public and professional acceptability of their inclusion in the healthcare process. Surprisingly, the health care sector is embracing the informatics revolution somewhat reluctantly. Even in the areas that progress can be seen and assessed, the rate of change is erratic and inconsistent when compared across the spectrum of health care informatics. The mystery intensifies if one considers the situation in global scale: despite the diversity in approaches and models used, the reluctance perseveres. One can only suspect that there is a common, underlying, reason which slows down the process and forces the whole sector in being reluctant to accept change.

Telematics in the northern United Kingdom.

The application, integration and development of methods and technology facilitating the seamless interchange of clinical, demographic and administrative information presented the medical and clinical community with unforeseen problems. Surprisingly, the wealth of existing solutions did not find the expected application and acceptance in hospital/General Practice environments. Even more surprising was the fact of the failure of many computer-based solutions to deliver the expected benefits. This paper outlines the Telematics project established in the Northern United Kingdom and its success in maintaining a working balance between technological needs and the clinical requirements. The result is a robust service linking five major Trusts and 12 General Practices in terms of clinical and administrative data, e-mail and other facilities.