Legalisation of e-scooters in the UK: the injury rate and pattern is similar to those of bicycles in an inner city metropolitan area.

INTRODUCTION: Rental electric scooters (e-scooters) have become more available to the UK public following amendments to legislation in 2020 affecting rideshare schemes. Existing literature from outside the UK demonstrates a worrying trend of increasing injuries related to their use and non-compliance with suggested safety precautions. An e-scooter rideshare scheme trial began in Liverpool in October 2020. We intended to identify the musculoskeletal injury rate and describe the injuries sustained during this pilot. METHODS: Data were collected retrospectively from electronic patient records on all patients at a major trauma centre covering the whole of the Liverpool rideshare trial site presenting with e-scooter and bicycle musculoskeletal injuries between the trial start on 6th October 2020 and 5th May 2021 and between 6th March 2020 and 5th October 2020. Data on rental e-scooter use were obtained from the rideshare operator. RESULTS: Fifty-one patients sustained musculoskeletal injuries involving e-scooters during the trial period and six injuries before the trial. Two-thirds of injuries were on rental e-scooters. We calculate an orthopaedic injury rate of 26.1 injuries per million km on e-scooters and 24.1 injuries per million km on bicycles. Over 70% of e-scooter patients had upper limb injuries, over 50% had lower limb injuries and 15.7% of patients required surgery. CONCLUSIONS: We observed an increase in musculoskeletal injuries presenting to hospital during the e-scooter pilot. Rates of musculoskeletal injuries were comparable to rates of injuries sustained on bicycles. E-scooters should be regulated closely and further safety measures introduced to minimise the rate of injuries.

Acute Compartment Syndrome: Do guidelines for diagnosis and management make a difference?

BACKGROUND: The best outcomes following Acute Compartment Syndrome (ACS) are attributed to early diagnosis and treatment. National guidelines were issued in the United Kingdom in 2014 (BOAST 10) to standardise and improve management. We analysed standards of diagnosis and management before and after the introduction of the guidelines. METHODS: We retrospectively reviewed the data of all patients with ACS requiring fasciotomy between March 2010 and May 2015 across four Major Trauma Centres (MTCs) in the Northwest of England. We analysed the pooled data for variations between the centres and the effect of BOAST10 implementation. RESULTS: 75 fasciotomies were recorded, with trauma being the cause in 42 cases (56%). The commonest site was the leg (44, 59%) followed by the forearm (15, 20%). The median time from decision to operate to fasciotomy was 2 h (range 0-6) and thereafter a median of 2 days (1-7) until a second visit. The practice across the four centres was similar up to diagnosis and treatment, but there was significant variation in practice after fasciotomy. The BOAST guidelines did not improve the time to surgery, time to second visit nor the recording of clinical signs. 21 patients had severe complications, including one death and 4 amputations. CONCLUSIONS: There continues to be significant variability in the definitive management of ACS. National guidelines do not appear to make a discernible impact on practice, and additional methods of ensuring safe management of this critical condition seem warranted.

Change the habit to change the practice: Do audits really ever change anything?

INTRODUCTION: Methicillin resistant staphylococcus aureus (MRSA) eradication by nurses and pre-op induction antibiotics are mandated for emergency surgery, where true status is unknown. We assessed adherence to local MRSA guidelines for patients undergoing emergency hip fracture surgery and employed point of decision prompts to influence clinicians' behaviour. METHODS: We undertook a retrospective record review for all patients undergoing emergency hip fracture surgery at a UK major trauma centre over 3-months. Demographics, MRSA eradication therapy and antibiotics were recorded. Admission-to-MRSA swab result time was compared to the admit-to-operation time. Posters on induction antibiotics were placed in anaesthetic rooms, stickers on MRSA eradication therapy on nursing care bundles and standards re-audited after 6 months. RESULTS: The case-mix was similar in both audit cycles: initial audit (n=69, mean age 76.9, range 33-94), re-audit (n=77, mean age 73.8, range 18-95). There was a small rise in adherence to eradication therapy prescription (1% vs 8%) after sticker distribution, although compliance was poor pre and post intervention. Correct antibiotic choice for MRSA unknown patients (18% vs 94%) improved significantly after poster intervention. Operations occurred at a median of 24.05h (Q1 17.6, Q3 32.3) from admission but MRSA swab results returned at a median of 48h (Q1 41.5, Q3 59.5) p=<0.0001. CONCLUSION: Providing reminders at the points where decisions are to be made are effective. Audit interventions should be easily undertaken and will become habitual if connected in sequence to old behaviours.

Adverse cardiovascular outcomes in relation to suboptimal antithrombotic therapy use in patients undergoing peripheral artery disease angioplasty: lost opportunities?

INTRODUCTION: Current guidelines recommend antithrombotic therapy with either aspirin or clopidogrel for all patients with peripheral arterial disease (PAD). Nevertheless, cardiovascular comorbidities and perceived bleeding risk complicate antithrombotic management of PAD patients. We studied the proportion of patients receiving optimal (guideline-recommended) antithrombotic therapy, and second, assessed the impact of suboptimal antithrombotic therapy use to long-term outcomes of PAD patients. METHODS: We performed a single centre retrospective analysis of patients with significant PAD, requiring percutaneous intervention. All patients coded as undergoing peripheral artery percutaneous transluminal angioplasty (PTA) between January 2007 and December 2011 were reviewed. Antithrombotic medication on discharge postprocedure was recorded. RESULTS: Across the study period, 473 patients were coded as having received a PTA, but yet only 336 (71%) had data available for review: 218 (35.2%) male, mean age 73 ± 11 years. Of the whole cohort, 236 (70.2%) were discharged on optimal (guideline-recommended) antithrombotic therapy, 30 (8.9%) were considered 'overtreated' and 70 (20.8%) were undertreated. On multivariate analysis, patients with heart failure were more likely to be undertreated (OR 2.38, 95% CI: 1.15-5.00, p = 0.02) while patient with coronary artery disease were more likely to be overtreated (OR 4.00, 95% CI: 1.61-10.00, p = 0.03). Undertreated patients had an increased risk for all-cause mortality [hazard ratio (HR) 2.96, 95% CI 1.81-4.82: p = 0.00001] and cardiovascular mortality (HR 3.16, 95% CI: 1.49-6.68, p = 0.003). CONCLUSION: In this single centre cohort of patients undergoing PTA, suboptimal antithrombotic therapy was not uncommon and had a major impact on long-term outcomes, resulting in increased all cause and cardiovascular mortality.

Electricity generation choices for the near term.

Electricity demand is expected to increase during the next few decades, especially if it is accepted that the primary goal of energy conservation is to reduce oil consumption. Although the renewable resources in principle have unlimited potential, it is not clear that they can make a major contribution to electricity expansion within the 20th century. Coal and nuclear power are the practical alternatives. The adverse effects of nuclear power probably remain less than those of coal, despite the impact of the Three Mile Island accident. It is important to explore and exploit all options, especially the endangered nuclear option.