Safety in out-of-hours operating in trauma and orthopaedics at a district general hospital.

INTRODUCTION According to the National Confidential Enquiry into Perioperative Deaths (NCEPOD), out-of-hours operating in trauma and orthopaedics should be reserved for life or limb threatening cases only. The aim of our study was to determine the nature of non-emergency work carried out in our trust at night in 2015. The overall efficacy and clinical safety of the services provided was evaluated. METHODS Surgical activity undertaken after 9pm was reviewed along with patient ASA (American Society of Anesthesiologists) grade, grade of operating surgeon and any complications that occurred following the procedure. Furthermore, the clinical urgency and safety of cases was assessed based on whether there was any record of life or limb threatening indications at the time of admission. RESULTS Overall, 131 procedures were performed after 9pm, with 102 performed between 9pm and midnight, and 29 after midnight. Consultants performed 16 cases and the remaining 115 cases were operated on by middle grades or specialty trainees. A fifth (20%) of the cases were genuinely life or limb threatening. A total of 123 procedures were classed as having good outcomes. The complication rate was 8%. CONCLUSIONS In our study, 80% of the procedures performed after 9pm could not be categorised as life or limb threatening. Appropriate NCEPOD classification would ensure that only life or limb threatening cases were listed for theatre after 9pm. Alternative methods of operating within working hours should be considered.

Pre-packing of cost effective antibiotic cement beads for the treatment of traumatic osteomyelitis in the developing world - an in-vitro study based in Cambodia.

The developing world often lacks the resources to effectively treat the most serious injuries including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. The study aims to test the effectiveness of locally made antibiotic beads and analyse their effectiveness after being gas sterilised, packaged and kept in storage Different antibiotic beads were manufactured locally using bone cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition.

Oral drug challenges in non-steroidal anti-inflammatory drug-induced urticaria, angioedema and anaphylaxis.

BACKGROUND: Urticaria, angioedema and anaphylaxis are common adverse reactions to non-steroidal anti-inflammatory drugs (NSAIDs). AIM: To investigate the clinical characteristics of NSAID-induced acute hypersensitivity reactions with structured oral drug challenges. METHODS: Patients with NSAID-induced urticaria, angioedema or anaphylaxis were challenged with either the homologous NSAID to confirm diagnosis or a heterologous NSAID to investigate cross-reactivity. Data were analysed retrospectively and supplemented by a telephone questionnaire. RESULTS: Sixty-eight patients (mean age 48.3, 53 females) reported a total of 75 instances of NSAID-induced reactions of which 64% were purely cutaneous and 36% were systemic anaphylaxis. Ibuprofen was the most frequent cause of reactions (35%), however, diclofenac was the most frequent cause of anaphylaxis (48%). Seventeen out of 40 (43%) homologous NSAID challenges were positive; presentation with anaphylaxis or reaction to diclofenac predicted a positive challenge. Only 7 of 28 (25%) of heterologous NSAID challenges were positive. Structured challenges enabled us to identify 23 (34%) patients with selective reactivity to a single NSAID, 19 (28%) patients with cross-reactivity to multiple NSAIDs and 23 (34%) patients in whom NSAID hypersensitivity was not reproduced. Selective reactors presented most often with anaphylaxis and some had a background of beta-lactam antibiotic allergy. Cross-reactive patients often had a background of chronic urticaria and presented with milder reactions. CONCLUSION: In the absence of a reliable in vitro test, structured drug challenges allow identification of selective and cross-reactive NSAID hypersensitivity syndromes. NSAID-induced anaphylaxis is often associated with selective hypersensitivity and patients may not need to avoid other NSAIDs.

Spleno-renal bypass facilitating endovascular stenting of a juxta-renal aortic aneurysm in a high risk patient.

The management of juxta-renal abdominal aortic aneurysms (AAA) is challenging. Open surgical repair is associated with significant morbidity (predominantly renal) and the absence of an adequate length of normal infra-renal aorta precludes the placement of a standard endograft. In high-risk patients who are unsuitable for standard open repair the endovascular options include fenestrated or branched stent grafts, which are complex, expensive and not widely available, especially in the acute setting. In this report, we describe a case of a hybrid endovascular graft utilising a spleno-renal bypass to facilitate the supra-renal fixation of an aorto-bi-iliac endovascular stent graft in a high-risk patient.

A comparison of foetal and labour outcomes in Caucasian and Afro-Caribbean women with diabetes in pregnancy.

Materno-foetal complications have an increased prevalence in pregnancies complicated by diabetes. Ethnicity and cultural background may further affect these outcomes. In this study, we compared labour and foetal outcomes in Afro-Caribbean and Caucasian women with diabetes in pregnancy, using the Birmingham computerised database of diabetes in pregnancy. A retrospective analysis, covering the period 1990-2002, was employed. Foetal outcomes included early foetal loss, neonatal and perinatal mortality, congenital malformations and infant size at delivery. Labour outcomes assessed were mode and time of delivery. Overall, Afro-Caribbean women achieve similar results to Caucasian women. No significant differences were seen in foetal outcomes between the two cohorts or between diabetic subtypes. Afro-Caribbean women were more likely to have a vaginal delivery, but present later for their first antenatal visit compared with Caucasian women. Variations in culture or access to health care may account for these differences. An awareness of the specific needs of ethnic minorities is essential to ensure that this encouraging trend continues.

Rapid cycling bipolar disorder.

Rapid cycling bipolar disorder (RCBD) is defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a type of manic-depressive illness in which the patient experiences four or more episodes of mania and/or major depression per year. It was first reported as a consequence of the reduced effectiveness of lithium carbonate in the treatment and prophylaxis of this form of bipolar disorder (BD) in contrast to those with less frequent cycling. Among the anticonvulsants, there have been reports with different degrees of controlled data concerning carbamazepine, valproate, lamotrigine, topiramate, gabapentin and primidone. There is a paucity of double-blind studies, but what is available supports the use of lamotrigine. There is open data supporting the use of carbamazepine, valproate and topiramate. Regarding other classes, nimodipine may have specific utility in ultradian- (ultra-ultra-) or ultra-RCBD and there is double-blind data regarding the specific utility of olanzapine in RCBD. Low thyroid function may be a factor in development of RCBD; therapies aimed at elevating thyroid levels, even beyond the usual range, have frequently produced benefits in open trials. More research is needed into the possible therapeutic benefits of verapamil, bupropion, choline, light therapy and electroconvulsive therapy (ECT).

Role of plants, mycorrhizae and phytochelators in heavy metal contaminated land remediation.

Phytoremediation is a site remediation strategy, which employs plants to remove non-volatile and immisible soil contents. This sustainable and inexpensive process is emerging as a viable alternative to traditional contaminated land remediation methods. To enhance phytoremediation as a viable strategy, fast growing plants with high metal uptake ability and rapid biomass gain are needed. This paper provides a brief review of studies in the area of phytoaccumulation, most of which have been carried out in Europe and the USA. Particular attention is given to the role of phytochelators in making the heavy metals bio-available to the plant and their symbionts in enhancing the uptake of bio-available heavy metals.