Vascular surgery is an unattractive career option for current basic surgical trainees: a regional perspective.

INTRODUCTION: The workload of vascular services will substantially increase in the foreseeable future with the recent changes in surgical training presenting a challenge to training and recruitment in vascular surgery. This study aimed to determine the current feelings towards vascular surgery as a career choice from basic surgical trainees (BSTs) within a single region. MATERIALS AND METHODS: BSTs from a single region were questioned. Probable career specialty choice was ascertained, as were suggestions for changes to the career pathway of a vascular surgeon to make it a more attractive career choice. RESULTS: Seventy-seven of 110 BSTs returned the questionnaire. Of the 77, 52 had previous experience of a vascular firm. Ten BSTs had been on a pure vascular firm as an SHO and 52 had been on a general surgical firm. No BST specified vascular surgery as their ultimate career choice. Career choices included general surgery (n = 30), orthopaedics (n = 17), plastic surgery (n = 9) and urology (n = 5). Thirty-three BSTs would not be tempted at all to a career in vascular surgery. Changes in the career structure that would result in BSTs contemplating a career in vascular surgery included the inclusion of endovascular surgery (n = 13), no compulsion to undertake a period of research (n = 5), pure vascular training (n = 2), more general surgical training (n = 2) and less onerous on-calls when older (n = 2). CONCLUSIONS: The lack of trainees wishing to become vascular surgeons is of grave concern. Increasing the endovascular capabilities of vascular surgeons as well as altering the stance on research may have an increasingly positive role in recruitment.

Use of the CRABEL Score for improving surgical case-note quality.

INTRODUCTION: Quality assurance of medical record keeping in general surgery is facilitated by use of the CRABEL Score. Critical appraisal and constant feedback to staff plays an important part in improving case-note quality. MATERIALS AND METHODS: For each case-note audit, a house officer reviewed two sets of case notes for each of six consultant surgeons. Scores were awarded according to initial clerking, subsequent entries, consent, and discharge summary. Overall scores were derived by subtracting deductions for omissions in each category from a starting score of 100. A larger number of points deducted due to absent data leads to a lower overall score and indicates poorer quality case notes. After four audits, a clerking proforma specifically designed to address some of the common areas of weakness identified in our record keeping was introduced and a further audit was performed in March 2004 to assess its impact. RESULTS: The mean score was lowest in the September 2001 audit and improved over the next two audits. However, there was a small reduction in September 2003 compared to September 2002. When the individual sections of the score were looked at separately, the greatest contribution to a poor score comes from the 'subsequent entries' section since there are five entries scored individually leading to a cumulative effect on the overall score. Within both the 'initial clerking' and 'subsequent entries' sections, early audits showed poor performance across a range of areas but consistent poor implementation of the guidelines was seen in a small number of specific areas as record keeping improved. The quality of medical notes improved over the first three cycles but the improvement was not maintained subsequently. DISCUSSION: The CRABEL score has been shown to be a useful, reproducible and easy-to-perform objective assessment of the quality of medical record keeping. Repeated audit cycles have ensured that case-note quality remains a high priority and have also led to the development of standardised admission documentation. Introduction of the latter has led to a measurable improvement in medical record keeping.

Accuracy of carotid duplex is laboratory specific and must be determined by internal audit.

OBJECTIVE: To assess the accuracy of carotid duplex in a single vascular laboratory at the prediction of an angiographic 70% internal carotid artery stenosis. DESIGN: A retrospective review of all patients who underwent both carotid duplex and angiography in a 1-year period at a vascular unit which participates in the ACST trial. METHODS: Peak systolic velocity was used as a primary end-point in carotid duplex examinations with a PSV > 130 cm/s used as an indication for angiographic assessment. Biplanar arch aortography and selective carotid catheterisation were performed as indicated and diameter reduction calculated by the ECST method. RESULTS: The sensitivity of 130 cm/s for the detection of a 70% stenosis was 96% and the specificity 67%. If a PSV of 250 cm/s were used the sensitivity would be only 37% and specificity 96%. CONCLUSIONS: Applying duplex criteria from one centre to another is inappropriate. Laboratory specific audit of duplex and angiography is essential before deciding to abandon preoperative angiography for carotid disease.

The management of pyloric stenosis in a district hospital.

Over a 10-year period, 80 infants were admitted with a diagnosis of pyloric stenosis. Seventy-nine underwent surgical pyloromyotomy (63 male, 16 female; mean age 5.6 weeks). Fifty-nine infants (75%) were operated upon by one of four consultant surgeons and 20 (25%) operations were undertaken by a registrar. Seventy operations (89%) were performed during normal working hours and thirty of these (43%) were placed first on the operating list. The mean length of stay was 6.9 days. Three infants required re-operation: there were two instances of wound dehiscence and one episode of bleeding from the edge of the pyloromyotomy. There were no deaths. The morbidity and mortality in this series was comparable with published results from specialist units.

Endotoxin, cellular immune dysfunction and acute pancreatitis.

Clinical similarities between the sepsis syndrome seen in severe acute pancreatitis (AP) and that seen after burns, postoperative infection and trauma led to a series of investigations to elucidate the nature of immunological compromise in cases of severe AP. Significant alterations in lymphocyte surface marker antigen expression were demonstrated with reduced total T-lymphocyte (CD3), T-helper (CD4) and T-suppressor (CD8) cell numbers (P < 0.001, Mann-Whitney U test) during the acute phase of severe attacks compared with mild attacks. These abnormalities were reversible with increased CD3 (P < 0.005, Student's t test), CD4 (P < 0.01) and CD8 (P < 0.05) numbers in the convalescent phase of severe attacks. Experiments with a murine model of acute pancreatitis demonstrated further cellular immune abnormalities in AP as have previously been documented in models of burn, trauma and sepsis. Decreased interleukin-2 production by mononuclear cells (P < 0.005) was associated with susceptibility to endotoxin challenge. Immunomodulatory therapy in the form of exogenous IL-2 therapy or with induction of endotoxin tolerance not only led to increased IL-2 production (P < 0.01) but also to significantly reduced mortality after endotoxin exposure compared with control animals (P < 0.05, Wilcoxon-Gehan statistic). Cellular immune dysfunction in acute pancreatitis is seen in humans and in a murine model; it is associated with endotoxin exposure and with susceptibility to the deleterious effects of endotoxin and can be partially reversed by exogenous IL-2 therapy and by induction of endotoxin tolerance.

Audit of vascular surgical workload: use of data for service development.

The power of surgical audit lies in the ability to clearly record complications and to compare case mix from year to year and between centres in order to compare results. In addition, accurate data about surgical activity is vital for the development of new services. We have analysed 52 weeks of activity in a developing pure vascular surgical service and compared activity against the recommendations previously published for consultant surgical workload. During the 12-month period the mean number of admissions per week was 25.3 (95% CI, 23.43-27.29). Mean elective surgical activity was 18.2 h/week (95% CI, 16.5-19.9) and mean emergency workload 12.7 h (95% CI, 10.7-15.4). Mean intermediate equivalent value (IEV) operations per week was 37 (95% CI, 33.6-40.8) and of these 26.4 IEV (95% CI, 22.96-29.6) were complex major operations. Finally, the mean bed occupancy of vascular patients on the unit was 23.3 (95% CI, 21.15-24.97). The recommendations for surgical activity are 3.5 IEV/list. In our unit this would equate to 21 IEV/week compared with 37.2 in our practice. This data forms the basis of a powerful bid for increased consultant manpower and theatre resources. Surgical audit is time-consuming and should be consultant led, but the benefits are tangible and the data generated can be used to support bids for resource re-allocation.

Reduction in circulating levels of CD4-positive lymphocytes in acute pancreatitis: relationship to endotoxin, interleukin 6 and disease severity.

The proportion of peripheral blood mononuclear cells expressing the T helper cell phenotype and levels of antiendotoxin core antibody, interleukin (IL) 6 and C-reactive protein (CRP) were determined within 48 h of admission in a group of 29 patients with acute pancreatitis (16 mild, 13 severe attacks). There was a significant decrease in the proportion of T helper cells (12.2 versus 34.9 per cent, P < 0.01) and significant increases in levels of IL-6 (69.5 versus < 10 pg/ml, P < 0.01) and CRP (119 versus 30.5 mg/l, P < 0.01) in severe compared with mild attacks. During the convalescent stage at 3 months after admission, severe attacks were characterized by a significant increase in the proportion of T helper cells compared with the acute period (22.4 versus 10.6 per cent, P < 0.01). A persistently low proportion of T helper cells was associated with residual pancreatic necrosis. The presence of circulating endotoxin was demonstrated in two mild and two severe attacks using the Limulus amoebocyte lysate assay, and abnormal levels of antiendotoxin core antibodies were found in 70 and 92 per cent of mild and severe attacks respectively. There was a strong inverse correlation between levels of CRP and the proportion of T helper cells in severe disease (r = -0.76, P = 0.004). Translocation of endotoxin from the gastrointestinal tract may partly explain the abnormal levels of T helper cells, IL-6 and CRP.