A Retrospective Study of Pilonidal Sinus Healing by Secondary Intention Using Negative Pressure Wound Therapy Versus Alginate or Gauze Dressings.

Pilonidal sinus (PS) disease is an inflammatory skin and subcutaneous tissue condition that presents with infection, acute abscess, chronic discharging wounds, and/or pain. Surgery with open healing by secondary intention typically is used to achieve the fastest healing time with minimal recurrence rates. A retrospective analysis was conducted of data extracted from the medical records of 73 consecutive patients who had symptomatic natal cleft PS over a 10-year period to compare use of NPWT to alginate-based/gauze daily dressing (DD) changes in terms of healing time and recurrence. Variables extracted included age, gender, PS wound diameter (small <1 cm, medium 1 cm to 3 cm, large >3 cm), and time in weeks to achieving the endpoint (epithelialization). Risk factors examined that can affect healing or recurrence of previously operated PS disease included initial drainage before excision and risk factors for impaired healing (morbid obesity as determined by body mass index [BMI] ≥35, chronic infective skin conditions, and ongoing therapy with immuno-modulating drugs or chemotherapy), and loss to follow-up. Data were collected and analyzed using the chi-squared statistic, Kaplan-Meier curves, and Cox regression models. The total time of follow-up was 390 weeks for the DD group and 311 weeks for NPWT group. Patient mean age was 26.5 ± 10.7 years, most (53, 72.6%) were male, and 12 (16.4%) had comorbidities potentially affecting healing. Nine (9) were treated with primary closure and 62 patients were treated with open healing by secondary intention (2 additional patients receiving DD were excluded from the analysis because they had small sinuses that made NPWT unfeasible). Among participants, 30 (48%) received DD and 32 had NPWT. The median time to healing was 10 weeks (95% CI: 7-17) in the DD group and 8 weeks (95% CI: 7-9) in the NPWT group (not significantly different). In patients who healed, the average time to healing was 15.0 ± 18.1 and 9.8 ± 6.3 weeks in the DD and NPWT groups, respectively (not significantly different). The PS wound recurred in 5 patients - 4 (12.5%) in the DD group and 1 (3.1%) in the NPWT group (P = .355). In univariate analysis, only the presence of comorbidities was found to significantly affect time to healing (HR 95%, CI: 0.40 [0.17-0.93]; P = .033]. Prospective, randomized controlled clinical studies are warranted.

Lumbar plexus schwannoma causing recurrent syncope.

Retroperitoneal schwannomas are rare and present non-specifically. They usually manifest secondary to their compressive effects on adjacent structures. We describe a patient who presented with recurrent syncope resulting from a large retroperitoneal schwannoma stretching the inferior vena cava and compromising venous return. We also discuss the salient aspects of preoperative investigations leading to definitive diagnosis and surgery.

Patients' perception of surgical training in private hospitals.

INTRODUCTION: Surgical training is traditionally a public hospital-based practice. At Epworth Private Hospital, Richmond, Victoria, there are three accredited surgical training positions and one fellowship position. We conducted a patient survey to review the patients' perspective of surgical trainees in private hospitals. METHODS: Over 6 weeks, 100 patients admitted under the surgical units with full-time surgical registrars were given a survey to complete in two parts on the training of surgeons in private hospitals. RESULTS: Seventy per cent of surveys were returned completed. Ninety per cent of respondents agreed that private hospitals should be involved in surgical training and 85.7% of patients were agreeable to having trainees involved in their operation. Only 1.4% of patients were not in agreement with surgical training in private and 8.6% of patients were neutral in their opinion. CONCLUSION: Our results clearly show that private hospital patients are generally favourably disposed to the presence and participation of surgical trainees in the private hospital setting.

The Victorian major trauma transfer study.

AIMS: To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events. METHODS: This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form. RESULTS: A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001). CONCLUSION: Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.

A benchmarking study of two trauma centres highlighting limitations when standardising mortality for comorbidity.

INTRODUCTION: A continuous process of trauma centre evaluation is essential to ensure the development and progression of trauma care at regional, national and international levels. Evaluation may be by comparison between pooled datasets or by direct benchmarking between centres. This study attempts to benchmark mortality at two trauma centres standardising this for multiple case-mix factors, which includes the prevalence of individual background pre-existing diseases within the study population. METHODS: Trauma patients with an Injury Severity Score (ISS) >15 admitted to the two centres in 2001 and 2002 were included in the study with the exception of those who died in the emergency department. Patient characteristics were analysed in terms of 18 case-mix factors including Glasgow Coma Scale on arrival, Injury Severity Score and the presence or absence of 9 co-morbidity types, and patient outcome was compared based on in-hospital mortality before and after standardisation. RESULTS: Crude mortality was greater at UHNS (18.2 vs 14.5%) with a non-significant odds ratio of 1.31 prior to adjusting for case-mix (P = 0.171). Adjustment for case mix using logistic regression analysis altered the odds ratio to 1.64, which was not significant (P = 0.069). DISCUSSION: This study did not demonstrate any significant difference in the outcome of patients treated at either hospital during the study period. More importantly it has raised several important methodological issues pertinent to researchers undertaking registry based benchmarking studies. Data at the two registries was collected by personnel with differing backgrounds, in formats that were not completely compatible and was collected for patients that met different admissions criteria. The inclusion of a meaningful analysis of pre-existing disease was limited by the availability of robust data and sample size. We suggest greater communication between trauma research coordinators to ensure equivalent data collection and facilitate future benchmarking studies.

Trial of interpersonal counselling after major physical trauma.

OBJECTIVE: The purpose of the present study was to determine if interpersonal counselling (IPC) was effective in reducing psychological morbidity after major physical trauma. METHODS: One hundred and seventeen subjects were recruited from two major trauma centres and randomized to treatment as usual or IPC in the first 3 months following trauma. Measures of depressive, anxiety and post-traumatic symptoms were taken at baseline, 3 months and 6 months. The Structured Clinical Interview for DSM IV diagnoses was conducted at baseline and at 6 months to assess for psychiatric disorder. RESULTS: Fifty-eight patients completed the study. Only half the patients randomized to IPC completed the therapy. At 6 months the level of depressive, anxiety and post-traumatic symptoms and the prevalence of psychiatric disorder did not differ significantly between the intervention and treatment-as-usual groups. Subjects with a past history of major depression who received IPC had significantly higher levels of depressive symptoms at 6 months. CONCLUSION: IPC was not effective as a universal intervention to reduce psychiatric morbidity after major physical trauma and may increase morbidity in vulnerable individuals. Patient dropout is likely to be a major problem in universal multi-session preventative interventions.

Tackling the burden of injury in Australasia: developing a binational trauma registry.

Existing trauma registries in Australia and New Zealand play an important role in monitoring the management of injured patients. Over the past decade, such monitoring has been translated into changes in clinical processes and practices. Monitoring and changes have been ad hoc, as there are currently no Australasian benchmarks for "optimal" injury management. A binational trauma registry is urgently needed to benchmark injury management to improve outcomes for injured patients.

Assessment of the trauma evaluation and management (TEAM) module in Australia.

AIM: To assess the immediate effect on trauma-related knowledge of the trauma evaluation and management (TEAM) program applied to medical students in Australia. METHODS: 73 final year medical students from Melbourne were randomly assigned to two experimental groups (E1 and E2 who completed the TEAM program after a 20 item MCQ pre-test on trauma resuscitation and a second MCQ exam after the TEAM program) and two control groups (C1 and C2 who completed the pre- and post-MCQ exams before completing the TEAM module). All 73 students completed an evaluation questionnaire. Paired and unpaired t-tests were used for within and between groups comparisons. RESULTS: Groups C1 and C2 had similar mean scores in pre- and post-tests ranging from 57.2 to 60.5%. Groups E1 and E2 had similar pre-test scores but increased their post-test scores (pre-test range 53.8-57.1% and post-test 68.8-77.4%, P < 0.05). On a scale of 1-5 with five being the highest, a score of four or greater was assigned by over 74% of the students that the objectives were met, over 80% that trauma knowledge was improved, 25-40% that clinical skills were improved with over 74% overall satisfaction. Over 75% assigned a score of four or greater suggesting the module be mandatory. CONCLUSIONS: After the TEAM program there was significant improvement in cognitive skills. The students strongly supported its introduction in the undergraduate curriculum.

Trauma management in Australia and the tyranny of distance.

Major trauma presents a time-critical medical emergency. Successful and expeditious management with early definitive treatment is required to prevent secondary injury. The resources in the prehospital setting, at the hospital of first treatment, and at the tertiary referral (major trauma) center all have an impact on the ability of an integrated trauma system to deliver optimal care to a patient. The time between leaving the injury site and instituting definitive care does not always equate with distance. Retrieval resources must be allocated carefully. Potentially preventable morbidity and mortality has been identified and is specifically related to the time between injury and definitive care and the efficiency of the retrieval and hospital transfer processes. These problems are being addressed with a further sophistication of integrated trauma systems. Regional trauma committees, unified and sophisticated ambulance services, good communication lines, adequate resources at major trauma services, and well developed surgical services are all essential for the appropriate and expeditious management of major trauma patients injured at a distance from tertiary referral (major trauma) centers.

Colon trauma: Royal Melbourne Hospital experience.

BACKGROUND: Recent studies from the USA and South Africa suggest that primary repair or resection and primary anastomosis have become the recommended treatment for most traumatic colon injuries. The aim of the present review is to determine the applicability of these studies to the urban Australian setting. METHODS: All patients with colon injuries operated on at the Royal Melbourne Hospital from March 1989 to March 1999 were identified. Data were collected by a retrospective chart review. RESULTS: A total of 20 patients sustained 26 injuries to the colon. Blunt injuries were more common than penetrating injuries (14 vs 6). Significant other injuries occurred in 15 patients. Colostomies were performed in four patients. The overall mortality rate was 10%. There were no anastomotic leaks. Primary repair or resection and primary anastomosis were not associated with any increase in intra-abdominal complications. CONCLUSION: Evidence from large trauma centres supporting primary repair or resection and primary anastomosis is also applicable to regions that have a low rate of traumatic colon injury.