Emergent craniotomy in rural and regional settings: recommendations from a tertiary neurosurgery unit: diagnosis and surgical decision-making.

Largely attributed to the tyranny of distance, timely transfer of patients with major traumatic brain injuries (TBI) from rural or regional hospitals to metropolitan trauma centres is not always feasible. This has warranted emergent craniotomies to be undertaken by non-neurosurgeons at their local hospitals with previous acceptable results reported in regional Australia. Our institution endorses this ongoing potentially life-saving practice when necessary and emphasize the need for neurosurgical units to provide ongoing TBI education to peripheral hospitals. In this first of a two-part narrative review, the authors describe the recommended diagnostic pathway for patients with a suspected TBI presenting to rural or regional hospitals and discuss local surgical management options in the presence or absence of a CT scanner.

Emergent craniotomy in rural and regional settings - recommendations from a tertiary neurosurgery unit: surgical technique and future prospects.

Kenneth G Jamieson described the emergent craniotomy for traumatic brain injuries (TBI) in the rural and regional setting back in 1965 in his book 'A First Notebook Of Head Injury'. Since then, there has been successful use of the technique in peripheral hospitals prior to the safe transfer of patients to metropolitan trauma centres. Although the procedure can be daunting in inexperienced hands, our institution supports ongoing education to continue implementation of trauma craniotomies by non-neurosurgeons if it means another life is potentially saved. Here we describe the surgical technique for an emergent craniotomy and craniectomy. Although the surgical technique has been described elsewhere, we have done so in a simplified 10-step approach with consideration of available resources in the peripheral hospital setting and the added pearls from the experience of a metropolitan neurosurgical unit. We also discuss future prospects for undertaking neurosurgical operations in peripheral hospitals but with intra-operative tele-surgery monitoring and supervision.

Index cholecystectomy rates in mild gallstone pancreatitis: a single-centre experience.

BACKGROUND: Gallstone pancreatitis (GSP) has evidence-based guidelines regarding management. Both the International Association of Pancreatology/American Pancreatology Association and American College of Gastroenterology recommend index admission cholecystectomy (IAC) in patients presenting with mild GSP. The aim of this study was to examine guideline adherence and GSP recurrence rate when IAC was not performed. A comparison between admitting specialty was also performed to examine the difference in compliance rates. METHODS: A retrospective chart review was conducted on all patients who presented to the Sunshine Coast Hospital and Health Service with GSP from December 2013 to December 2016. Patient demographics, timing of surgery, admitting specialty, laboratory and imaging results were recorded. RESULTS: A total of 95 patients were identified with a first presentation of mild GSP during the study period. Of whom, 66 (69.5%) underwent IAC and 29 (30.5%) were discharged prior to cholecystectomy with 10 of those patients receiving index admission endoscopic sphincterotomy. Five patients (17%) who did not receive IAC were readmitted with gallstone-related complications with the mean time to re-presentation of 12.8 days (range 7-21 days). Patients were more likely to receive IAC when admitted under surgery compared with gastroenterology (76% versus 20%, P < 0.001). CONCLUSION: Two out of three patients presenting with mild GSP underwent IAC in accordance with evidence-based management guidelines. Patients should be admitted under a surgical service to prevent delay in definitive management.

Addressing social influences reduces antibiotic duration in complicated abdominal infection: a mixed methods study.

BACKGROUND: Antimicrobial therapy for intra-abdominal infections is often inappropriately prolonged. An intervention addressing factors influencing the duration of intravenous antibiotic use was undertaken. This study reports the antibiotic prescribing patterns before and after the intervention and a qualitative analysis of the experience of the intervention. METHODS: Quantitative: A retrospective audit of patients with complicated intra-abdominal infection before and after a multifaceted persuasive intervention was performed. Qualitative: Semi-structured interviews were performed to evaluate which elements of the intervention were perceived to be effective. RESULTS: An intervention including collaborative inter-specialty and inter-professional educational meetings, and education of all professional streams was undertaken. Quantitative: Twenty-three patients before and 22 patients after the intervention were included. The total duration of antibiotics decreased significantly following the intervention (9.2 versus 6.6 days P = 0.02). The duration of intravenous antibiotics did not change significantly (5.4 versus 4.5 days, P = 0.06). Qualitative: Eighteen health-care professionals participated. Thematic analysis indicated that a collaborative approach between senior surgical and infectious disease specialists in the pre-intervention stage led to perceived ownership and leadership of the intervention by the surgical team, which was thought critical to the success of the intervention. Conversely, the ability of nurses and pharmacists to influence antibiotic practice was considered limited and a poster promoting the intervention was perceived as ineffective. CONCLUSION: Consultant leadership and specialty ownership of the process were perceived to be critical in the success of the intervention. Antibiotic stewardship programs which address social factors may have greater efficacy to optimize antimicrobial prescribing.

Yield of adenomas and colorectal cancers within 5 years of a negative colonoscopy: are the guidelines guiding?

BACKGROUND: Screening for colorectal cancers outside the recommended guidelines presents a considerable burden to resource management in many public hospitals. The aim of this study is to evaluate the frequency, indications and outcomes for repeat colonoscopy performed within 5 years of a negative colonoscopy. METHODS: A retrospective review of all colonoscopies at Nambour Hospital in 2008 was performed to identify those with a negative colonoscopy. The charts of patients undergoing repeat colonoscopy at the same institution within 5 years of a negative colonoscopy were examined further, and data obtained regarding indications and outcomes of subsequent colonoscopies. RESULTS: A total of 616 colonoscopies were identified, 427 (69.3%) were negative for adenoma and carcinoma. Of these patients, 74 (17.3%) underwent a repeat colonoscopy at Nambour Hospital within 5 years. Eighteen out of 74 (24.3%) were outside guideline recommendation. Overall, one patient (1.4%) had cancer and 11 patients (14.9%) had polyps detected at repeat colonoscopy. Most of the polyps detected had low-risk features and were detected in the fourth and fifth years of the study period. CONCLUSION: The yield of a second colonoscopy within 5 years of a good-quality negative colonoscopy is low but not zero. In the absence of new concerning symptoms or other risk factors, patients can be reassured and guidelines adhered to.

Outcomes of percutaneous cholecystostomy and predictors of subsequent cholecystectomy.

BACKGROUND: The use of a percutaneous cholecystostomy (PC) in the management of severe acute cholecystitis is a well recognized alternative to acute cholecystectomy. The need for definitive surgical management remains controversial. METHODS: A retrospective analysis of hospital records at Nambour General Hospital between 2012 and 2016 was conducted and data relating to indications, demographics, comorbidities and outcomes were collected. RESULTS: Thirty PC patients (20 male and 10 female) were identified, with a mean age of 77 years (range 46-93). Thirteen proceeded to cholecystectomy, nine elective and four emergent. Mean time to operation was 97 days (range 1-480). Ten were performed laparoscopically with a complication rate of 23% (3/13). One patient in the operative group died. Seventeen patients did not proceed to cholecystectomy. Fifteen resolved and were discharged, and two died. Three of those discharged were readmitted with gallstone disease requiring treatment, one of which died. A total of 71% (12/17) of the non-operative group died and three of those had a cause of death related to gallstone disease. The operative group was younger (P = 0.01) and had a lower estimated mortality risk (P < 0.05). In this cohort, this translated to an overall survival benefit (P < 0.01). CONCLUSION: Predictors of eventual cholecystectomy include younger age and lower estimated mortality risk. Patients who require a PC for the treatment of acute cholecystitis and subsequently go on to cholecystectomy can expect to have a favourable outcome.

The Duari hernia and recognition of the femoral vein compression sign.

Femoral hernias can be difficult to diagnose and are at high risk of strangulation. This report is of a rare case of an irreducible femoral hernia containing caecum and appendix presenting as an emergency. To the authors' knowledge, there have only been three cases reported, the first described by Duari. This case was incorrectly diagnosed preoperatively as an inguinal hernia, so the CT diagnosis of femoral hernias is reviewed, in particular demonstrating the radiological use of the femoral vein compression sign.

Hyperbilirubinaemia: its utility in non-perforated appendicitis.

BACKGROUND: The diagnosis of acute appendicitis is made using clinical findings and investigations. Recent studies have suggested that serum bilirubin, a cheap and simple biochemical test, is a positive predictor in the diagnosis of appendiceal perforation and may be more specific than C-reactive protein (CRP) and white cell count (WCC). The aim of this study was to investigate the utility of the serum bilirubin level in patients with suspected acute but non-perforative appendicitis. METHODS: A retrospective chart review of 213 patients who presented with suspected appendicitis in a 6-month period to Nambour General Hospital was performed. Serum bilirubin, WCC and CRP were recorded and analysed as to their utility in relation to the final diagnosis. RESULTS: A total of 196 patients underwent an appendicectomy and 41 of these were negative. The specificity of hyperbilirubinaemia for appendicitis overall was 0.83 with a positive predictive value (PPV) of 0.86, compared with CRP (specificity 0.40, PPV 0.75) and WCC (specificity 0.67, PPV 0.85). The area under the receiver operating characteristic curve for bilirubin was 0.6289 compared to 0.6171 for CRP and 0.7219 for WCC. A subgroup analysis of those with complicated appendicitis demonstrated a PPV for bilirubin of 0.66 compared to 0.58 for WCC and 0.34 for CRP in agreement with the literature. Subgroup analysis of hyperbilirubinaemia in simple appendicitis demonstrated a PPV of 0.81 compared to CRP (0.71) and WCC (0.82). CONCLUSION: Bilirubin had a higher specificity than CRP and WCC overall in patients with appendicitis. Hyperbilirubinaemia had a high PPV in patients with simple appendicitis.

Insurance status and time to completion of surgery for breast cancer.

BACKGROUND: The aim of this study was to compare the time to re-operation, following inadequate loco-regional surgery for breast cancer, between the public and private sectors of the Sunshine Coast region. METHODS: A retrospective review was performed of the medical records of all female patients undergoing guide wire-localized, breast-conserving surgery at Nambour General Hospital and in the local private sector from January 2009 until April 2010. The dates of initial consultation, operation, post-operative consultation and any subsequent reoperation were recorded. RESULTS: One hundred and seventeen public sector patients and 113 private sector patients were identified during the study period. Thirty-seven public patients (32%) and 46 private patients (41%) required re-operation. This difference was not significant (χ(2) = 2.06, degrees of freedom (df) = 1, P = 0.15). The mean time and standard error from the initial consultation to the first operation and re-operation in the public sector was 26 (2.3) and 62 (3.8) days, and in the private sector was 12 (1.2) and 30 (4.4) days, respectively P < 0.001. On average, 70% of public patients and 96% of private patients completed the surgical component of their breast cancer management within the Queensland Health-recommended time frame of 30 days (χ(2) = 26, df = 1, P < 0.001). CONCLUSION: While experiencing similar rates of re-operative surgery in breast cancer management in the public and private sectors, the private sector deals with this issue in a more time efficient manner. An opportunity for intervention by quarantining theatre time is explored to improve the public sector time management.

Short-term and long-term results of combined sclerotherapy and rubber band ligation of hemorrhoids and mucosal prolapse.

PURPOSE: Rubber band ligation is a common office procedure for symptomatic hemorrhoids. The aim of the study was to assess our short-term and long-term results of combined sclerotherapy and rubber band ligation in the management of hemorrhoids and incomplete mucosal prolapse. METHODS: Data on 6,739 patients who had previous combined sclerotherapy and rubber band ligation by the senior authors (GLN and PRD) were retrieved from the database dating between January 1976 and June 2000. These patients either had hemorrhoids or incomplete mucosal prolapse. Furthermore, questionnaires were sent to a random sample of 2,400 patients. Telephone interviews were performed for 600 of the nonrespondents. RESULTS: Of 6,739 patients (3,683 males; mean age, 46.7 years) in the database, 4,686 (70 percent) received the procedure once, and 2,053 (30 percent) received the procedure more than once. There were 5,689 patients (84 percent) who had their procedures performed consecutively within a planned period, and only 1,050 patients (16 percent) had repeat procedures after a period of more than 12 months from their last treatments. Thus, the recurrence rate was 16 percent. The overall complication rate was 3.1 percent, with minor bleeding being the major complaint. With regard to the questionnaire, 44 percent responded. The mean follow-up period was 6.5 (range, 1-11) years. There were patients who had residual symptoms of bleeding (19 percent), itch (21 percent), and lump (20 percent). However, 58 percent of patients who replied were asymptomatic. With satisfaction scores ranging from +3 to -3 (+3 indicating complete satisfaction and -3 indicating complete dissatisfaction), 90 percent scored >/=1, 9 percent scored 0 or less, and 1 percent did not specify a score. Hemorrhoidectomy was required in 7.7 percent of the responders. Of 600 phone interviews with the nonrespondents, 152 responded to the questionnaires. Although there was less satisfaction from the phone respondents, which may have accounted for the initial nonresponse, no statistical difference was detected in residual symptoms. CONCLUSIONS: Combined triple sclerotherapy and rubber band ligation is an effective treatment for early hemorrhoids and incomplete mucosal prolapse, with low rates of recurrence, complications, and hemorrhoidectomy, and it can be repeated easily.