Systematic review of the use of endo-luminal topical negative pressure in oesophageal leaks and perforations.

Topical negative pressure is widely used in the management of superficial wounds. The use of this technology in the management of oesophageal perforations is becoming increasingly common. This systematic review aims to capture available evidence about its use in this setting. Medline and Embase were searched using MeSH terms and free text: esophageal perforation; esophageal injury; vacuum assisted closure; vacuum therapy device; esophagus; wounds penetrating; esophageal perforation; wound healing; negative pressure wound therapy. Searches were carried out between April and November 2015. Case series, cohort trials and controlled trials were included. Additional studies were found by hand searching reference lists. Eleven studies met the inclusion criteria with 180 patients. Nine of the studies were case series and two were retrospective comparisons of negative pressure with stents or clips. Healing of the perforation occurred in 163/179 patients and the overall mortality was 12.8%. Compared with published data on mortality from oesophageal perforation, the application of negative pressure appears to be beneficial. The studies are, however, limited to case series and retrospective cohort studies. The number of patients in each study is small and in the absence of randomized trials demonstrating a lack of bias firm conclusions cannot be made.

British Military surgical key performance indicators: time for an update?

BACKGROUND: Key performance indicators (KPIs) are metrics that compare actual care against an ideal structure, process or outcome standard. KPIs designed to assess performance in deployed military surgical facilities have previously been published. This study aimed to review the overall performance of surgical trauma care for casualties treated at Role 3 Camp Bastion, Medical Treatment Facility, Afghanistan, in light of the existing Defence Medical Services (DMS) KPIs. The secondary aims were to assess the utility of the surgical KPIs and make recommendations for future surgical trauma care review. METHODS: Data on 22 surgical parameters were prospectively collected for 150 injured patients who had primary surgery at Camp Bastion between 1 May 2013 and 20 August 2013. Additional information for these patients was obtained using the Joint Theatre Trauma Register. The authors assessed data recording, applicability and compliance with the KPIs. RESULTS: Median data recording was 100% (IQR 98%-100%), median applicability was 56% (IQR 10%-99%) and median compliance was 78% (IQR 58%-93%). One KPI was not applicable to any patient in our population. Eleven KPIs achieved >80% compliance, five KPIs had 80%-60% compliance and five KPIs had <60% compliance. Recommendations are made for minor modifications to the current KPIs. CONCLUSION: 78% compliance with the DMS KPIs provides a snapshot of the performance of the surgical aspect of military trauma care in 2013. The KPIs highlight areas for improvement in service delivery. Individual KPI development should be driven by evidence and reflect advances in practice and knowledge. A method of stakeholder consultation, and sequential refinement following evidence review, may be the right process to develop the future set of DMS KPIs.

Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis.

INTRODUCTION: Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies. METHODS: Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation. RESULTS: 26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI=5.10-7.51), and 15.90 (95% CI=9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay. CONCLUSION: Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen.

Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom.

The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.

Damage control - trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care.

INTRODUCTION: Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. METHODS: The Ovid MEDLINE(®), EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. FINDINGS: A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome.

Identification of dental implants through the use of Implant Recognition Software (IRS).

AIM: To develop computer software to allow general dental practitioners and others to identify unidentified implants in patients' mouths using a range of criteria. METHODS: Internet searches for implant manufacturing companies worldwide in all languages using terms: dental implants, dental implant manufacturers and dental implant companies. Once identified, all relevant information including images regarding dental implant products was collected even that for discontinued products. A program was then devised using key design factors to enable identification of individual implants. RESULTS: The searches produced details for 87 implant manufacturers based in 21 countries with 231 different implant designs. The resultant program has been successfully trialled and used in both general dental practice and for forensic identification. CONCLUSION: The program developed provides a valuable adjunct to the identification of implant systems present in patients' mouths.

Stability and haplotype analysis of the FRAXE region.

FRAXE full mutations are rare and appear to be associated with mild mental retardation. As part of a screening survey of boys with learning difficulties to determine the frequency of full and premutations, we have collected data on the frequency of instability at FRAXE for about 4000 transmissions and the haplotype for over 7000 chromosomes. The distribution of FRAXE repeats was similar to other English populations but differed from two North American Caucasian series. Observed instability at FRAXE was rare but increased with increasing repeat number, and there were no expansions into the full mutation range, except in pedigrees ascertained through a full mutation. Haplotype analysis suggested division into five groups with each group having a characteristic distribution of FRAXE repeats. Fourteen of the 15 full mutations occurred on a single haplotype and this haplotype also had a significant excess of intermediate-sized alleles, suggesting that full mutations originate from large normal alleles. However, a related haplotype also had a significant excess of intermediates but we observed no full mutations on this haplotype, suggesting either loss or gain of stability determinants on it. We suggest that whilst triplet repeat size is a significant predisposing factor for expansion at FRAXE other genetic determinants are also likely to be important.

FRAXA and FRAXE: the results of a five year survey.

We report the results of a five year survey of FRAXA and FRAXE mutations among boys aged 5 to 18 with special educational needs (SEN) related to learning disability. We tested their mothers using the X chromosome not transmitted to the son as a control chromosome, and the X chromosome inherited by the son to provide information on stability of transmission. We tested 3738 boys and 2968 mothers and found 20 FRAXA and one FRAXE full mutations among the boys and none among the mothers. This gives an estimated prevalence of full mutations in males of 1 in 5530 for FRAXA and 1 in 23 423 for FRAXE. We found an excess of intermediate and premutation alleles for both FRAXA and FRAXE. For FRAXA this was significant at the 0.001 level but the excess for FRAXE was significant only at the 0.03 level. We conclude that the excess of intermediate and premutation sized alleles for FRAXA may well be a contributing factor to the boys' mental impairment, while that for FRAXE may be a chance finding. We studied approximately 3000 transmissions from mother to son and found five instabilities of FRAXA in the common or intermediate range and three instabilities of FRAXE in the intermediate range. Thus instabilities in trinucleotide repeat size for FRAXA and FRAXE are rare, especially among alleles in the common size range.

FRAXA and FRAXE: evidence against segregation distortion and for an effect of intermediate alleles on learning disability.

There have been several claims of segregation distortion (meiotic drive) for loci associated with diseases caused by trinucleotide repeats, leading us to test for this phenomenon in a large study of the X-linked loci FRAXA and FRAXE. We found no evidence of meiotic drive in females and no convincing evidence in males, where the limitation of risk to daughters creates a testing bias for alleles of interest. Alleles for pre- and full mutation, intermediate alleles, and common alleles were analyzed separately, with the same negative results that are extended in the discussion to claims of meiotic drive for other diseases. On the other hand, an excess risk of learning difficulties was confirmed for intermediate FRAXA alleles (relative risk, 2.58 +/- .74) and suggested for intermediate FRAXE alleles. The penetrance of learning difficulty is low, the risk being estimated as .039 for FRAXA common alleles and .101 for intermediate alleles. Because of their lower gene frequency, full mutations are a less frequent cause of learning difficulty than intermediate alleles, which contribute .0020 to total prevalence and .0012 to attributable prevalence of learning difficulty.

The role of size, sequence and haplotype in the stability of FRAXA and FRAXE alleles during transmission.

Factors involved in the stability of trinucleotide repeats during transmission were studied in 139 families in which a full mutation, premutation or intermediate allele at either FRAXA or FRAXE was segregating. The transmission of alleles at FRAXA, FRAXE and four microsatellite loci were recorded for all individuals. Instability within the minimal and common ranges (0-40 repeats for FRAXA, 0-30 repeats for FRAXE) was extremely rare; only one example was observed, an increased in size at FRAXA from 29 to 39 repeats. Four FRAXA and three FRAXE alleles in the intermediate range (41-60) repeats for FRAXA, 31-60 for FRAXE) were unstably transmitted. Instability was more frequent for FRAXA intermediate alleles that had a tract of pure CGG greater than 37 although instability only occurred in two of 13 such transmissions: the changes observed were limited to only one or two repeats. Premutation FRAXA alleles over 100 repeats expanded to a full mutation during female transmission in 100% of cases, in agreement with other published series. There was no clear correlation between haplotype and probability of expansion of FRAXA premutations. Instability at FRAXA or FRAXE was more often observed in conjunction with a second instability at an independent locus suggesting genomic instability as a possible mechanism by which at least some FRAXA and FRAXE mutations arise.

Dieldrin toxicity in housed merino sheep.

An outbreak of nervous disease with deaths and reproductive failure was investigated in a fully housed flock of 640 super fine wool (Sharlea) Merino sheep. During the 4 months after the flock was dipped in dieldrin, 70 adult sheep died and no live lambs were produced by the ewes. The diagnosis of poisoning with dieldrin was based upon the presence of characteristic clinical signs, pathological findings and the detection of residues of dieldrin in tissues. Deficiency of vitamin A was confirmed in 2 sheep and may have contributed to the reproductive failure.

An association between encephalomyocarditis virus infection and reproductive failure in pigs.

An outbreak of reproductive failure, characterised by mummified foetuses and stillbirths, was investigated in an intensive piggery. Six foetuses that died towards the end of gestation had multifocal myocardial necrosis and encephalomyocarditis virus was recovered from 4 of these foetuses but not from 6 mummified foetuses. There was also a significant increase in failure of conception or early embryonic deaths in sows mated at the same time as sows which produced affected litters.