Intravenous fluid and electrolyte administration in elective gastrointestinal surgery: mechanisms of excessive therapy.

INTRODUCTION While clinical guidelines stress the importance of the judicious perioperative intravenous fluid administration, data show that adherence to these protocols is poor. The reasons have not been identified. We therefore audited the magnitude and indications of fluid and electrolyte administration in a teaching hospital. We hypothesised that epidural analgesia is associated with excessive fluid therapy. MATERIALS AND METHODS Intravenous fluid and electrolyte administration during the day of surgery and the subsequent 2 days in consecutive patients undergoing elective gastrointestinal surgery between November 2013 and May 2014 were retrospectively audited. Timing, volumes and indications were recorded. RESULTS One hundred patients undergoing elective gastrointestinal resection were studied. Patients received 9030 ml ± 2860 ml (mean ± standard deviation) intravenous fluids containing a total of 1180 ml ± 420 mmol sodium and resulting in a cumulative fluid balance of +5120 ml ± 2510 ml; 44% ± 14% of total volumes were given in theatre. Nearly all fluid was given for maintenance, 100% (96-100%, interquartile range), with 17 patients only receiving replacement or resuscitation. Independent predictors of increased volumes included open surgery, upper gastrointestinal surgery, increased duration and epidural analgesia but not body weight. Postoperative fluid volume was the only independent predictor of postoperative complication grade (P = 0.0044). CONCLUSIONS Despite published guidelines, perioperative fluid and electrolyte administration were excessive and were associated with postoperative morbidity. Substantial volumes were administered in theatre. Nearly all administration was for maintenance, yet patients received approximately five times the amount of sodium required. Epidural analgesia was an independent predictor of fluid volumes but body weight was not.

Mothers' decision-making during times of stress as a lone parent: a qualitative study.

INTRODUCTION: Little empirical evidence exists to identify the impact that a partner's absence or presence has on the mother's decision-making and her consequential help-seeking behaviour when her child is unwell. METHODS: This study used a qualitative design in three phases using focus groups and interviews to explore Army mothers' help-seeking behaviour as a lone parent when their child was unwell during the out-of-hours period. Thirty-one parents from a British Army garrison were interviewed. RESULTS: The findings demonstrated that Army life created a combination of stressors for Army mothers, which altered their help-seeking behaviour when their child was unwell. When their partner was available, mothers contacted health services as a last resort, once all other avenues had been exhausted. However, in contrast, in their partners' absence, they were contacted as a first resort. CONCLUSION: An algorithm was generated from the findings, which illustrates the importance of ascertaining whether the mother is alone at the time of the consultation. Increased emotional vulnerability intensified the need for reassurance and affected a mother's decision-making ability. Primary healthcare staff should ascertain whether mothers are currently lone parents at an early stage of their assessment, as this may influence the entire consultation.

Rear Operations Group medicine: a pilot study of psychological decompression in a Rear Operations Group during Operation HERRICK 14.

OBJECTIVES: To investigate group activity psychological decompression (GAPD) in a Rear Operations Group. METHODS: Provision of military archaeological exercises for a Rear Operations Group's medical centre patients during Op HERRICK 14 with analysis of before and after Patient Health Questionnaires (PHQ), Work and Social Adjustment Scales, generalised anxiety disorder (GAD) 7 Anxiety, Audit Questionnaire and Impact of Events Scale Revised and analysis of interviews with supervisors and soldiers. RESULTS: Soldiers reported a mean of 13%-38% improvement across the self-reported domains. The civilian archaeologists reported improvements in self-esteem, morale and team-working. 10 out of 24 soldiers have expressed an interest to pursue archaeology further; eight soldiers disclosed mental health issues for the first time, four of whom required mental health referral. CONCLUSIONS: GAPD can help early-returned soldiers in reducing symptoms of anxiety, depression, isolation and psychological traumatic symptoms. It also helps to increase perception of their ability to work and socialise as a team and help them to an early return to work. It can provide soldiers with the opportunity to approach their supervisors in an informal manner and help in early detection of mental health problems.

Factors affecting front line casualty care in Afghanistan.

OBJECTIVE: Limited research has been undertaken to assess the effectiveness of pre-hospital care given at the point of wounding, nor how battlefield conditions affect the implementation of Battlefield Advanced Trauma Life Support (BATLS). This study examines the quality of care given at Role 1 and the psychological impact on clinical personnel of the application of current pre-hospital trauma management guidelines. METHOD: Data was collected through 17 digitally recorded semi-structured interviews with healthcare clinicians deployed in Role 1 medical facilities on OP HERRICK 14 following major medical incidents. Interview transcripts were subjected to content analysis based on a modified grounded theory approach. RESULTS: Triage was found to be done poorly with individuals treating patients as they were found rather than by identifying clinical priorities. Pain management was not always achieved. Fluid replacement was hampered with difficulty in obtaining parenteral access. Subsequently fluids were sometimes given in excess of protocols. Clinical documentation was not always completed even after a patient had been evacuated. Some interesting elements were noted, such as post incident reports being used as a reflective process which may be self-developmental and help clinicians deal psychologically with the incident. Clinical personnel carry out their duties, irrespective of personal injury or threats to their safety. However their performance may be tapered under such stress. Human factors training prior to deployment may help to ensure adherence to BATLS protocols despite the complexities of the battle space. CONCLUSIONS: The data identified a number of factors that affected clinicians ability to provide a high standard of casualty care. The general perception of this research cohort was that despite all the obstacles, the level of trauma care was of a high nature. However, the study provides pointers to a number of areas for future exploration where patient care was not BATLS protocol compliant.

Detecting post-deployment mental health problems in primary care.

Post-deployment mental health problems are a source of potential concern for health professionals and politicians in military forces in the world; the UK Armed Forces are no exception. This article examines practical ways in which General Practitioners in Primary Care can enhance their ability to detect post-deployment mental health problems and offers suggestions on immediate management and assessment, based on contemporary evidence and clinical experience.

The doctor vs. the Command: can disagreement arise?

Doctors have long since assisted the Command on operations and in providing day to day bespoke medical care to the UK Armed Forces. Doctors and the Command work along different models that confer different obligations and priorities. For doctors the patient and their wellbeing is of primary importance and for the Command, the Unit as a whole with its military goals are of primary concern. Most of the time these two models work in harmony. However occasionally disagreement can arise. This article examines the models guiding their respective practice in order to understand the underpinnings of these disagreements, and offers some discussion of the issues, particularly as they pertain to the deployed environment. Finally, some recommendations are made to equip doctors and the Command to contain any disagreements.

Which quality and outcomes framework (QOF) clinical indicators are applicable for British Forces Germany Health Service (BFG HS) primary care?

OBJECTIVES: To determine which QOF clinical indicators are applicable for BFG HS primary care. METHOD: In depth cross-sectional survey of BFG HS general practitioners. Participants were requested to assess all 19 QOF clinical domains (80 clinical indicators) and to indicate to what extent these were applicable for BFG HS (Likert scale 1-5). Response rate was documented. Cronbach's alpha reliability was calculated and a comparison of the mean responses of training and non-training practices was made. RESULTS: The response rate was 80% (28/35). Cronbach's alpha was 0.91.The mean score for both training practices and non-training practices was 3.9. Based on the mean score the applicable indicators were (in descending order): Hypothyroidism (mean 4.6, 95% confidence interval 4.5-4.8), Hypertension (4.6, 4.5-4.8), Asthma (4.3, 4.2-4.5), Diabetes mellitus (4.3, 4.2-4.3), Obesity (4.1, 4.0-4.2), Chronic Heart Disease (4.1, 3.9-4.2), Epilepsy (4.0, 3.9-4.2) and Smoking (4.0, 3.7-4.2). Problematic were (descending means): Cancer (3.9, 3.6-4.2), Stroke and TIA (3.8, 3.7-4.0), Atrial fibrillation (3.6, 3.3-3.8), Learning disabilities (3.5, 3.1- 4.0), Chronic kidney disease (3.5, 3.3-3.8), Chronic Obstructive Pulmonary Disease (3.5, 3.3-3.7), Mental health (3.5, 3.3-3.6), Heart failure (3.4, 3.1-3.7), Depression (3.2, 2.8-3.5) and Palliative care (3.2, 2.7-3.6). Not applicable was Dementia (2.4, 2.0-2.8). CONCLUSION: This study shows that several but not all QOF clinical indicators are applicable in BFG HS. Therefore QOF cannot be directly transferred to BFH HS and an adapted quality framework is required.

Analysis of out of hours telephone consultation at the medical reception station Sennelager, British Forces Germany.

The advent of 'NHS Direct', has centred attention on nurses giving telephone advice as part of the provision of out of hours medical care. A three month retrospective study of telephone consultations by nurses at the MRS Sennelager showed that telephone consultation greatly contributes to "out of hours" medical care. The outcome of telephone consultations made out of hours revealed that in 70% of telephone calls the advice given enables the patient to stay at home. Twenty eight percent of patient contact out of hours was by telephone.

Carers as equal partners in care planning.

This was a pilot study that assessed the process and outcome of an initiative whereby carers of patients with dementia were given a designed package of documentation to hold at home. The research involved 20 carers of patients with dementia having carer-held records at home for a 6-month period. The aims of the research were: to assess carers' satisfaction with the system; to evaluate the actual use made of the documents by both carers and professionals: to assess the suitability of the document design; and to assess carers' roles as partners with professionals in care planning via use of the record. Both quantitative and qualitative data were obtained by use of a questionnaire that used quantitative scales of measurement and allowed carers to express views. The results showed that carers reported benefits of the system and felt more empowered and valued by service providers because of use of the documentation. However, there were design faults in the document itself, which were addressed as a result of the pilot study. A need for preparatory and on-going education of clients and professionals was also identified regarding the best use of the document for all parties. A follow-up three-year longitudial study is planned in which health outcomes of the use of carer-held records will be quantitatively measured. The problems identified in this pilot study will be addressed before the launch of the main study; several potential confounding variables have been recognized and can be controlled.

Late complications after open carpal tunnel decompression.

66 patients (89 hands) were assessed at least 10 months after open carpal tunnel decompression. Tender scars were found in 19% of the hands and 4% were affected by pillar pain. Grip strength was reduced in more than half of the operated hands. Hypo- and anaesthesia in the scar area were affecting 7% but were not considered disabling. In 18% of the cases there was incomplete relief of primary symptoms.

Survey of carer satisfaction with the quality of care delivered to in-patients suffering from dementia.

Quality assurance in British National Health Service provision stresses the importance of taking account of the consumer's viewpoint. Elderly patients with dementia are not always able to contribute usefully to satisfaction surveys. Therefore, their careers' views were sought in order to assess the quality of services offered to this client group. Forty-one careers of patients discharged from the eight wards for the elderly mentally ill in Leicestershire, England, were randomly selected. Individual focused interviews were conducted in careers' own homes. Both quantitative and qualitative data were obtained by use of a questionnaire designed to tap the patients'/careers' experiences from pre-admission, through hospital stay to post-discharge. Interviews were asked to describe their favorable/unfavorable impressions of, and reactions to, all aspects of hospital care. These interviews were tape-recorded. Analysis of the data included quantitative measurements of scale ratings. Grounded theory was used to analyse qualitative data. A wealth of information was uncovered using this research technique. Much that was positive about the service was elicited. However, careers highlighted areas where they felt the quality of care could be improved within all the foci discussed. Twenty-two recommendations for quality improvements in service provision were made in the report as a result of this survey.

Koppitz scoring system as a measure of Bender-Gestalt performance in behaviorally and emotionally disturbed adolescents.

Data are presented to assess the use of the Koppitz scoring system for the Bender-Gestalt Test in a sample (N = 87) of behaviorally and emotionally disturbed adolescents. Results suggested that age was modestly related to Koppitz Developmental scores, an indication that visual-motor skills continue to develop beyond age 11. Scores were related to spatial perception skills as measured on the WISC-R. Gender, primary psychiatric diagnosis, educational tests, and MMPI scores were not related to Bender performance. Findings are discussed in terms of a need for additional research into the utility of the Bender as a measure of visual-motor skills in adolescents.

Method of recruiting subjects and performance on cognitive tests.

College students often serve as participants in psychological research. The effects of three methods of recruiting subjects for laboratory tests of attention and memory were assessed in a series of studies. The performance of students who received monetary incentives and the performance of students who received course-credit incentives were compared with the performance of students recruited from classes where research participation was a requirement. Monetary incentives resulted in slight, but significant, improvements in performance on tests of sustained attention and recognition memory. Course-credit incentives did not affect subjects' test performance. Test performance did not differ as a function of the time of the semester when studies were conducted. Recruitment issues pertinent to departmental subject pools are discussed.

Computed tomography with a linear accelerator with radiotherapy applications.

An earlier paper [Simpson et al., Med. Phys. 9, 574 (1982)] described a computed tomography (CT) scanner that was constructed by adding a detector array to a 4-MV isocentric linear accelerator. Since the previous article, the detector array has been improved and we now demonstrate better than 3-mm spatial resolution and better than 1% relative electron density discrimination. A series of pictures from volunteer patients is included. Normal anatomy is visualized with bone, muscle, fat, and air being clearly delineated.

A 4-MV CT scanner for radiation therapy: the prototype system.

A Varian 4-MV isocentric therapy accelerator has been modified to perform also as a CT scanner. The goal is to provide a computed tomography capability for use in radiotherapy at low cost. We envision three principal uses for the system. These are (i) to provide two and three-dimensional maps of electron density distribution for CT assisted therapy planning; (ii) to aid in patient set up by providing sectional views of the treatment volume and high contrast scout-mode verification images; and (iii) to provide a means for periodically checking the patients anatomical conformation against that which was used to generate the original therapy plan. The machine was modified by mounting an array of detectors on a frame that is bolted to the counterweight end of the gantry in such a manner as to define a "third generation" CT scanner geometry. Details of the detectors and data acquisition electronics are provided. We present results of phantom studies which demonstrate that this prototype system has a spatial resolution of 4 mm and the ability to discriminate electron density differences of less than 1%. We also show that the system is exactly linear over a wide range of electron densities corresponding to those found in body tissues.

Imaging with rotating slit apertures and rotating collimators.

The statistical quality of conventional nuclear medical imagery is limited by the small signal collected through low-efficiency conventional apertures. Coded-aperture imaging overcomes this by employing a two-step process in which the object is first efficiently detected as an "encoded" form which does not resemble the object, and then filtered (or "decoded") to form an image. We present here the imaging properties of a class of time-modulated coded apertures which, unlike most coded apertures, encode projections of the object rather than the object itself. These coded apertures can reconstruct a volume object nontomographically, tomographically (one plane focused), or three-dimensionally. We describe a new decoding algorithm that reconstructs the object from its planar projections. Results of noise calculations are given, and the noise performance of these coded-aperture systems is compared to that of conventional counterparts. A hybrid slit-pinhole system which combines the imaging advantages of a rotating slit and a pinhole is described. A new scintillation detector which accurately measures the position of an event in one dimension only is presented, and its use in our coded-aperture system is outlined. Finally, results of imaging test objects and animals are given.

Closed rupture of extensor digitorum communis tendon following fracture of the radius.

A case of closed rupture of the extensor digitorum communis tendon following a fracture of the lower end of the radius with anterior displacement, is described. This rare complication was treated successfully by abductor pollicis longus tendon transfer.

Interpositional arthroplasty of the wrist in rheumatoid arthritis.

The procedure of interpositional arthroplasty of the wrist joint in rheumatoid arthritis, using silicone sheeting, is described. The results and complications of sixty arthroplasties are presented.