Postgraduate trauma education; the surgeon; the cost

Injuries account for 3.6 million hospital admissions and approximately 100 billion dollars in health care costs annually. Surgical educators have expressed concern about the adequacy of postgraduate trauma education in light of this trauma epidemic. The purpose of this report was to evaluate our residents' trauma exposure and to examine the associated cost of training a physician to treat critically injured patients. From July 1982 through June 1987, 38,714 patients were evaluated for injuries in the emergency department. Five thousand sixty-one patients required admission to the hospital, and of these, 2,045 were admitted to the intensive care unit. In addition, 3,851 major trauma operations were performed during this 5-year period. The majority of these procedures were neurosurgical and orthopedic; however, we have seen an increasing percentage of abdominal operations in the last 2 years. The last five graduating chief residents averaged 181 major trauma operations during their training. The hospital currently writes off an average of $250,000 per month in trauma patient non-collections. This averages to 1.5 million dollars per resident for 5 years of trauma education in our institution. It is imperative that we continue to train trauma surgeons to manage critically ill patients; however, society must address the enormous cost of doing so.     

老年科护士对皮肤撕裂伤的认知现状及影响因素研究

目的 了解老年科护士对皮肤撕裂伤的认知现状,分析其影响因素,为开展相关培训提供参考。方法 采用便利抽样法,使用一般资料调查表、皮肤撕裂伤知识评估工具对武汉市3所三级甲等综合医院的286名老年科护士进行横断面调查。结果 老年科护士的皮肤撕裂伤认知得分为（9.53±2.02）分。老年科护士对皮肤撕裂伤认知正确率排名前5个条目分属于特殊群体、病因学、分类和观察维度;排名最低的5个条目分属于预防、治疗和风险评估维度。影响老年科护士对皮肤撕裂伤认知水平的主要因素为学历、工作年限、是否为专科护士、皮肤撕裂伤相关培训（均P<0.05）,共解释总变异的31.7%。结论 老年科护士对皮肤撕裂伤认知水平处于中等偏低水平,对与临床实践相关的预防、治疗和风险评估认知相对不足,应加强相关培训,提高老年科护士对皮肤撕裂伤的关注度,从而提高皮肤撕裂伤整体预防及护理水平。     

ASO Visual Abstract: Preoperative FDG Positive Lymph Nodes Predict the Postoperative Prognosis in Resectable Biliary Tract Cancers

Annals of Surgical Oncology -     

Give the patients the choice—The ‘walk in walk out’ hernia clinic

Background

Patients referred with symptomatic inguinal hernias traditionally make at least three visits to the hospital and wait on average 41-53 weeks for their operation. Approximately, 10-15% of patients either do not attend (DNA) their clinic appointment, attend on the day of operation or are cancelled by the hospital due to bed shortage, lack of theatre space or associated co-morbidities. This results in a significant psychological strain on the patients and a financial drain on NHS resources.

Aims

To set up a hernia service within the confines of the NHS and give patients the choice of having their hernia repaired under local anaesthetic with only one visit to the hospital, on a date of their choosing, as in private hernia centres but without incurring the cost.

Patients and Methods

An e-mail containing two detailed proformas, “suitability criteria” and “instructions for patients” was sent to each general practitioner (GP) referring hernia patients to the North West London Hospitals NHS Trust (Northwick Park and Central Middlesex Hospitals). The GP gave each suitable and willing patient the instructions booklet and faxed a referral letter to the consultant's (RPB) scheduler. Patients were advised to read the instruction booklet and, when ready, ring the scheduler to make an appointment for a date of their convenience for the consultation and operation at the same visit.

Results

Ninety patients have been referred to the ‘walk in walk out’ (WIWO) clinic in the last 6 months. Ninety one percent of these patients have had successful ‘tension free’ open mesh repair under local anaesthetic. There were five (6%) inappropriate referrals (recurrent or bilateral hernias), and three patients (3%) did not attend their appointment due to ill health or family bereavement.

Conclusion

Patients with unilateral primary reducible inguinal hernias, regardless of their ASA status can safely have open ‘tension free’ mesh repair under local anaesthetic on a date of their choosing by making just one visit to the hospital. In just 6 months this ‘WIWO’ hernia clinic has shown a high level of patient satisfaction, significant reduction in ‘did not attend’/cancellation rates and financial savings for the Trust. Similar clinics set up across the nation would multiply the benefits we have shown.     

Proteoglycans: the "Teflon" of the airways?

Proteoglycans are a family of structurally distinct, polyanionic complex carbohydrates composed of repeating disaccharide units. Proteoglycans include heparin, heparan sulphate, chondroitin 4- sulphate, chondroitin 6-sulphate, dermatan sulphate, and hyaluronic acid. Heparin is found in the granules of a subset of mast cells where it is bound to various mediators including histamine. Heparan sulphate has a much wider distribution in the body, being associated with stromal matrices, basement membrane and many cell surfaces, particularly the surface of endothelial cells. Heparin is an anticoagulant, but it is now very apparent that it possesses many other biological activities that have relevance to our understanding of lung diseases, particularly inflammatory diseases of the airway. Recent evidence suggests in the airway when administered by inhalation that could be exploited therapeutically.