Computed tomography in blunt abdominal trauma: an analysis of clinical management and radiological findings.

We have retrospectively assessed the computed tomography (CT) findings in 92 patients suffering severe blunt abdominal trauma. Surgical findings and clinical follow-up were correlated with the CT findings. In nine patients CT was first used after emergency surgery and provided baseline data which was useful for further management. In two patients CT did not demonstrate small hepatic lacerations seen during previous surgery. No deaths were recorded. In 16 patients surgery followed CT within 24 h; there was good correlation between the CT and operative findings in 10 patients. However, CT failed to detect significant solid organ injury in five patients and was misleading (false positive) in another patient. There were two deaths amongst these 16 patients. Sixty-seven haemodynamically stable patients were initially managed non-operatively. Fifteen of these 67 patients had normal CT examinations; only one had subsequent laparotomy (for reasons unconnected with the trauma) where no injury was detected; there were no deaths. Of the 52 patients with an abnormal CT examination, 43 were successfully managed non-operatively. There were three deaths, including one where an injury missed at CT contributed to the demise of the patient. After an initial trial of non-operative management, the remaining six patients went to surgery where there was good concordance with the CT findings except for one missed renal injury. Active non-operative management of blunt abdominal trauma is widely accepted in haemodynamically stable patients and this report shows how CT supports this policy of surgical restraint in such cases. However, on review CT missed 13 injuries in nine patients overall; stricter attention to technique and better equipment may lead to improved results in the future.     

Integrating children's services in England: national evaluation of children's trusts

Background Poor co‐ordination of services can have severe consequences for disadvantaged children with complex needs. Since 2003 national and local governments in England embarked on sweeping reforms aimed at improving and integrating local health, education and social services for children. These were to be organized locally by children's trusts and piloted by 35 children's trust pathfinders. Methods This study described and compared the experience of integrating children's services in all 35 children's trust pathfinders, covering 20% of children in England. It had a prospective mixed‐methods design. Over 3 years we interviewed 147 managers and professionals working in the children's trusts, including 172 semi‐structured interviews, carried out two questionnaire surveys of the 35 children's trusts and analysed official documents. Results In most areas different agencies jointly commissioned children's services, especially for mental health, disabilities and multi‐purpose children's centres, and increasingly pooled finances. Provision of multi‐agency and multi‐professional services was increasing. Professionals generally supported these changes but found them stressful. All children's trusts appointed directors of children's services and established boards representing multiple agencies. Systems for sharing information about individual children were mostly in place but were still underused. Health services were generally less involved in joint work than were local authorities' education and social care services, with notable exceptions. Areas where local authorities and health authorities shared geographical boundaries made most progress. Some children's trusts made few changes beyond their statutory obligations. Conclusion Children's trusts enabled major changes to services in areas where local actors and organizations were motivated and empowered. In other areas the remit of children's trusts was often too broad and vague to overcome entrenched organizational and professional divisions and interests. Policymakers need to balance facilitation of change in areas with dynamic change agents with methods for ensuring that dormant areas and agencies are not left behind.     

Outcome of laparoscopic Nissen fundoplication in patients with disordered preoperative peristalsis.

BACKGROUND: A 360 degrees or Nissen fundoplication remains controversial in patients with disordered peristalsis, some surgeons preferring a partial wrap to minimise postoperative dysphagia. AIM: To evaluate symptoms and manometric outcome in patients with disordered peristalsis after Nissen fundoplication. PATIENTS: In an initial series of 345 patients studied prospectively, 31 patients who had undergone a Nissen fundoplication had disordered peristalsis. Using preoperative manometry, patients were classified as: equivocal primary peristalsis (eight patients); abnormal primary peristalsis (four patients); abnormal maximal contraction pressure (13 patients); abnormal primary peristalsis and maximal contraction pressure (six patients). METHODS: Postoperatively, patients underwent a barium meal, oesophageal manometry and standardised clinical review by a blinded scientific officer. RESULTS: Twenty eight (90%) patients had satisfaction scores of at least 8 out of a maximum of 10 and all would undergo surgery again. Whereas 15 (48%) patients had dysphagia scores greater than 4/10 preoperatively, only two (6%) had these scores at one year. Improved peristalsis was seen in 78% of postoperative manometric studies, and mean preoperative lower oesophageal sphincter pressure increased from 6.6 (range 0-21) mm Hg to 19 (4-50) mm Hg. CONCLUSIONS: These results are similar to the overall group of 345 patients and suggest that disordered peristalsis, and possibly even absent peristalsis, is not a contraindication to Nissen fundoplication as performed in these patients.     

Narrative and procedural discourse in temporal lobe epilepsy.

It is well established that some individuals with temporal lobe epilepsy (TLE) demonstrate language deficits at the single word level. However, discourse production rarely has been examined quantitatively within this group. This study compared adult TLE patients with an early seizure onset (< or = age 14 years, n = 27) to a control group (n = 28) on narrative and procedural discourse tasks. As a group, the TLE patients performed normally on the procedural discourse task, but differed significantly from the controls on several narrative discourse variables. At the individual level, 30% of the TLE patients versus 4% of the controls demonstrated impaired discourse ability (p and 0.01). Within this early onset TLE group, discourse performance was not associated with demographic or seizure history variables. Considering the cognitive domain, discourse performance correlated significantly with working memory. In summary, mild discourse dysfunction was present in a significant minority of early onset TLE patients, but this deficit was not closely associated with other language measures. Discourse ability and its neuropsychological, neuroanatomical and conversational speech correlates deserve further study in TLE patients.     

Influence of peripheral afferents on cortical and spinal motoneuron excitability.

The objective of this study was to establish to what extent muscle, cutaneous, and joint afferents alter the excitability of spinal and cortical motor neurons. This question was examined by studying the impact of electrical stimulation of the second and third digits, the median nerve at the wrist, and the recurrent thenar motor branch on the F/H and magneto-electrical cortical motor responses (MEPs) of the thenar muscles. The firing frequencies of single F/H motor unit action potentials were unaltered by the foregoing conditioning peripheral stimuli. MEPs conditioned by motor threshold stimulation of the median nerve at the wrist or the recurrent motor branch were significantly increased in size at conditioning to test intervals of 50 to 80 milliseconds. No significant change in MEP size resulted from conditioning stimulation of the digital nerves. We conclude that muscle afferents were primarily responsible for the increase in MEP size. Conditioning stimuli may allow examiners to assess central motor conduction where it would otherwise be impossible.