Neonatal education in the North East: A collaborative venture

This article describes a change in the teaching and learning strategy for newly qualified neonatal nurses who wish to become qualified in the speciality (QIS) of neonatal nursing. Two modules have undergone revision in the light of feedback from the Regional Neonatal Network and evaluations from stakeholders. This paper provides the rationale for change and discusses developments in teaching and learning strategies, and the planning and implementing process involved in the change. Factors to take into consideration when evaluating the change and implications for future developments are also briefly discussed.     

Three Different Ways Mental Health Nurses Develop Quality Therapeutic Relationships

The purpose of this study was to determine if there were different ways in which mental health nurses develop quality therapeutic relationships with patients. A taxonomy of 140 attributes were identified as important to the formation of a quality therapeutic relationship in mental health nursing. These attributes provided the basis for the development of a Q-sort instrument, which was piloted. Results led to the identification of three clusters of mental health nurses who share similar beliefs regarding the attributes required to develop a quality therapeutic relationship with patients. These groupings of attributes were called “Equal Partner,” “Senior Partner,” and “Protective Partner.” Recommendations are provided and include that nurses consider their nursing style in their choice of employment environment and that managers consider their nurses' individual styles in determination of an optimal case mix.     

The effect of first metatarsophalangeal joint arthrodesis on the first ray and the medial longitudinal arch: a radiographic study.

The purpose of this study was to examine the effect of first metatarsophalangeal arthrodesis on the sagittal plane orientation of the first ray and the medial longitudinal arch. Lateral weightbearing radiographs of 48 patients (54 feet) having undergone the procedure were retrospectively reviewed. Patients were separated into three groups based on their preoperative diagnosis: hallux rigidus, hallux valgus, or rheumatoid forefoot deformity. First metatarsal declination, talometatarsal, talar declination, calcaneal inclination, and talocalcaneal angles were measured on pre- and postoperative radiographs. Multivariate analysis of variance determined that there was a significant postoperative change (p < .001) in angular measurements, particularly in the first metatarsal declination, talometatarsal, and talocalcaneal angles. There was also a significant difference (p < .01) in the angular measurements between the hallux rigidus group and the other two groups. However, the amount of change from pre- to postoperatively did not vary significantly between the groups. A calculation of Pearson correlation coefficients found no significant correlation between the hallux dorsiflexion angle and changes in angular measurements. The radiographic changes found in this study support Hicks' windlass model: fixed dorsiflexion of the hallux causes plantarflexion of the first ray and an increase in the medial longitudinal arch.     

A meta-analysis of optimum plane placement and related morbidity in primary breast augmentation

Despite extensive clinical experience of breast implants, there is continued controversy regarding the optimum placement of the prosthesis. More importantly, there is insufficient data to accurately determine whether subglandular (SG) or submuscular (SM) placement of the prosthesis diminishes postoperative complications. A search of published trials (n = 34) examined complication rates following SG and SM implant placement was conducted. Pubmed (MEDLINE) database was used and the available data was then cross-referenced. Eligible trials (n = 6) were then reviewed and selected data extracted. Primary outcomes measured were postoperative haematoma, infection, capsular contracture and implant migration. 3603 patients were identified from relevant trials examining postoperative complication rates for both subglandular and submuscular implant planes. The submuscular implant plane was associated with a higher incidence of postoperative haematoma (OR 2.87, 95% CI, 1.44-6.11). The incidence of capsular contracture (OR 4.77) is more common when a subglandular plane is used. No significant difference was noted in the rate of postoperative infection (OR 1.20, 95% CI 0.57-2.58) or implant migration (OR 1.56, 95%CI 0.12-87.4) between the two groups. This meta-analysis confirms that subglandular augmentation results in lower short-term morbidity; however, submuscular placement appears to provide the best long-term outcome in terms of morbidity. In the absence of randomized controlled trials comparing these two techniques, this meta-analysis provides evidence to guide surgeons to achieve the best outcomes for their patients.     

Subintimal angioplasty for femoro-popliteal occlusive disease

There has been a longstanding debate about the roles of surgical bypass graft, percutaneous transluminal angioplasty, subintimal angioplasty, and conservative management for femoro-popliteal occlusive disease. Subintimal angioplasty was first described in 1987 as a method of performing an endovascular arterial bypass. The subintimal space at the start of the occlusion is entered with a catheter and a wire loop is used to cross the occlusion and reenter the vessel lumen distally. In patients with critical limb ischemia, there is high quality evidence demonstrating that the limb salvage rate and amputation-free survival rates for surgery and endovascular treatment are similar, but surgery is more expensive than angioplasty in the short term. In patients with intermittent claudication, surgical bypass using an autologous saphenous vein graft is currently believed to be the gold standard, but this is increasingly questioned in the light of recent advances in endovascular techniques. Surgical bypass with vein graft offers a 2-year patency of 81%, compared with 67% for a polytetrafluoroethylene (PTFE) graft and at best 67% for subintimal angioplasty. The better patency offered by surgery must be balanced against a higher morbidity and mortality. To conclude, subintimal angioplasty is an extremely valuable technique in the management of critical limb ischemia. Based on the evidence to date, this technique is likely to have an increasing role in the management of intermittent claudication over the coming years, particularly if the risk of general anaesthesia is high or there is no suitable vein.     

The Revised ACPGBI Model is a Simple and Accurate Predictor of Operative Mortality After Potentially Curative Resection of Colorectal Cancer

Background  

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) risk-adjustment model for colorectal cancer surgery has been recently revised. The aim of the present study was to compare the performance of the revised ACPGBI model, the original ACPGBI model, P-POSSUM, and CR-POSSUM, in the prediction of operative mortality after resection of colorectal cancer.     

Outcomes and costs of penetrating trauma injury in England and Wales

BACKGROUND: Penetrating trauma injury is generally associated with higher short-term mortality than blunt trauma, and results in substantial societal costs given the young age of those typically injured. Little information exists on the patient and treatment characteristics for penetrating trauma in England and Wales, and the acute outcomes and costs of care have not been documented and analysed in detail. METHODS: Using the Trauma Audit Research Network (TARN) database, we examined patient records for persons aged 18+ years hospitalised for penetrating trauma injury between January 2000 and December 2005. Patients were stratified by injury severity score (ISS). RESULTS: 1365 patients were identified; 16% with ISS 1-8, 50% ISS 9-15, 15% ISS 16-24, 16% ISS 25-34, and 4% with ISS 35-75. The median age was 30 years and 91% of patients were men. Over 90% of the injuries occurred in alleged assaults. Stabbings were the most common cause of injury (73%), followed by shootings (19%). Forty-seven percent were admitted to critical care for a median length of stay of 2 days; median total hospital length of stay was 7 days. Sixty-nine percent of patients underwent at least one surgical procedure. Eight percent of the patients died before discharge, with a mean time to death of 1.6 days (S.D. 4.0). Mortality ranged from 0% among patients with ISS 1-8 to 55% in patients with ISS>34. The mean hospital cost per patient was pound7983, ranging from pound6035 in patients with ISS 9-15 to pound16,438 among patients with ISS>34. Costs varied significantly by ISS, hospital mortality, cause and body region of injury. CONCLUSION: The acute treatment costs of penetrating trauma injury in England and Wales vary by patient, injury and treatment characteristics. Measures designed to reduce the incidence and severity of penetrating trauma may result in significant hospital cost savings.     

Emergency Medical Service (EMS) systems in developed and developing countries

OBJECTIVES: To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries. METHOD: We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries. RESULTS: A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1min) and Montreal, Canada (median 16.1min) reported the shortest and Germany (median: 30min) and Austria (median: 26min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively). CONCLUSION: This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.