Experience of managing open fractures of the lower limb at a major trauma centre

Introduction

In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network.

Methods

From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC.

Results

Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover.

Conclusions

Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.     

运动障碍疾病与脑内金属铜、铁、钙沉积

在过去的20年,金属及其代谢过程对神经疾病的影响引起了神经科学家的极大兴趣。近年来大量文献报道,铁、铜、锰和锌作为重要的神经化学因子与目的蛋白相互作用导致了与疾病病理生理密切相关的反应。     

Surgery as a Bridge to Palliative Chemotherapy in Patients with Malignant Bowel Obstruction from Colorectal Cancer

Background Malignant bowel obstruction (MBO) is a feature of the clinical course of 10–28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. Methods Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. Results Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). Conclusion Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival. Dr. Calvin Law is a Career Scientist of the Ontario Ministry of Health and Long Term Care and is supported through a Health Research Personnel Development—Career Scientist Award.     

A systematic review of surgery for non-curative gastric cancer

Background

Most gastric cancer patients present with advanced stage disease precluding curative surgical treatment. These patients may be considered for palliative resection or bypass in the presence of major symptoms; however, the utility of surgery for non-curative, asymptomatic advanced disease is debated and the appropriate treatment strategy unclear.

Purpose

To evaluate the non-curative surgical literature to better understand the limitations and benefits of non-curative surgery for advanced gastric cancer.

Methods

A literature search for non-curative surgical interventions in gastric cancer was conducted using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases from 1 January 1985 to 1 December 2009. All abstracts were independently rated for relevance by a minimum of two reviewers. Outcomes of interest were procedure-related morbidity, mortality, and survival.

Results

Fifty-nine articles were included; the majority were retrospective, single institution case series. Definitions describing the treatment intent for gastrectomy were incomplete in most studies. Only five were truly performed with relief of symptoms as the primary indication for surgery, while the majority were considered non-curative or not otherwise specified. High rates of procedure-related morbidity and mortality were demonstrated for all surgeries across the majority of studies and treatment-intent categories. Median and 1-year survival were poor, and values ranged widely within surgical approaches and across studies.

Conclusions

A lack of transparent documentation of disease burden and symptoms limits the surgical literature in non-curative gastric cancer. Improved survival is not evident for all patients receiving non-curative gastrectomy. Further prospective research is required to determine the optimal intervention for palliative gastric cancer patients.

     

A systematic review of the accuracy and utility of peritoneal cytology in patients with gastric cancer

Background  

Although malignant diseases are known to be associated with immune suppression, the detailed mechanisms involved are still unknown. NKG2D is an activating cell surface receptor expressed by natural killer (NK) cells and CD8+ T cells, and the engagement of NKG2D is extremely important for NK cell activation. Although decreased NKG2D expression on NK cells is closely related to immune evasion by some cancers, the immunopathological importance of this phenomenon in gastric cancer patients remains unclear.     

Tai chi for psychosocial well‐being in older people

Lee LYK, Lee DTF, Woo J. The psychosocial effect of tai chi on nursing home residents. J Clin Nurs 2010; 19: 927–38.     

The use of complementary and alternative medicines among patients with locally advanced breast cancer – a descriptive study

Background  

Complementary and alternative medicine (CAM) use is common among cancer patients. This paper reviews the use of CAM in a series of patients with locally advanced breast cancer (LABC).     

Molecular and epidemiologic analysis of a county-wide outbreak caused by <Emphasis Type="Italic">Salmonella enterica</Emphasis> subsp. <Emphasis Type="Italic">enterica</Emphasis> serovar Enteritidis traced to a bakery

Background  

An increase in the number of attendees due to acute gastroenteritis and fever was noted at one hospital emergency room in Taiwan over a seven-day period from July to August, 2001. Molecular and epidemiological surveys were performed to trace the possible source of infection.