Leadership development as part of quality improvement in district general hospitals.

OBJECTIVE: Effective clinical leadership is crucial for the delivery of high-quality medical care. However, the extent to which current leadership development effectively enhances leadership competencies for junior doctors remains uncertain. METHODS: This study aimed to investigate the utilisation of quality improvement projects (QIPs) to enhance leadership skills among junior doctors in a District General Hospital. Additionally, the feasibility of implementing a leadership programme in a smaller District General Hospital alongside didactic learning, reflection and stakeholder engagement was assessed. The Medical Leadership Competency Framework Self-Evaluation Tool was used to assess current leadership qualities and develop personal action plans. RESULTS: While the majority of junior doctors completed QIPs, only a few engaged in reflective practice. Moreover, limited participation in formal leadership programmes was observed. CONCLUSION: The study suggests that effective interpersonal development combined with long-term leadership training can be a resource-intensive yet valuable approach to adequately prepare future leaders even within District General Hospitals. The findings highlight the need for a structured leadership curricula utilising longitudinal project-based learning.

Does Immediate Breast Reconstruction Lead to a Delay in Adjuvant Chemotherapy for Breast Cancer? A Meta-Analysis and Systematic Review.

Timely delivery of adjuvant chemotherapy is crucial. With an increasing frequency of immediate breast reconstructions (IBR) following mastectomy (MAS), concerns have arisen regarding its complication rates and effects on time to chemotherapy. The aim was to conduct a systematic review and meta-analysis to determine if there is a prolonged time to chemotherapy (TTC) after IBR and MAS. Electronic databases, reference lists and relevant articles were searched systematically. Eligibility criteria included women receiving adjuvant chemotherapy who underwent either MAS only or MAS and IBR. Random-effects models were used in the analysis. A total of 29 studies were included in qualitative analysis, comprising of 156,000 patients (IBR: 57,159; MAS: 98,841). But 23 studies had sufficient data to be included in the meta-analysis. Sixteen papers concluded there was no difference in TTC compared to MAS. There was a difference of 3.50 days between TTC in IBR versus MAS (95% CI [0.42, 6.57], P value = .0256; IBR = 43.56 days, MAS = 40.38 days). The rate of patients being delayed past 90 days was not significantly higher in IBR (OR = 1.34, 95% CI [0.76, 2.38], P = .310). IBR patients were more likely to have complications compared to the MAS group (OR = 2.04, 95% CI [1.04-4.01], P < .01). We concluded that there is a statistically significant longer time to chemotherapy following IBR of 3.50 days, yet there is no difference in delays past 90 days. Therefore, the longer TTC in IBR is unlikely to be of any clinical significance.

Could the Emergency Department Facilitate the Start of a Holistic Follow-Up Pathway for Patients Recovering from COVID-19?

Background: For many patients suffering from COVID-19, Emergency Departments (ED) facilitate the first contact with clinicians. There is a high rate of psychiatric symptoms in COVID-19 survivors, including anxiety, depression, fatigue and sleep disturbance, which persist months after the acute phase. Aims: To investigate if COVID-19 patients discharged from ED have a higher prevalence of mental health symptoms than those admitted.In addition, this study will investigate if discharged ED patients who now require COVID-19 follow-up with the respiratory team had a higher prevalence of mental health symptoms than admitted patients requiring follow-up. Methods: This was a retrospective cohort study (n = 472) with the PHQ2 and GAD-2 scoring systems to quantify current anxiety and depression symptoms via a telephone consultation. Results: The PHQ-2 and GAD-2 scores were significantly higher for discharged ED patients than the admitted patients. There was a higher proportion of females with a positive PHQ2 or GAD-2 score. Of the patients requiring respiratory follow-up, discharged ED patients were more likely to have a positive PHQ-2 or GAD-2 score than those admitted. Conclusions: Clinicians should maintain a low threshold for referring patients with psychiatric complaints post-COVID alongside respiratory symptoms irrespective of admission. It is imperative that available psychological services, crisis lines and other avenues of support post-COVID-19 are signposted to patients before discharge to facilitate earlier intervention.

Traits data for the butterflies and macro-moths of Great Britain and Ireland.

Butterflies and moths, collectively Lepidoptera, are integral components of ecosystems, providing key services such as pollination and a prey resource for vertebrate and invertebrate predators. Lepidoptera are a relatively well studied group of invertebrates. In Great Britain and Ireland numerous citizen science projects provide data on changes in distribution and abundance. The availability of high-quality monitoring and recording data, combined with the rapid response of Lepidoptera to environmental change, makes them ideal candidates for traits-based ecological studies. Recently, there has been an increase in the number of studies documenting traits-based responses of Lepidoptera, highlighting the demand for a standardized and referenced traits database. There is a wide range of primary and secondary literature sources available regarding the ecology of British and Irish Lepidoptera to support such studies. Currently these sources have not been collated into one central repository that would facilitate and enhance future research. Here, we present a comprehensive traits database for the butterflies and macro-moths of Great Britain and Ireland. The database covers 968 species in 21 families. Ecological traits fall into four main categories: life cycle ecology and phenology, host plant specificity and characteristics, breeding habitat, and morphological characteristics. The database also contains data regarding species distribution, conservation status, and temporal trends for abundance and occupancy. This database can be used for a wide array of purposes including further fundamental research on species and community responses to environmental change, conservation and management studies, and evolutionary biology. There are no copyright restrictions, and this paper must be cited if data are used in publications.

Human-wildlife conflicts with crocodilians, cetaceans and otters in the tropics and subtropics.

Conservation of freshwater biodiversity and management of human-wildlife conflicts are major conservation challenges globally. Human-wildlife conflict occurs due to attacks on people, depredation of fisheries, damage to fishing equipment and entanglement in nets. Here we review the current literature on conflicts with tropical and subtropical crocodilians, cetaceans and otters in freshwater and brackish habitats. We also present a new multispecies case study of conflicts with four freshwater predators in the Western Amazon: black caiman (Melanosuchus niger), giant otter (Pteronura brasiliensis), boto (Inia geoffrensis) and tucuxi (Sotalia fluviatilis). Documented conflicts occur with 34 crocodilian, cetacean and otter species. Of the species reviewed in this study, 37.5% had conflicts frequently documented in the literature, with the saltwater crocodile (Crocodylus porosus) the most studied species. We found conflict severity had a positive relationship with species body mass, and a negative relationship with IUCN Red List status. In the Amazonian case study, we found that the black caiman was ranked as the greatest 'problem' followed by the boto, giant otter and tucuxi. There was a significant difference between the responses of local fishers when each of the four species were found entangled in nets. We make recommendations for future research, based on the findings of the review and Amazon case study, including the need to standardise data collection.

Tibioperoneal Occlusive Disease: A Review of below the Knee Endovascular Therapy in Patients with Critical Limb Ischemia.

BACKGROUND: Tibioperoneal occlusive disease is one of the most difficult disease processes to successfully treat. Previous studies have attempted to address the outcomes of tibial interventions in this patient population; however, the majority of these study cohorts are composed of patients who have undergone concomitant aortoiliac or femoral procedures. Our objective was to present the outcomes of patients treated with endovascular intervention for isolated below-the-knee atherosclerotic disease causing critical limb ischemia (CLI). METHODS: We performed a retrospective review of all patients who underwent isolated endovascular treatment of the below-knee popliteal, tibial, and/or peroneal arteries for CLI (Rutherford class 4-6). Primary outcomes include wound healing, reintervention rates, and amputation-free survival out to 5 years, as well as 1-year primary patency rates. RESULTS: 116 patients were identified as having undergone a tibial endovascular intervention. Ninety-two had concomitant aortoiliac or femoropopliteal interventions; after excluding those patients, we identified 24 limbs that were treated for isolated below-knee popliteal, tibial, and/or peroneal occlusive disease using an endovascular modality. 62.5% of limbs had successful wound healing, whereas 37.5% eventually required a major amputation. Mean time to amputation was 514.6 days (standard error: 57.3). Of those patients with successful limb salvage (n = 15), 66.7% required only the index procedure to heal; the remaining 33.3% required a repeat endovascular intervention, an arterial bypass, or a combination to successfully heal. The mean time to reintervention was 780.1 days (standard error: 179.5). The 1-year primary patency rate was 52.6% (n = 19). CONCLUSIONS: Patients with CLI secondary to isolated below-the-knee atherosclerotic occlusive disease are a difficult population to successfully treat; despite this, these patients benefit from an initial attempt at endovascular limb salvage. In our experience, this approach resulted in a respectable limb salvage rate of 62.5% and did not compromise open surgical solutions in the event of nonhealing.

Vascular Injuries in Combat-Specific Soldiers during Operation Iraqi Freedom and Operation Enduring Freedom.

BACKGROUND: This study sought to identify vascular injury patterns among combat-specific cavalry scout personnel within the Iraq and Afghanistan Wars. METHODS: The Armed Forces Medical Examiner System and Joint Theater Trauma Registry were queried for all injuries with the cavalry scout designation from 2003 to 2011, including those both wounded in action (WIA) and killed in action (KIA). A description of vascular injury, combat causality care statistics, mechanism of injury, and demographic data were recorded. RESULTS: Sixteen percent (n = 111) of the 701 cavalry scouts with a combat wound sustained a vascular injury. Among cavalry scouts sustaining vascular injuries, 69% were caused by an explosive mechanism of injury, 63% were KIA, and 29% had a major extremity amputation. Cavalry scout soldiers with a vascular injury were significantly more likely to result from explosion (P < 0.0001), be KIA (P < 0.0001), and occur in Iraq (P < 0.0001). The rate of noncompressible arterial injury was 65%. WIA cavalry scout soldiers with a compressible vascular injury with clear documentation of prehospital tourniquet utilization arrived at a Medical Treatment Facility in 67% of cases with a tourniquet in place. Of these transported with a prehospital tourniquet 83% survived. CONCLUSIONS: The high rates of KIA and extremity amputation among cavalry scout soldiers with a vascular injury denotes the lethality of these combat injuries. Uniformly equipping soldiers with battlefield tourniquets and educating them on their prehospital use might improve the survivorship of those servicemembers sustaining a compressible vascular injury.

Evaluating Alternatives to Traditional Cotton Laparotomy Sponges for Blood Absorption in the Austere and Mobile Surgical Environment.

BACKGROUND: The operative control of noncompressible hemorrhage is the single largest impact that could be addressed in reducing the mortality on the battlefield. Laprotomy pads, traditionally used for hemorrhage evacuation, are made of woven cotton, and, while effective, their use requires a substantial amount of space and adds weight. This poses no concern in traditional operating rooms but is a hindrance for mobile providers and providers in austere environments. We sought to compare different absorptive compunds to ascertain their utility as alternatives for traditional laparotomy pads. METHODS: Samples of cotton laparotomy pads, pure rayon sheets, rayon-polypropylene composite sheets, and non-polyester composite "microfiber" sheets were weighed and submerged in heparinized whole bovine blood. After saturation, the favrics were weighed, wrung dry, reweighed, and resubmerged. This process was performed for a total of three sequential submersions. The saturated weights and dry weights of each fabric were used to calculate how much blood each fabric could absorb initially and after multiple repeated uses. The initial densities of the four fabrics was calculated and compared. RESULTS: The initial submersions demonstrated that 1g each of cotton, rayon, rayon-polypropylene, and nylon-polyester were able to absorb 7.58 g, 12.98 g, 10.16 g, and 9.73 g of blood respectively. The second and third sequential trials, which were statistically similar, demonstrated that 1g of cotton, rayon, rayon-polypropolyene, and nylon-polyester were able to absorb 1.73 g, 2.83 g, 2.3g, and 2.3g of blood, respectively. The calculated densities of cotton, rayon, rayon-polypropylene, and nylon-polyester were 0.087 g/cm³, .012 g/cm³, 0.098 g/cm³, and 0.093 g/cm³, respectively. CONCLUSION: Per gram, rayon absorbed approximately 1.7 times more blood thancotton and three-quarters the amount of the storage space. Rayon also retained its superior absorption abilites on repeated uses, demonstrating the potential for re-use in remote and austere environments. Thus, rayon could serve as a viable alternative to traditional cotton laparotomy pads in the austere environments.

Effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function.

A specific training program emphasizing the neuromuscular recruitment of the plantar intrinsic foot muscles, colloquially referred to as "short foot" exercise (SFE) training, has been suggested as a means to dynamically support the medial longitudinal arch (MLA) during functional tasks. A single-group repeated measures pre- and post-intervention study design was utilized to determine if a 4-week intrinsic foot muscle training program would impact the amount of navicular drop (ND), increase the arch height index (AHI), improve performance during a unilateral functional reaching maneuver, or the qualitative assessment of the ability to hold the arch position in single limb stance position in an asymptomatic cohort. 21 asymptomatic subjects (42 feet) completed the 4-week SFE training program. Subject ND decreased by a mean of 1.8 mm at 4 weeks and 2.2 mm at 8 weeks (p < 0.05). AHI increased from 28 to 29% (p < 0.05). Intrinsic foot muscle performance during a static unilateral balancing activity improved from a grade of fair to good (p < 0.001) and subjects experienced a significant improvement during a functional balance and reach task in all directions with the exception of an anterior reach (p < 0.05). This study offers preliminary evidence to suggest that SFE training may have value in statically and dynamically supporting the MLA. Further research regarding the value of this exercise intervention in foot posture type or pathology specific patient populations is warranted.

Endovascular repair of an abdominal aortic aneurysm in a patient with stenosis of bilateral common iliac artery stents.

BACKGROUND: The explosion in endovascular interventions for peripheral vascular disease has resulted in procedures being used by a multitude of specialties. Nonvascular surgeons performing these interventions can create scenarios that may make future vascular interventions difficult. In this article, we present a case report illustrating this point. METHODS: A 68-year-old man with severe chronic obstructive pulmonary disease, coronary artery disease with prior myocardial infarction, and multiple abdominal operations presented with an abdominal aortic aneurysm. In our opinion, this patient was at a prohibitive operative risk for open repair. Review of his imaging results revealed a 6.7-cm infrarenal aneurysm with bilateral common iliac artery (CIA) stents (right: 8 mm; left: 6 mm) and 6-mm self-expanding stents extending from the right external iliac artery through the common femoral artery. A Cook Zenith Renu (30 × 108 mm) graft (Cook Medical Inc., Bloomington, IN) was advanced after serial dilation and balloon angioplasty of the stenotic right CIA stent. Left brachial access was used for arteriographic imaging. The left common femoral artery was accessed and the left CIA was coil-embolized to prevent backbleeding. A femoro-femoral artery crossover bypass was then performed after segmental resection of the right common femoral artery stent. RESULTS: The patient tolerated the procedure well and was discharged home on postoperative day 3. Subsequent postoperative computed tomography arteriogram after 1 month showed palpable pulses and no evidence of endoleak with flow in the femoro-femoral graft on clinical exam. CONCLUSIONS: This case demonstrates an endovascular intervention which limited the potential options available for aneurysm repair. Similar problems may become increasingly common as more providers offer endovascular interventions, thus emphasizing the importance of a collaborative approach to the patient with complex aorto-iliac occlusive disease and abdominal aortic aneurysm. It is the duty of the vascular surgeon to offer his vital expertise and leadership in the care of these patients.

Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas.

PURPOSE: Over the last decade, K-DOQI guidelines have increasingly emphasized the importance of autogenous arteriovenous fistulas (AVF) for dialysis access. A complication of AVF is aneurysmal dilatation with a subset developing massive diffuse aneurysm. Treatment of massive aneurysmal AVF generally involves either ligation or resection with use of prosthetic interposition. To maintain an all-autogenous access, we developed a procedure to treat massive aneurysmal AVF in which the luminal diameter is reduced, excess length is resected, and the new reconstructed AVF is re-tunneled for continued use. The purpose of this study is to examine the midterm outcomes of this novel procedure. METHODS: Over a 4-year period, the reduction/revision procedure was performed on 19 patients with an AVF diameter of 4-7 cm. Indications for operation were thrombosis, skin breakdown, infection, bleeding, and/or poor flow. Revision was performed by resecting redundant length, reducing diameter, and then reconstructing the fistula. RESULTS: The median patient age was 47, interquartile range (IQR) 29. There were 13 men and 6 women. The median follow-up was 23 months, IQR 22. The median primary patency was 14 months, IQR 24. The median secondary patency was 16.5 months, IQR 26. Two patients died, one AVF thrombosed, and two were ligated secondary to infection. Three fistulae developed a stenosis that was treated with percutaneous angioplasty. There are no recurrent aneurysms to date. CONCLUSION: Surgical resection of excess length, reduction of luminal diameter, and reconstruction is a viable option for the treatment of complicated massive diffusely aneurysmal AVF. This technique offers the ability to maintain the benefits of an all autogenous dialysis access while conserving future dialysis sites.

Management of a catecholamine-secreting paraganglioma requiring aortic reconstruction.

INTRODUCTION: Retroperitoneal paragangliomas are rare extraadrenal pheochromocytomas that can involve major vascular structures. RESULTS AND DISCUSSION: A case of periaortic catecholamine-secreting paraganglioma was reviewed and literature search performed to summarize the current surgical management of this disease process. CONCLUSION: Resection for cure of retroperitoneal paragangliomas with vascular reconstruction can be performed with acceptable morbidity and mortality with the use of current vascular techniques.

Inferior vena cava aneurysm.

Aneurysms of the inferior vena cava (IVC) are exceedingly rare; less than 50 cases have been reported in the world literature. Owing to the paucity of data regarding the natural history of IVC aneurysms, there is no consensus on their treatment. This case report describes the evaluation of an IVC aneurysm in a 56-year-old male, briefly discusses the embryologic development of the IVC, and revisits the question of whether surgical intervention is indicated in these patients.

Hemodialysis-related steal syndrome: predictive factors and response to treatment with the distal revascularization-interval ligation procedure.

Hand ischemia due to steal causes major disability in affected members of the hemodialysis population. Between February 2000 and March 2007, 24 patients aged 37-77 years were identified who developed hand ischemia distal to a hemodialysis access and required a distal revascularization-interval ligation (DRIL) procedure. Of the 24 patients, 22 (92%) were diabetic, 14 (58%) were women, 7 (29%) had prosthetic grafts, and 17 (71%) had fistulas, all originating from the brachial artery. Duration between the initial dialysis access and the DRIL procedures ranged 12 hours to 10 months. Conduits used were saphenous vein in 13 (54%) cases, cephalic vein in 3 (12%) cases, basilic vein in 5 (21%) cases, and prosthetic grafts in 3 (12%) cases. There were no operative deaths. Improved blood flow and relief of symptoms were observed in 23 (96%) patients. The procedure failed early in one patient who had thrombosis of a prosthetic graft. Two patients required digital amputations. At a median follow-up of 50 months, 14 (58%) patients died using the access requiring the DRIL, 2 (8%) did not require dialysis, 3 (12%) were using a new access, and 5 (21%) were still using the access that had required the DRIL. In late follow-up, only one DRIL bypass required revision and the remainder were patent. One patient developed an ischemic hand 5 years after his DRIL procedure despite a patent bypass. The development of ischemic steal requiring performance of a DRIL procedure is most likely to occur in diabetic patients with dialysis access originating from the brachial artery. The procedure is effective in ameliorating symptoms while preserving the vascular access. The high long-term mortality rate observed in this series underscores the fact that patients requiring a DRIL procedure represent a subset of dialysis patients with advanced diabetic vascular disease and a limited life expectancy. Despite the effectiveness of the DRIL procedure, efforts should be concentrated on prevention of ischemic steal in order to lessen the morbidity and expense of this condition in the dialysis population.

Kawasaki disease in the adult: a case report and review of the literature.

Kawasaki disease, predominantly a disease of childhood, includes such symptoms as acute vasculitis, mucosal inflammation, rash, cervical adenopathy, and edema. Its most severe forms are associated with coronary artery aneurysms. We report a rare case of this disease in an asymptomatic adult and review its epidemiology, etiology, diagnosis, treatment, and prognosis.