Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom.

The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.

A phase II study to evaluate the efficacy of dexmedetomidine for sedation in the medical intensive care unit.

OBJECTIVE: To evaluate dexmedetomidine for sedation of patients in the medical ICU. DESIGN AND SETTING: Prospective observational study in an intensive care unit of a university hospital. PATIENTS. Twelve ventilated patients with median APACHE II score 23 (range 10-26). INTERVENTIONS: Patients received a loading dexmedetomidine infusion of 1 microg x kg(-1) over 10 min followed by a maintenance infusion rate of 0.2-0.7 microg x kg(-1) x h(-1) for up to 7 days. After experience with the first four patients this maintenance rate of infusion was increased to a maximum of 2.5 microg kg(-1) x h(-1). If required, propofol and morphine provided rescue sedation and analgesia, respectively. RESULTS: The first four patients with dexmedetomidine infusion at 0.7 microg x kg(-1) x h(-1)all required rescue sedation with a propofol infusion. A protocol amendment allowed the next eight patients to receive higher dexmedetomidine infusions (mean 1.0+/- microg x kg(-1) x h(-1)). Five of the next eight patients did not required propofol, and two patients only required minimal propofol infusions (20-40 mg x h(-1)). A further patient, with hepatic encephalopathy, required a propofol at 50-100 mg x h(-1). Only modest falls in arterial pressure, heart rate and cardiac output were seen, and no rebound sequelae occurred on discontinuation of dexmedetomidine. Adverse cardiovascular events were nearly all confined to the initial loading dose period of dexmedetomidine. CONCLUSIONS: Sedation with dexmedetomidine is efficacious in critically ill medical patients requiring mechanical ventilation in the intensive care unit. A reduction in loading infusion is advised, but higher maintenance infusions may be required to that seen previously in the postoperative ICU patient.

Localization of mRNA for the apoptosis-linked gene ALG-2 in young and aged rat brain.

ALG-2 is a recently described pro-apoptosis gene that codes for a Ca2+-binding protein involved in T-cell receptor-, Fas- and glucocorticoid-induced cell death. We have used in situ hybridization histochemistry to examine the regional distribution of ALG-2 mRNA in the brain of 3- and 24-month old rats. There was widespread, predominantly neuronal distribution of ALG-2 mRNA throughout the brain. Areas expressing high levels included the granule and pyramidal cell layers of the hippocampus, choroid plexus, area postrema, and a number of hindbrain nuclei. ALG-2 mRNA levels in aged rats were not significantly different to young animals. The pattern of expression of ALG-2 mRNA in adult brain is similar to other apoptosis-related genes and suggests it may be involved in neuronal survival.

Studies of hydration and swelling pressure in normal and osteoarthritic cartilage.

An experimental study was carried out which involved comparing cartilage from normal and osteoarthritic joints with respect to (a) swelling pressure and (b) variation of hydration with applied pressure. The main conclusion was that whilst osteoarthritic cartilage is undoubtedly less able to resist water loss under a given applied pressure than normal cartilage, this is not due to a change in the "quality" of the proteoglycans, resulting in a change in the osmotic pressure of the latter, but simply to a decreased fixed charge density. The latter decrease is either caused by an increase in the water content - and this we attribute to a weakened collagen network - and/or to a loss of part of the proteoglycans from the tissue.

The influence of timing and suppository use on efficiency and effectiveness of bowel training after a stroke.

This study was designed to determine the efficiency and effectiveness of four bowel training protocols for stroke patients (N = 46) differing in two variables: (a) consistent use of suppositories, and (b) time of day scheduled for the bowel training program. Eighty-five percent of the subjects (n = 39) achieved effective bowel training within 1 month. Patients assigned to morning bowel training groups were significantly more efficient than those in evening groups in establishing effective bowel regimens. No significant differences were found between scheduled versus prn suppository use. Efficiency was highest for those assigned to a bowel training group whose time coincided with their previous pattern and lowest for those assigned to a group whose time conflicted with a previous pattern.

Effect of a barley breakfast cereal on blood glucose and insulin response in normal and diabetic patients.

Prowashonupana (Prowash) is a shrunken-endosperm, short awn, waxy starch, hulless barley with low starch, high fiber, high protein, and a relatively high concentration of free sugars. The study was designed to compare equivalent breakfast meals (w/w) of Prowash and oatmeal for glycemic response in diabetic and non-diabetic subjects. A commercial liquid meal replacer (LMR) was included as a reference standard. A substantial reduction of the post-prandial glycemic peak following ingestion of Prowash was observed as compared to LMR or oatmeal. In the non-diabetic subjects, the maximal rise in glucose from baseline was 26.3 +/- 3.9 mg/dL after LMR, 41.3 +/- 3.9 mg/dL after oatmeal and 6.4 +/- 2.7 mg/dL after Prowash (p < 0.01). The maximal increase in glucose in the diabetic patients was 69.9 +/- 4.5 mg/dL after LMR, 80.8 +/- 8.8 mg/dL after oatmeal and 28.4 +/- 3.5 mg/dL after Prowash (p < 0.01). The maximal increase in insulin post-LMR was 33.9 +/- 3.6 mIU/ml in the diabetic patients and 54.0 +/- 9.8 mIU/ml in the non-diabetic controls. Oatmeal elicited a maximal insulin increase of 29.9 +/- 4.2 mIU/ml in the control subjects and 21.4 +/- 2.5 mIU/ml in the diabetic patients. In contrast, the maximal insulin increase after Prowash was 8.6 +/- 1.5 mIU/ml in the non-diabetic controls and 6.8 +/- 1.2 mIU/ml in the diabetic patients (p < 0.01).

Chemical composition of human femoral and head cartilage: influence of topographical position and fibrillation.

Topographical variations in the composition of cartilage have been described in post-mortem femoral head cartilage. Weight bearing cartilage of the superior region was considerably thicker and had a higher glycosaminoglycan content and lower water and collagen content than cartilage at the periphery and below the fovea. These topographical variations in composition may result both from variations in thickness of the cartilage and from regional areas of degeneration. The composition of cartilage at different depths and with different surface characteristics from different areas of the femoral head was measured. Fibrillated cartilage both from the inferior and superior perifoveal areas had a reduced glycosaminoglycan content and higher water content than intact post-mortem specimens. Cartilage adjacent to fibrillated areas from the superior region did not differ in composition from intact areas of cartilage from the zenith of the femoral head.

Variation of chemical composition with age in human femoral head cartilage.

The chemical composition of intact femoral head cartilage was investigated with age. Full-depth cartilage showed a decrease in water content and an increase in keratan sulphate and noncollagenous material with age. When analyzed through the depth of the cartilage, keratan sulphate was shown to appear first in the deep zones and later in the surface, while water content was lost mainly in the deep zones. On a dry weight basis collagen content decreased with age. This was not a real loss but was due to a change in the proportions of other materials, mainly in the deep zones.

Chemical composition and swelling of normal and osteoarthrotic femoral head cartilage. I. Chemical composition.

Radiochemical and biochemical methods were used to characterize post-mortem and osteoarthrotic femoral head cartilage. Fixed charge density measurements were correlated with glycosaminoglycan content as estimated by uronic acid and hexosamine analyses. In post-mortem cartilage water content decreased from a maximum at the surface to a minimum in the deep zones. In the osteoarthrotic specimens water content was greatest in the middle zones. Glycosaminoglycan content increased with depth and in the osteoarthrotic specimens was reduced throughout the depth of the cartilage. With increasing degeneration there was an increase in water content and decrease in glycosaminoglycan content. The difference in the water content profile in osteoarthrotic cartilage was explained in terms of damage to the collagen network. In osteoarthrosis the latter is no longer capable of restraining the swelling pressure produced by the glycosaminoglycans and swelling is greatest in the midzones, where glycosaminoglycan content is highest.

Chemical composition and swelling of normal and osteoarthrotic femoral head cartilage. II. Swelling.

Studies of the equilibrium, partition, and diffusion of tritiated water were carried out on normal and osteoarthrotic cartilage as well as on cartilage from which proteoglycans had been extracted chemically. All the water was found to be freely exchangeable in both normal and degenerate specimens. The diffusiviity of the water was equal to about 40% of the value in free solution, with an activation energy equal to that in free solution. It was concluded that the swelling of degenerate tissue is not due to any changes in the state of the water, but to a failure of the damaged collagen network to oppose the swelling pressure of the proteoglycans. Swelling similar to that observed in fibrillated cartilage was also found in initially normal specimens treated with collagenase.

Further studies on the composition of human femoral head cartilage.

This report continues our previous studies on the composition and swelling of articular cartilage. When the protein part of the proteoglycan moiety has been taken into consideration, there is no longer a large fraction of the tissue which is not accounted for. In fact, the collagen, proteoglycans, and free electrolyte represent over 92% of the dry weight of adult femoral head cartilage, the remainder consisting most probably of other glycoproteins. Once the composition of cartilage had been well defined, it was possible to calculate the overall wet volume of tissue per unit weight of collagen for both normal and osteoarthritic cartilage. This is an important parameter, as it constitutes a direct measure of the extensibility of the collagen network. By determining the fixed charge density profile close to the articular surface, we have also been able to estimate the swelling pressure due to the proteoglycans in this region of the tissue, and to show that there is a gentle grading of osmotic stresses.

Digestion of native collagen in the gut.

The digestion and absorption of collagen, native and artificially cross-linked, has been examined in the rat and the Gaboon viper, by feeding known quantities and measuring the hydroxy-proline content of the faeces and of the contents of the gut at different levels, and comparing with an unabsorbable marker (polyethylene glycol). Incubation of collagen in vitro with pepsin at 37 degrees C at pH 1.5 followed by trypsin or chymotrypsin converted about 40% into dialysable material.

Structure of proteoglycans from different layers of human articular cartilage.

Full-depth plugs of adult human articular cartilage were cut into serial slices from the articular surface and analysed for their glycosaminoglycan content. The amount of chondroitin sulphate was highest in the mid-zone, whereas keratan sulphate increased progressively through the depth. Proteoglycans were isolated from each layer by extraction with 4M-guanidinium chloride followed by centrifugation in 0.4M-guanidinium chloride/CsCl at a starting density of 1.5 g/ml. The efficiency with which proteoglycans were extracted depended on slice thickness, and extraction was complete only when cartilage from each zone was sectioned at 20 microns or less. When thick sections (250 microns) were extracted, hyaluronic acid was retained in the tissue. Most of the proteoglycans, extracted from each layer under optimum conditions, could interact with hyaluronic acid to form aggregates, although the extent of aggregation was less in the deeper layers. Two pools of proteoglycan were identified in all layers by gel chromatography (Kav. 0.33 and 0.58). The smaller of these was rich in keratan sulphate and protein, and gradually increased in proportion through the cartilage depth. Chondroitin sulphate chain size was constant in all regions. The changes in composition and structure observed were consistent with the current model for hyaline-cartilage proteoglycans and were similar to those observed with increasing age in human articular cartilage.

Histological and biochemical studies on cartilage from osteoarthrotic femoral heads with special reference to surface characteristics.

A study has been made of cartilage from osteoarthrotic femoral heads in an attempt to relate histological to biochemical and metabolic changes. Cartilage showing different surface characteristics and originating from different areas of the femoral head has been studied. Depending on its surface characteristic and location, the osteoarthrotic cartilage ranged in composition and sulphate metabolism from practically normal to glycosaminoglycan depleted and metabolically depressed. There was no indication of elevation in the sulphate incorporation in the osteoarthrotic cartilage.

The experience and impact of contacting a cancer information service.

Our objective was to review the quality of service delivered by a national cancer information service--the British Association of Cancer United Patients (BACUP)--and to consider the implications for future policy and practice. We used a sample of callers over a 10-day period, responding to a structured postal questionnaire. The sample included patients, relatives, friends, and general public who called the service with any concern relating to cancer. Of the 406 invited to take part, 282 responded (69%). The questionnaire was designed to evaluate the callers' perceptions of the information they received, their perceptions of the nurse's communication skills, the emotional impact of the call, and their overall satisfaction with the service. The results indicate that over 90% of callers evaluated the information they received and the nurse's communication skills positively, and there was no difference between the two major groups of callers, i.e. patients and relatives/friends. Both groups reported that the call had a positive emotional impact on them and that they were satisfied with the service. Emotional impact was predicted by quality of information for patients and nurse's communication skills for friends/relatives; overall satisfaction was predicted by nurse's communication skills for patients and both measures for relatives/friends. We conclude that the telephone is an effective medium for conveying information about cancer, and BACUP is meeting its needs. The needs of patients and relatives/friends are different--principally information for patients and support for relatives/friends--and it may be possible to improve training still further by focusing on those differences. The main challenge for cancer information services is to meet the ever-increasing demand.