The rate of iatrogenic injuries in surgical patients appears resistant to multiple interventions: what can we learn from aviation safety?

BACKGROUND: This project analyses all iatrogenic injuries from our department over the last decade and tracks their rate against several interventions. METHODS: All patients who sustained an iatrogenic injury between 2012 and 2022 were reviewed. RESULTS: A total of 946 iatrogenic injuries occurred in 731 patients. Sixty per cent of these patients were male; the median age was 39 years. Of 946 injuries, 574 (60.7%) occurred during an operation, and 372 (39.3%) were not related to an operation. Of the operative injuries 412 (71.8%) were enteric injuries. Of the 372 non-operative iatrogenic injuries 304 (82%) were due to indwelling devices (ID), and 34 (10%) occurred during flexible endoscopy. Fifty-five per cent of the injuries due to ID were due to central venous catheters (CVC) and urinary catheters (UC). CVC contributed toward 31% of all non-operation related iatrogenic injuries. One in 54 admissions (946/51 178) and one in 47 (574 /27 342) patients undergoing an operation sustained an iatrogenic injury. The annual rate of iatrogenic injuries did not decrease over the decade despite a multifaceted approach to reduce them. Interventions included electronic database development, procedural standardisation, and checklist implementation. CONCLUSION: Despite multiple interventions over a decade, our rate of iatrogenic injury remains constant. Ongoing multifaceted efforts to reduce this rate must focus on engendering a culture of safety at all levels of healthcare if we hope to match the enviable safety record of the aeronautics industry.

Adverse events associated with the use of indwelling devices in surgical patients.

BACKGROUND: Indwelling devices (IDs) are ubiquitous in modern healthcare and may often be associated with morbidity. This paper investigates adverse events related to IDs in surgical patients, which are generally placed into patients either to administer therapy, manage outputs or for specific therapeutic benefit. METHODS: A retrospective electronic database-based assessment of all adverse events relating to IDs was undertaken from December 2012 to August 2021. All events were categorised by device type, event type, and event severity. RESULTS: A total of 11 130 morbidities were captured over the study period. Of those, 2 195 entries pertained to an ID with 2 402 reported adverse events affecting 1 592 patients. Two-thirds occurred in males and injuries occurred in patients age ranging from eight days to 93 years, with an average age of 36 years. The most frequently implicated devices were surgical drains (including intercostal chest drains), accounting for 491 (20.44%) of adverse events. Central venous catheters (CVCs) and intravenous cannulae were involved in 374 (15.57%) and 332 (13.83%) events, respectively. Unplanned removal (346, 13.91%), output not measured (319, 12.82%), injury (314, 12.62%), and blockage (279, 11.21%) were the most common error types. The majority of adverse events were considered minor, however 27 (1.1%) patients experienced organ dysfunction as a result of an ID-related adverse event, and seven (0.3%) died. CONCLUSIONS: Morbidity related to IDs in surgical patients is a relatively frequent occurrence. Standardisation of ID insertion and care, staff education, and improvements in communication have been identified as the most important strategies by which we can limit error-associated morbidity in patients with IDs.

Transdiaphragmatic pericardial washout post penetrating cardiac injury found incidentally at diagnostic laparoscopy.

SUMMARY: A 22-year-old male presented following a precordial stab. He was haemodynamically and metabolically normal. Initial investigations did not reveal pericardial fluid or haemothorax. At diagnostic laparoscopy, we encountered haemoperitoneum and a diaphragmatic injury through which the heart was visible. After pericardial washout, laparoscopic repair was effected. This case highlights a potential problem with extended focused assessment with sonography in trauma (eFAST) in that it will only be positive if there is an accumulation of pericardial fluid. It also confirms the utility of diagnostic laparoscopy for penetrating left thoracoabdominal injuries and shows that principles of open surgery can be safely applied laparoscopically in select patients.

Trauma patterns during the COVID-19 lockdown in South Africa expose vulnerability of women.

BACKGROUND: Trauma care places a significant burden on the South African (SA) healthcare system, and this has not changed significantly in recent history. We speculated that the COVID-19 lockdown regulations (travel restriction and alcohol ban) would affect trauma patterns. OBJECTIVES: To compare the burden and nature of trauma over the COVID-19 lockdown period with the equivalent period over the past 5 years using routinely collected data from the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, SA. METHODS: All trauma patients admitted to Grey's Hospital in Pietermaritzburg between 23 March 2015 and 31 May 2020 were identified and reviewed. RESULTS: A total of 8 859 trauma patients were admitted over the 6-year period, with a total of 1 676 admitted during the periods 23 March - 31 May. These 1 676 formed the study cohort. Of these patients, 998 had sustained blunt trauma, 665 penetrating trauma, and 13 a combination of blunt and penetrating trauma. A total of 14 categories of blunt trauma were reviewed, of which the three most common were assault, motor vehicle accidents (MVAs) and pedestrian vehicle accidents (PVAs). Between 23 March and 31 May 2020, a total of 23 patients were victims of blunt assault. The median number of assault victims over the equivalent period during the previous 5 years was 48. The 5 preceding years had a median of 56 MVAs and 33 PVAs, compared with 23 and 10 during the lockdown. The median number of gunshot wound (GSW) victims for the preceding years was 41, compared with 30 during the lockdown. During the lockdown, 24 stab wound victims were admitted, compared with a median of 73 for the preceding years. The proportion of females who sustained penetrating trauma and blunt assault increased significantly during the lockdown. The proportion of females sustaining a GSW or blunt trauma secondary to an MVA remained constant. CONCLUSIONS: The study showed that during the period of lockdown in SA there was a significant decrease in MVAs, PVAs and interpersonal violence. Assaults involving a knife seemed to decrease dramatically, but the rate of GSWs remained constant.

Structure of the chicken interferon-gamma gene, and comparison to mammalian homologues.

The sequence of the chicken interferon-gamma (ifn-gamma) gene was determined, one of the first non-mammalian cytokine gene structures to be elucidated. Initial genomic clones were amplified from chicken genomic DNA and were used to isolate a cosmid clone covering the entire gene for sequencing. The exon:intron structure of chicken ifn-gamma is very similar to those of its mammalian homologues, with the exception of the third intron, which is markedly shorter in the chicken. The first exon contains both 5' UTR and signal sequence and the first 22 aa of the mature protein. The remainder of the coding region lies in exons 2-4. Exon 4 also encodes the stop codon and the 3' UTR, including two possible polyadenylation signals. A number of potential regulatory sequences similar to those found in mammals have been identified, in the promoter, in each intron and in the 3' UTR. In the promoter, these include the TATAATA- and CCAT-boxes, a consensus GATA motif in the reverse orientation and a potential NF-kappa B binding site. Other regulatory elements identified in the promoters of mammalian ifn-gamma genes are absent. Internal to the gene structure, regulatory sequences identified include elements found in the DNase I hypersensitivity region of the first intron of the human ifn-gamma gene and several potential NF-kappa B binding sites. The 3' UTR contains an AT-rich sequence, including nine repeats of the 'instability' motif ATTTA. As in mammals, chicken ifn-gamma is a single copy gene. The gene is highly conserved, with no polymorphisms yet identified using either RFLP or SSCP in the coding region. However, promoter sequence polymorphisms between different inbred lines of chickens have been identified, with possible links to disease resistance.

Emergency room use of hypnosis.

Myths about hypnosis have interfered with its use in emergency settings. Specifically, included are myths about who induces the hypnotic state, the length of induction time, and the traumatized patient's inability to concentrate on a focal point. It is suggested, however, that altered states of awareness occur rapidly and spontaneously in the patient who has experienced acute trauma and/or pain. Two cases are presented that illustrate spontaneous trancelike states occurring in traumatic situations. The cases also show how the recognition of these altered states can facilitate the patient's care and treatment in an emergency setting.

Psychiatric morbidity in medical and surgical patients evacuated from the Persian Gulf War.

Acute treatment records of all medical and surgical patients evacuated to Walter Reed Army Medical Center in Washington, D.C., from the Persian Gulf theater (N = 161) were examined to better understand the relationship of injury to psychiatric symptoms. A total of 110 (68 percent) sustained a traumatic injury. They were significantly more likely to have an axis I disorder or psychiatric symptoms of concern than participants in the Persian Gulf War who did not sustain traumatic injuries but who were evacuated for medical conditions. The results indicate that traumatically injured veterans are at greater risk of psychiatric symptoms than veterans who are not injured and that they should be referred for psychiatric evaluation.

The effects of hypnosis on a parkinsonian tremor: case report with polygraph/EEG recordings.

Although Parkinsonian tremors typically disappear during sleep and are reduced during relaxation periods, the effects of hypnosis on this type of movement disorder have been generally ignored. We observed a patient's severe Parkinsonian tremor under hypnosis and monitored it with EEG and EMG studies. The patient was taught self-hypnosis and performed it three to four times daily in conjunction with taking medication. The results suggest that daily sessions of self-hypnosis can be a useful therapeutic adjunct in the treatment of Parkinsonian tremors.

Pain as a biopsychosocial entity and its significance for treatment with hypnosis.

Pain is a subjective metaphorical experience. Effective treatment of the pain patient remains an enigma. The present paper considers and reviews the significance of pain from a biopsychosocial perspective. The need to understand and recognize the variables contributing to the biopsychosocial aspects of the pain patient and its use in creating an effective treatment strategy with hypnotic intervention is described. Case reports where several techniques as well as collaborative efforts with other specialties are presented to highlight the discussion.

Targeting of marker loci to chicken chromosome 16 by representational difference analysis.

Representational difference analysis (RDA) was initially used to identify differences between two inbred lines of chickens, line N and line 15I, on which the Compton mapping reference population is based. RDA was subsequently used to identify marker loci targeted specifically to chicken chromosome 16. Chromosome 16 contains the major histocompatibility complex (MHC), nucleolar organiser region (NOR) and Rfp-Y complex. To generate markers specific for this chromosome a bird was selected from the Compton mapping reference population which had inherited N line alleles for the MHC, NOR and Rfp-Y regions on this chromosome. DNA from this bird was compared with pooled DNA from 16 of its siblings, all of which had inherited line 15I alleles for the MHC, NOR and Rfp-Y regions. Initially amplicons were derived from BamHI digested samples, RDA products were cloned after the first round of hybridisation and 113 clones were investigated: 45 of these identified BamHI polymorphisms in this population. Of the 45 polymorphic clones, 17 have been mapped in the reference population so far, and these have identified seven new loci on chromosome 16. Interestingly a group of 16 other loci were linked on chromosome 4. The same birds were also compared by RDA following digestion with TaqI. Again large numbers of clones were generated of which 65 were investigated. Of these 17 clones were polymorphic and of five clones mapped so far three lie on chromosome 16. Two of the loci mapped to chromosome 16 have been used to identify yeast artificial chromosome (YAC) clones.