'Working together' - A new approach to Reviewing the Quality of Postgraduate Medical Training Posts in Northern Ireland?

Many of us are involved in the education and training of junior doctors. Maintaining and improving the quality of such training is the common goal of all medical educators, including those working in the Northern Ireland Medical and Dental Training Agency (NIMDTA) and within our hospitals - the Local Education Providers (LEPs). The development of NIMDTA's Placement Quality Initiative (PQI) aims to create a more collaborative working relationship between NIMDTA and the LEPs, working together, to achieve a shared goal and develop and implement strategies to improve current practice. We review the PQI process, from both a trainee and trainer's perspective, and ascertain if this approach has facilitated positive, reproducible changes in training programmes that are felt at ground level.

Extensor motoneurone properties are altered immediately before and during fictive locomotion in the adult decerebrate rat.

This study examined motoneurone properties during fictive locomotion in the adult rat for the first time. Fictive locomotion was induced via electrical stimulation of the mesencephalic locomotor region in decerebrate adult rats under neuromuscular blockade to compare basic and rhythmic motoneurone properties in antidromically identified extensor motoneurones during: (1) quiescence, before and after fictive locomotion; (2) the 'tonic' period immediately preceding locomotor-like activity, whereby the amplitude of peripheral flexor (peroneal) and extensor (tibial) nerves are increased but alternation has not yet occurred; and (3) locomotor-like episodes. Locomotion was identified by alternating flexor-extensor nerve activity, where the motoneurone either produced membrane oscillations consistent with a locomotor drive potential (LDP) or did not display membrane oscillation during alternating nerve activity. Cells producing LDPs were referred to as such, while those that did not were referred to as 'idle' motoneurones. LDP and idle motoneurones during locomotion had hyperpolarized spike threshold (Vth ; LDP: 3.8 mV; idle: 5.8 mV), decreased rheobase and an increased discharge rate (LDP: 64%; idle: 41%) during triangular ramp current injection even though the frequency-current slope was reduced by 70% and 55%, respectively. Modulation began in the tonic period immediately preceding locomotion, with a hyperpolarized Vth and reduced rheobase. Spike frequency adaptation did not occur in spiking LDPs or firing generated from sinusoidal current injection, but occurred during a sustained current pulse during locomotion. Input conductance showed no change. Results suggest motoneurone modulation occurs across the pool and is not restricted to motoneurones engaged in locomotion.

Assessment of complications following strictureplasty for small bowel Crohn's Disease.

BACKGROUND: Surgical intervention is required in a significant proportion of patients with small bowel Crohn's disease (CD). Strictureplasty is an effective bowel-sparing alternative to resection. AIM: The aim of this study is to assess the primary complications of small bowel strictureplasty for CD (bleeding and leakage). Other postoperative complications encountered, postoperative duration of hospital stay, 30-day mortality, and the incidence of reoperative surgery are also discussed. METHODS: A retrospective review of patients undergoing small bowel strictureplasty at The Royal Hospital between 1992 and 2007 was conducted. Twenty-seven patients underwent 34 laparotomies and 100 strictureplasties. RESULTS: There was no procedure-specific morbidity and mortality. Other common complications encountered were ileus (3/34) and surgical site infection (3/34). CONCLUSION: Most of the patients in this study have recurrent diffuse intestinal CD requiring synchronous bowel resection. Strictureplasty is a safe and effective bowel-sparing surgical option in this group of patients.

Intrahepatic delivery of feeds caused by a displaced percutaneous radiological gastrostomy catheter.

Percutaneous radiological gastrostomy (PRG) is a safe and accepted method of providing enteral nutrition in those with inadequate oral intake. We report a case of PRG that required laparotomy for intrahepatic displacement of a catheter that had been placed inadvertently through the liver under fluoroscopic guidance. Additional ultrasound or CT guidance may help to define a safe tract to avoid liver or colonic injury. Although transhepatic placement is reported to be well tolerated, this case raises concerns of additional morbidity associated with intrahepatic displacement.

Intravasation of barium sulphate at barium enema examination.

We report a case of venous intravasation of barium sulphate occurring during a routine barium enema examination for investigation of rectal bleeding. The patient suffered a cardiopulmonary arrest, but made a full recovery after organ support in intensive care. Review of radiographs from the examination showed intravasated barium in pelvic vessels. We review the literature on this rare, but serious, complication of barium enema examination and suggest measures by which intravasation can be prevented.

Use of vacuum-assisted closure for healing of a persistent perineal sinus following panproctocolectomy: report of a case.

Perineal sinus is a troublesome complication after proctectomy for inflammatory bowel disease or rectal cancer. The results from treatment with simple dressings with or without surgical debridement are suboptimal. Definitive management may require complex operations with muscular or musculocutaneous flaps. Vacuum-assisted dressings have been used successfully for management of chronic wounds and soft tissue defects. This technique was successfully used in the management of a perineal sinus, which occurred after proctectomy for rectal cancer developing on a background of inflammatory bowel disease and preoperative radiotherapy.

The effect of lower limb ischaemia-reperfusion on intestinal permeability and the systemic inflammatory response.

OBJECTIVES: a relationship has been demonstrated between increased intestinal permeability, endotoxaemia and the development of the systemic inflammatory response syndrome (SIRS) after aortic surgery. The aim of this study was to evaluate whether isolated lower limb ischaemia-reperfusion (I/R) injury affects intestinal mucosal barrier function and cytokine release. PATIENTS AND METHODS: four groups of patients were investigated, group I, patients with critical limb ischaemia (CLI) undergoing infra-inguinal bypass surgery (n=18); group II, patients with intermittent claudication (IC) undergoing infra-inguinal bypass surgery (n=14); group III, patients with CLI unsuitable for arterial reconstruction, undergoing major amputation (n=12); and group IV, patients undergoing carotid endarterectomy for symptomatic carotid stenosis (n=13). Intestinal permeability, endotoxaemia and urinary soluble tumour necrosis factor receptors were assessed (p55TNF-R). RESULTS: an increase in intestinal permeability was observed on the 3rd postoperative day only in CLI group. This was found to correlate with arterial clamp time. Patients who had a femoro-distal bypass had significantly higher intestinal permeability compared to those who had femoro-popliteal bypass. Endotoxaemia was not detected in any of the groups. Postoperative urinary p55TNF-R concentrations were significantly higher in CLI group compared to the other groups. These did not correlate with the increased intestinal permeability. CONCLUSIONS: our results support the hypothesis that revascularisation of critically ischaemia limbs leads to intestinal mucosal barrier dysfunction and cytokine release. They also suggest that the magnitude of the inflammatory response following I/R injury is related to the degree of initial ischaemia.

Vacuum assisted closure system in the management of enterocutaneous fistulae.

BACKGROUND: A very important yet often troublesome element in the conservative management of enterocutaneous fistulae is the protection of the surrounding skin from contact with the effluent. This report describes the successful use of a vacuum assisted closure (VAC) system in dealing with this problem. METHODS: The results of using the VAC system were studied in three patients with moderate or high volume output enterocutaneous fistulae where conventional treatment had failed to prevent skin excoriation. RESULTS: The VAC system was found to be highly effective in controlling fistula effluent and in promoting healing of excoriated skin in all three patients. Complete healing of the fistula was also achieved in two of the three patients. CONCLUSION: The VAC system can be an effective and economically viable method of containing fistula effluent and protecting the skin of patients with enterocutaneous fistulae. Contrary to conventional thought, the VAC system may also actually promote healing of the fistula.

Successful colonoscopy; completion rates and reasons for incompletion.

Factors such as poor bowel preparation or obstructing colonic disease may confound the reporting of colonoscopy completion rates, as these factors are outside of the control of the endoscopist performing the procedure. By adjusting for these factors when calculating a colonoscopy completion rate, it may be possible to make a more accurate assessment of a unit's or individuals' competence. Details of two thousand two hundred and sixteen colonoscopies performed by four consultants and their trainees between 1993-2000 were analysed retrospectively from a prospective endoscopy database. Crude (all cases) and adjusted (excluding poor bowel preparation and disease as causes of incompletion) rates were recorded for each sex, and by age according to cause. Overall crude and adjusted completion rates were 77.9% and 85.0% respectively. There was a significant difference between male and female completion rates due to a difference in the incidence of excess looping and intolerance of the procedure (adjusted rate 88.9% in males vs. 81.6% in females, p<0.05). There was a non-significant trend to lower completion rates in patients over 75 years of age compared to younger patients. Completion rates were significantly higher following bowel resection (adjusted rates 93.5% vs. 82.8%, p<0.05). There was no significant difference between completion rates for inpatient and outpatient referrals (P=0.36). Reporting colonoscopy completion rates by adjusting for factors such as poor bowel preparation and obstructing colonic disease allows for direct comparisons of completion rates reported by different units. Reporting completion rates in this way also highlights the effect of inadequate bowel preparation on successful colonoscopy.

Progress in the understanding and treatment of chronic anal fissure.

BACKGROUND: Chronic anal fissure is a common and painful condition associated with internal anal sphincter hypertonia. Reduction of this hypertonia improves the local blood supply, encouraging fissure healing. Surgical sphincterotomy is very successful at healing these fissures but requires an operation with associated morbidity. Temporary reduction in sphincter tone can be achieved on an outpatient basis by applying a topical nitric oxide donor (for example, glyceryl trinitrate) or injecting botulinum toxin into the anal sphincter. METHODS: A Medline database was used to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure. RESULTS: Review of the literature shows botulinum toxin injection to be more effective at healing chronic anal fissures than topical glyceryl trinitrate. Topical isosorbide dinitrate has not been directly compared with either of these two agents but has a healing rate approaching that of botulinum toxin injection. The main side effect of botulinum toxin injection is temporary faecal incontinence in approximately 2% of cases, whereas topical nitrates cause headaches in 20%-100% of cases. No long term side effects were identified with any of the medical treatments. CONCLUSION: Chemical sphincterotomy is an effective treatment for chronic anal fissure and has the advantages over surgical treatment of avoiding long term complications (notably incontinence) and not requiring hospitalisation.

Extraperitoneal approach reduces neutrophil activation, systemic inflammatory response and organ dysfunctionin aortic aneurysm surgery.

OBJECTIVES: to compare the effects of transperitoneal and extraperitoneal approaches on systemic inflammatory response, neutrophil activation and organ dysfunction in elective abdominal aortic aneurysm (AAA) repair. PATIENTS AND METHODS: twenty patients admitted for elective infrarenal AAA repair were prospectively randomised into transperitoneal (n =10) or extraperitoneal ( n =10) groups. Neutrophil activation was assessed by measuring the plasma levels of neutrophil elastase/alpha(1)-anti-trypsin complexes before surgery, intraoperatively and at 6 h, 12 h, 24 h and then daily after surgery. Venous blood samples for estimation of liver function tests, full blood counts, urea and electrolytes and arterial samples for blood gas analysis were taken daily from preoperatively to day 5 after surgery. Multiple organ dysfunction (MOD) and systemic inflammatory response (SIR) scores were calculated daily. RESULTS: the concentrations of neutrophil elastase/alpha(1)-anti-trypsin complexes were significantly higher in the transperitoneal group at 6 h after surgery compared to the extraperitoneal group (799(455-921) ng/ml (median(i.q.r.)) vs 307(171-395) ng/ml, p<0.005), and at 12 h (397(364-936) ng/ml vs 319(134-352) ng/ml, p <0.05). The MOD scores were significantly higher in the transperitoneal group in comparison to the extraperitoneal group at day 1 (2.5(2-3.3) vs 1(0-1), p<0.001) and day 2 (2.5(2-3.3) vs 1(0-1), p <0.001). The SIR scores were also significantly higher at day 1 (1(0-2) vs 0, p <0.01), day 2 (1.5(0-2.3) vs 0, p <0.01), and day 3 (1(0-1) vs 0, p <0.05). CONCLUSIONS: neutrophil activation, systemic inflammatory response and organ dysfunction are increased in elective AAA repair when a transperitoneal approach is used. This may be related to intestinal manipulation and mesenteric traction which are reduced in the extraperitoneal approach.

Flexible sigmoidoscopy and the changing distribution of colorectal cancer: implications for screening.

BACKGROUND AND AIMS: There has been a significant proximal shift in the distribution of colorectal cancer (CRC) in Northern Ireland over recent decades. The aim of this study was to investigate the potential implications of this proximal shift in CRC distribution on the efficacy of flexible sigmoidoscopy (FS) as a screening tool. PATIENTS AND METHODS: The site distribution of 5153 CRCs was available from the Northern Ireland Colorectal Cancer Register for the period 1990-1997. Similar data on 1241 CRCs between 1976 and 1978 were available from a previous study. Data on the site reached by FS were obtained from a prospectively collected endoscopy database at one of Northern Ireland's main teaching hospitals for the period 1993-1998. RESULTS: There was a significant proximal shift in CRC distribution between the two periods (23.5% proximal to the splenic flexure between 1976 and 1978 v 36.7% between 1990 and 1997; p<0.001). The descending colon was visualised during 74.4% of FS examinations. By combining the observed extent of FS examination with CRC site distribution, it was calculated that FS could have visualised 68.8% of CRCs between 1976 and 1978 but only 56.0% between 1990 and 1997. Extrapolating these data to a Northern Ireland screening programme involving FS and faecal occult blood testing suggests that significantly more CRCs could have been detected between 1976 and 1978 than between 1990 and 1997 (51.7% v 48.2%, respectively; p=0.03). CONCLUSIONS: This study confirms the previously documented left to right shift in CRC distribution in Northern Ireland and demonstrates that if this shift continues, FS will become less successful as a screening tool than is currently predicted.