Generational and occupational differences in human factors knowledge and awareness: a comparison study.

INTRODUCTION: Increasing healthcare sector litigation, accountability and governance has resulted in the identification of human factors (HF) as a common source of error. Both NHS and military doctors must have awareness of HF to enhance safety and productivity. There is limited published evidence examining knowledge of HF in these two healthcare professional groups. METHODS: Doctors of all grades and specialties across the NHS and 3 military groups including the Defence Deanery within the UK were invited to complete a 10-item web-based survey. Questions focused on training undertaken, HF knowledge and potential future training needs. RESULTS: The survey link was emailed to 250 military and 1400 NHS doctors, 191 military and 776 NHS responded (response rate: 76% and 55%, respectively). Military doctors above foundation trainees are more familiar with HF, have had more training and recognise a requirement for additional training. Military foundation trainees had similar responses to their NHS colleagues. Doctors who had not undertaken any HF training are less likely to appreciate its value, with almost 60% of senior NHS doctors reporting no training. Foundation trainees have more training in HF than their senior peers when military seniors are excluded and more frequently identified a need for further training. Junior doctors identified stress, fatigue, communication and leadership more frequently, with seniors identifying work environment and music in theatre correctly more often. CONCLUSION: Non-training grade doctors are less likely to seek HF training. Military doctors are more familiar with HF and have undertaken more training. Given the role of HF in communication, human error, potential litigation, stress, conflict and gross negligence manslaughter convictions, further education is vital.

Civilian and military doctors' knowledge of tranexamic acid (TXA) use in major trauma: a comparison study.

INTRODUCTION: Tranexamic acid (TXA) administration within the recommended time of 3 hours has been demonstrated to improve outcomes following trauma. The aim of this study was to identify potential knowledge gaps in the administration of TXA in order to target further educational training in those doctors responsible for the management of acute trauma. METHODS: 104 military and 852 civilian doctors were invited to complete a four-item web-based questionnaire pertaining to the indications, dose, side effects and evidence base for TXA administration in trauma. Doctors of all grades and surgical specialties including emergency trainees and anaesthetics were surveyed. RESULTS: 65 military and 460 civilian doctors responded with a response rate of 62% and 54%, respectively. Responses were required for every question to allow progression and submission. 93% of military doctors knew the initial dose of TXA compared with 34% of civilian doctors. The Clinical randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) 2 trial was known to 91% of military doctors compared with 24% of civilian doctors. The optimal time for delivery of TXA in under 3 hours was correctly identified by 91% of military doctors compared with 10% by civilian doctors. DISCUSSION: Military doctors are more familiar with TXA and its side effect profile. Given the potential impact of TXA on patient outcome and the findings of this study, further education of all doctors is recommended including dose, timing and potential side effects.

Routine versus selective histological examination after cholecystectomy to exclude incidental gallbladder carcinoma.

Introduction Gallstone disease is treated commonly with cholecystectomy. Malignant disease of the gallbladder may present similarly and has a poor prognosis. It is common for cholecystectomy specimens to be sent for histological examination to exclude malignancy. However, the incidence of incidental gallbladder carcinoma (IGBC) is low and it has therefore been suggested that macroscopic inspection of the gallbladder by the surgeon, followed by selective histological examination of abnormal specimens, may be safe and cost saving. Methods All cholecystectomies performed between 1 May 2003 and 1 September 2009 were identified from clinical coding. Pathology records were used to identify gallbladder malignancies; these were searched manually to identify IGBC. Pathology reports and case notes were cross-referenced to determine whether there were macroscopic abnormalities present. Annual cost savings were estimated by comparing the number of gallbladder specimens over one year (May 2013 - April 2014) with the total number of cholecystectomies performed in that time. Results Of 4,776 cholecystectomies identified, 12 (0.25%) were cases of IGBC. These cases had a higher median age (68 vs 54 years, p<0.001) and a higher proportion were emergency operations (50% vs 12%, p<0.001). All cases had some form of macroscopic abnormality, most commonly wall thickening (n=6, 50%). Only two cases (17%) had a visible tumour present. Conclusions All cases of IGBC in this study had a macroscopically abnormal gallbladder. Our findings suggest it is safe to adopt a selective approach to histological examination. Savings of almost £20,500 per annum have been achieved.

Pre-operative gastric emptying time correlates with clinical response to gastric electrical stimulation in the treatment of gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) may be of benefit in cases of gastroparesis that fail to respond to standard medical therapy. Response to this treatment is varied and prediction of clinical improvement is difficult. METHODS: This was a retrospective review and symptom questionnaire survey for all patients who underwent GES insertion in a single institution from November 2008 until May 2010 using the gastroparesis cardinal symptom index (GCSI). RESULTS: 14 out of 17 patients who had GES insertion responded to telephone or postal questionnaire. Mean pre-operative gastric emptying time was 151 min (median 146 min, range 18-318). Median follow up was 14 months (range 7-25 months). The mean reduction in GCSI score after GES insertion was 51% (13.4 vs 6.4, Z = 0.0013). Percentage reduction in GCSI correlated with pre-operative solid gastric emptying time (p = 0.0086). Two patients who responded to questionnaire required device removal, one due to a gastric perforation and the other for discomfort related to the implant and a poor clinical response. CONCLUSIONS: GES significantly improves symptoms of gastroparesis on the GCSI score. Not all patients respond equally to GES, and response may be predicted by pre-operative solid gastric emptying times.

Day-case laparoscopic Nissen fundoplication.

INTRODUCTION: Nissen fundoplication has been performed laparoscopically for over 15 years, being associated with shorter hospital stay and fewer complications than conventional open surgery with good long-term outcomes. Day-case laparoscopic Nissen fundoplication (LNF) is rarely performed in the UK and most series in the literature report length of stay >2 days. METHODS: The objective of this study was to examine the safety and efficacy of day-case LNF. The clinical records of all patients undergoing LNF under the care of three surgeons in a district general hospital (DGH) during a 5-year period (January 2003 to December 2007) were reviewed to examine length of stay, complications, length of procedure, grade of operating surgeon and symptoms on follow-up. RESULTS: One hundred thirteen day-case LNFs were recorded in this series. Day-case LNF patients had median age of 45 years (range 20-68 years, 65% (64.6%) male) and 98% were American Society of Anesthesiologists (ASA) grade I or II. Twenty-one cases (19%) were performed by higher surgical trainees. Median operative time was 54 minutes (range 25-120 min). Only one perioperative complication (port-site bleed) occurred, treated without prolonging length of stay. The proportion of all LNF performed as day cases increased from 8% to 52% during the study period. Median operative time has significantly reduced from the first 20 consecutive LNF cases to the latest 20 cases [65 min (range 40-120 min) versus 48 min (range 25-72 min); p = 0.037]. At follow-up (median 7 weeks, range 2-31 weeks) 82% of patients had improvement in all presenting symptoms. Eight patients had postoperative complications [wound infection (n = 2), persistent regurgitation requiring laparoscopic division of a gastric band adhesion (n = 1), dysphagia (n = 5 with two patients requiring redo partial fundoplication and one patient requiring dilatation) and there were no conversions to open surgery. CONCLUSION: Day-case LNF is safe and effective for treating selected patients with gastroesophageal reflux disease (GERD) in a DGH. The proportion of day-case LNFs is increasing in our unit. Half of the LNFs in a DGH can be done as day cases. Experience is associated with a significant reduction in operative time.

Avoidance of tattoo disruption: a further benefit of laparoscopic surgery.

INTRODUCTION: Tattoos are increasingly common in both male and female patients. Abdominal skin tattoos may be present at the site of proposed incisions for conventional surgery whereas laparoscopic port site placement can be adjusted to accommodate tattoo constraints. METHODS: Patients with tattoos were questioned by face-to-face interview to determine how long ago they had their tattoo, financial cost of the tattoo, and potential degree of distress caused by disruption of their tattoo (on a scale of 1-10). Consultant and higher surgical trainee general surgeons were asked by e-mail survey whether they had encountered a patient with a tattoo at the site of a proposed incision, did they avoid incising the tattoo during surgical intervention, and had they received a complaint from a patient about tattoo distortion. RESULTS: Ninety six patients (50 male, median age 29 years) were questioned. Median cost of the tattoos was pound35 ($70). Female patients were more likely to be distressed and complain than men about tattoo disruption (p = 0.0003) and there was a significant inverse correlation between time from tattooing and distress (p = 0.02). Most (79%) of the general surgeons questioned (n = 107, response rate 82%) had encountered tattoos at proposed incision sites; 61% had avoided making an incision through it and 4% had received a complaint about tattoo disruption by a patient. CONCLUSION: Tattoo disruption by surgical incision may cause distress especially in female patients who had their tattoo recently. Tattoos should be avoided where possible by alternative port site placement.

Day case emergency laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy (LA) is associated with a shorter hospital stay and fewer complications than conventional open appendectomy (OA). This study aimed to examine the safety and efficacy of day case emergency LA. METHODS: The records of patients undergoing emergency LA under the care of two laparoscopic surgeons over a 3-year period (Februrary 2003 to February 2006) were reviewed to examine hospital length of stay (LOS), complications, histology, grade of the operating surgeon, and time required to perform the procedure. RESULTS: A total of 104 patients (median age, 25 years; range, 11-72 years; 58 men) underwent LA, with 9 and 66 patients discharged in 8 and 24 hours, respectively (median LOS 22 hours: range 6-170 hours). One patient underwent conversion to OA. Histologically, 86 patients had appendicitis and 18 had normal appendices with another pathology present. The median operative time was 35 min (range, 20-80 min). The complications included three wound infections and two pelvic abscesses not requiring further operative intervention. CONCLUSION: Day case emergency LA is safe and effective for treating selected patients.

The carbon footprint of laparoscopic surgery: should we offset?

The aim of this study was to estimate the effect that the expansion of laparoscopic surgery has had on global warming. Laparoscopic procedures performed in a hospital over a 10-year period were analysed. The number of CO(2) cylinders (size C) used over a 2.5-year period and the "carbon footprint" of each cylinder was calculated. There was a fourfold increase of in the number of laparoscopic procedures performed over the past 10 years (n = 174-688). Median operative time for the laparoscopic procedures performed over the past 2.5-years (n = 1629) was 1.01 h (range 0.3-4.45 h) with 415 cylinders used in this period giving an operative time per cylinder of 3.96 h. Each cylinder produces only 0.0009 of tonnes of CO(2). Despite increasing frequency of the laparoscopic approach in general surgery, its impact on global warming is negligible.

G17DT: an antigastrin immunogen for the treatment of gastrointestinal malignancy.

G17DT (Gastrimmune) is an antigastrin-17 immunogen, raising antibodies that blockade gastrin-stimulated tumor growth. It has completed Phase III trials in patients with pancreatic cancer, and Phase III trials in gastric cancer are planned. Preclinical studies have confirmed that the G17DT-induced antibodies both reduce gastrin-17-stimulated gastric acid secretion and inhibit gastrin from interacting with the cholecystokinin-2 receptor. The efficacy of both passive and active immunization with G17DT has been established in a number of tumor systems, with additive effects demonstrated in combination chemotherapy in pancreatic, colon and gastric tumor models. Phase I/II studies in advanced gastrointestinal malignancies have shown no systemic or autoimmune reactions to active immunization with G17DT. The use of an optimized dose and dosing schedule has yielded a high proportion of antibody responders (70%), with minimal side effects and antibody titers measurable within 2 - 4 weeks. Phase II trials of G17DT in combination with chemotherapy have also been conducted in gastric and colorectal cancer. A Phase III, multicenter, double-blind, randomized, controlled trial of G17DT versus placebo in patients with advanced pancreatic cancer confirmed improved survival of patients in the G17DT group through an intention-to-treat analysis. The results of a randomized, double-blind, multinational, multicenter study of G17DT in combination with gemcitabine versus placebo and gemcitabine in patients with advanced pancreatic cancer failed to show improved overall survival except on subset analysis of patients with high antibody titers. Therefore, G17DT represents an emerging new modality for gastrointestinal malignancy.

The effect of jaundice on the generation of anti-gastrin antibodies in G17DT immunized patients with advanced pancreatic cancer.

AIM: The aim of this study was to determine the ability of G17DT to generate anti-gastrin antibodies in jaundiced patients with biliary obstruction due to advanced pancreatic cancer. METHODS: G17DT was administered to 41 patients with advanced pancreatic adenocarcinoma by intramuscular (i.m.) injection at a dose of 250mcg at weeks 0, 1 and 3 of the study. RESULTS: Thirty-five of 41 patients participating in the study were categorized as responders in terms of their gastrin-17 antibody response. There was no correlation between the maximum G17 antibody response and the bilirubin level at either week 0 or week 12. The median survival of patients from the time of the first injection of G17DT was 204 days with 25% of patients surviving for or=305 days. CONCLUSION: This study shows that G17DT administered to jaundiced patients with advanced pancreatic cancer is immunogenic and well tolerated.

Day-case breast cancer axillary surgery.

INTRODUCTION: The standard locoregional management of breast cancer is excision of the primary tumour and axillary staging with suction drainage of the axilla. The objective of this study was to determine the safety, tolerability and efficacy of day-case surgery without suction drainage. PATIENTS AND METHODS: A review of complete, prospectively collected data was performed on all breast cancer patients (screening and symptomatic) planned to undergo day-case axillary surgery at a University Teaching Hospital between 2000 and 2002. Postoperative complications were recorded and the notes of patients not discharged on the day of their surgery were also examined to establish the reason for overnight stay. RESULTS: 165 patients underwent intended day-case axillary surgery (axillary dissection level 1/2; median age, 55 years; range, 39-76 years). Of these, 16 (9.7%) were admitted overnight usually due to over-running of theatre lists (n = 13; 81%). 29 patients (17.6%) underwent axillary dissection alone, the remainder had axillary surgery combined with wide local excision (median number of lymph nodes excised 11; range, 2-18). Complications included symptomatic seroma formation in 37 patients (22%) and wound infection in 16 patients (10%). CONCLUSIONS: Day-case axillary surgery can be performed safely with surgical morbidity comparing favourably to published work of 'traditional' axillary drainage following lymphadenectomy.

Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults.

BACKGROUND: Secondary peritonitis is associated with a high mortality rate and if not treated successfully leads to development of abscesses, severe sepsis and multi-organ failure. Source control and adjunctive antibiotics are the mainstay of treatment. However, no conclusive evidence suggest that one antibiotic regimen is better than any other but at the same time have a lower toxicity. OBJECTIVES: To ascertain the efficacy and adverse effects of different antibiotic regimens in treating intra-abdominal infections in adults. Outcomes were divided into primary (clinical success and effectiveness in reducing mortality) and secondary (microbiological success, preventing wound infection, intra-abdominal abscess, clinical sepsis, remote infection, superinfection, adverse reactions, duration of treatment required, effectiveness in reducing hospitalised stay, and time to defervescence). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SR-COLOCA. Bibliographies of identified studies were screened for further relevant trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing different antibiotic regimens in the treatment of secondary peritonitis in adults were selected. Trials reporting gynaecological or traumatic peritonitis were excluded from this review. Ambiguity regarding suitability of trials were discussed among the review team. DATA COLLECTION AND ANALYSIS: Six reviewers independently assessed trial quality and extracted data. Data collection was standardised using data collection form to ensure uniformity among reviewers. Statistical analyses were performed using the random effects model and the results expressed as odds ratio for dichotomous outcomes, or weight mean difference for continuous data with 95% confidence intervals. MAIN RESULTS: Fourty studies with 5094 patients met the inclusion criteria. Sixteen different comparative antibiotic regimens were reported. All antibiotics showed equivocal comparability in terms of clinical success. Mortality did not differ between the regimens. Despite the potential high toxicity profile of regimens using aminoglycosides, this was not demonstrated in this review. The reason for this could be the inherent bias within clinical trials in the form of patient selection and stringency in monitoring drug levels. AUTHORS' CONCLUSIONS: No specific recommendations can be made for the first line treatment of secondary peritonitis in adults with antibiotics, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. Future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.

A phase II study of G17DT in gastric carcinoma.

PURPOSE: G17DT is a gastrin immunogen, raising antibodies that blockade gastrin-stimulated growth. The aim of the study was to characterise antibody response and assess safety and tolerability of G17DT given to patients with gastric cancer. EXPERIMENTAL DESIGN: G17DT was administered to 52 patients with gastric adenocarcinoma at weeks 0, 2 and 6 by intramuscular injection at doses of 10, 100 and 250 microg. Antibody levels were measured by an ELISA assay. A radioligand displacement assay determined the ability of G17DT-immunised patients' sera to inhibit binding of 125IG17 to cholecystokinin (CCK)-2 receptors. RESULTS: By week 12 of the study, 6/12 evaluable stage I-III patients achieved an antibody response in the 10 microg group, 7/11 in the 100 microg group, and 11/12 in the 250 microg group. Stage IV patients dosed at 250 microg achieved a similar response rate to stage I-III patients dosed at 10 or 100 microg. G17DT was well tolerated in 47/52 patients. Two patients suffered significant adverse reactions including injection site pain and abscess. G17DT antibodies displaced iodinated gastrin from CCK-2 receptors, with the level of displacement correlating with antibody titre. CONCLUSIONS: G17DT immunisation is a well-tolerated method of raising functional antibodies to 17 amino acid gastrin forms in patients with gastric carcinomas.

The 'two-week' target for the diagnosis of pancreatic carcinoma: an achievable aim?

AIM: The aim of this study was to evaluate the current diagnostic process for patients with pancreatic cancer in a University teaching hospital and to determine whether the 'two-week' target for rapid assessment was being met. METHODS: The notes of all patients with pancreatic cancer from June 1998 to June 2000 were reviewed to determine the time to diagnosis, investigations and procedures performed, number of admissions, length of hospital stay and survival RESULTS: There were 146 patients in total with a median (range) age of 71 (38-92) years. 18 (12%) had resectable lesions, while the remaining 128 patients had 134 palliative interventions (33 surgical; 101 radiological or endoscopic). The median number of hospital admissions for each patient was 2 (range 1-6) with a median length of hospital stay of 9 days (range 1-35 days). The median (IQR) time to diagnosis was significantly less in the jaundiced patients [7 (6-10) days vs. 32 (18-46) days, P<0.0001]. There was no significant correlation between age and time to diagnosis (r=0.08, P=0.36). There were 105 (72%) deaths in the study population, 82 in the jaundiced group and 23 in the non-jaundiced group. There was no significant difference in median (IQR) duration from referral to death in the jaundiced and non-jaundiced groups [59.5 (18-175) days vs. 35 (16-137) days, P=0.45]. CONCLUSIONS: A diagnosis within 14 days was achieved in 77% of patients. Patients with jaundice were more likely to have an earlier diagnosis than those without jaundice but this had no impact on survival.

Barrett's esophagus: patient information and the Internet. The patient's perspective.

Barrett's esophagus is being diagnosed more frequently in the UK. Today patients are encouraged to be actively involved in the treatment decision-making process. To do this they must receive adequate information and, more importantly, understand it. In patients with Barrett's, this information is often given to the patient immediately following an endoscopy, when patients find it difficult to absorb. The Internet can provide patients with up-to-the-minute information that they can digest in their own time. The aim of this study was to assess the current information given to patients and their views on using the Internet for these purposes. A postal questionnaire was devised, and sent to the 267 patients with Barrett's. The questionnaire sought to determine the source and quality of current patient information, and patients' willingness to use the Internet for medical information. One hundred and ninety-five (73%) questionnaires were returned. One hundred and fifty-three patients (78.5%) of those who responded stated they wanted more information about their condition. Sixty-eight patients (33.8%) had Internet access. One hundred and five (53.8%) patients stated that they would use an Internet site if access were available. The average age of this group was 58.7 years. Seventy-nine (40.5%) stated they would not use an Internet site; their average age was 69.4 years. Current patient information is often inadequate. A significant proportion of the patients would use the Internet. Those who had already used the Internet to access information found existing sites to be very 'American', and presented in a way that made them difficult for a layperson to understand. It is essential that patients have adequate information in a format they can access and understand.

Finding the best from the rest: evaluation of the quality of patient information on the Internet.

INTRODUCTION: Information is of utmost importance for patients at risk of developing cancer who require regular screening. Quality assessment is vital to ensure correct information is published on the Internet. METHOD: A postal questionnaire was sent to patients under follow-up for Barrett's oesophagus and colonic polyps. Questions related to computer/Internet access, where patients had previously sought information, whether web-sites would be of use, and what information they would like displayed. A review of on-line patient literature for Barrett's oesophagus and colorectal adenomas was performed. RESULTS: Of the 200 questionnaires sent, 161 patients responded (80.1%). The majority of patients (88%, n = 141) wanted more information on their condition, with 45% (73) having home Internet access and a further 32% (52) having web access from other sources. Only 8% (12) had used the Internet as a source of information; however, the majority of patients (57%) would access a recommended web-site. The Barrett's search resulted in 10/200 sites with full information (i.e. score > 8/10 points). For colorectal polyps there were 12/200 sites. CONCLUSIONS: Accessing quality Internet health information is very time consuming. Recommended web-sites that provide the best information would help patients avoid being overwhelmed with irrelevant and confusing literature.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom.

BACKGROUND: The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. METHODS: A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. RESULTS: Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). CONCLUSION: Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.