National audit to assess standards of care for deliberate self-harm patients presenting to trauma centres with penetrating wounds and recommendations for action.

BACKGROUND: The authors assessed the standard of care for patients presenting with deliberate self-harm (DSH) injuries to major trauma centres (MTCs) in England as well as hospitals within the major trauma network in Scotland. This was to generate an understanding of current practice, identify any shortfall and develop recommendations to improve safety and patient care. METHODS: We contacted all MTCs in England and hospitals in the major trauma network in Scotland, asking their permission to be included in this study. Emergency department (ED) consultants at each unit were then invited to complete a telephone questionnaire clarifying their current management policies of DSH patients against NICE guidance. The telephone questionnaire was carried out by the same author to ensure interpretation was consistent. RESULTS: Twenty-seven MTCs within England as well as the four hospitals in the major trauma network within Scotland were contacted. There was a total of 15 responses - 14 responses from MTCs within England and 1 response from a hospital in the trauma network in Scotland. The clear deficit in practice was identified and recommendations were generated. CONCLUSION: Our study has shown that patients are transferred following DSH without a clear review of their physical, psychological and social needs. We hope to share our recommendations for the implementation of a local protocol to improve standards and safety.

Determining the real site of peroneal nerve injury with knee dislocation: Earlierier is easier.

Common peroneal nerve (CPN) injury is a recognised complication of traumatic knee dislocation with a direct association between the degree of ligamentous injury and the degree of CPN injury. It is essential explore and repair these injuries in good time to reduce morbidity. Often exploration only involves the portion of this nerve associated with the joint as it courses around the fibular head. However, a recent case highlighted the importance of proximal exploration to its branching point from the sciatic nerve, a known point of fragility, even if other defects have been identified.

Salvage of an Exposed Axillo-profunda Bypass Graft and Discussion of Reconstructive Options on the Torso.

INTRODUCTION: A case of salvage of an exposed axillo-profunda bypass graft is presented. REPORT: Robust coverage of the graft was achieved with a pedicled latissimus dorsi muscle flap and overlying bi-pedicled cutaneous flap. DISCUSSION: Reconstructive options to salvage an exposed prosthetic graft will depend on the position on the trunk but can be successful if a reconstructive plastic surgery algorithm is followed. The options are discussed within this report. Exposed axillo-profunda graft can be salvaged successfully through a variety of reconstructive techniques. Close cooperation between vascular and plastic surgeons is vital for a successful outcome.

Can leucocyte depletion reduce reperfusion injury following cardiopulmonary bypass?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Can leucocyte depletion (LD) reduce reperfusion injury following cardiopulmonary bypass?'. Altogether more than 74 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that there appears to be little or no clinical benefit gained from the use of LD treatment. The majority of studies, looking at outcomes including the duration of hospital and intensive care unit (ICU) stay, intubation time, inotropic support required and postoperative arrhythmias, found the results comparable between patients receiving LD treatment and controls. Biochemical parameters of reperfusion inflammation and cardiac damage are reduced in many studies, suggesting an attenuation of reperfusion injury at a cellular level, but this does not appear to be transferable to clinical improvement. However, one study using patients with severely low left ventricular ejection fractions (LVEF), found those receiving LD treatment required less inotropic support and experienced a significant increase in LVEF postoperatively when compared with controls, indicating that the benefit of LD may depend on preoperative status and susceptibility to reperfusion damage. In conclusion, LD should not be used routinely in cardiac surgery.

Is a sleeve lobectomy significantly better than a pneumonectomy?

A best evidence topic was written according to a structured protocol. The question addressed was 'whether a sleeve lobectomy results in a better survival rate than a pneumonectomy in suitable patients?' Altogether, more than 327 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude in the biggest meta-analysis of nearly 3000 patients, the five-year survival was 50% for sleeve lobectomy compared to 30% for pneumonectomy. Operative mortality was 3% vs. 6% for pneumonectomy, and locoregional recurrence was 17% vs. 30%. These results are broadly consistent across all the 13 cohort studies presented here many of which document a 20-year single centre experience or more. There are significant issues in all cohort studies on this subject as, due to their non-randomized nature, the reason for not performing a sleeve resection may well have been more advanced disease, which would necessarily mean that the pneumonectomy patients would have a lower expected survival and higher local recurrence. In addition, there have been many large cohort studies to date and thus no more are required, as future studies are unlikely to resolve this issue. Thus, the only study that would adequately correct for this issue would be a randomized trial, but to prove a 10% increase in five-year survival a 300 patient study would be needed. This is bigger than any study ever done in this area and as some centres took 30 years to collect these numbers of potential sleeve patients an RCT is not a realistic possibility. Therefore, we conclude that no more cohort studies should be performed, as the results will be consistent with the meta-analyses and an RCT to eliminate their bias is unattainable, and thus no more research should be done on this topic and surgeons should use the figures presented above and in more detail in this best evidence topic to govern their management in the future.