The impact of trauma centre designation on open tibial fracture management

INTRODUCTION

The British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons guidelines for the management of open tibial fractures recommend early senior combined orthopaedic and plastic surgical input with appropriate facilities to manage a high caseload. The aim of this study was to assess whether becoming a major trauma centre has affected the management of patients with open tibial fractures.

METHODS

Data were obtained prospectively on consecutive open tibial fractures during two eight-month periods: before and after becoming a trauma centre.

RESULTS

Overall, 29 open tibial fractures were admitted after designation as a major trauma centre compared with 15 previously. Of the 29 patients, 21 came directly or as transfers from another accident and emergency deparment (previously 8 of 15). The time to transfer patients admitted initially to local orthopaedic departments has fallen from 205.7 hours to 37.4 hours (p=0.084). Tertiary transferred patients had a longer hospital stay (16.3 vs 14.9 days) and had more operations (3.7 vs 2.6, p=0.08) than direct admissions. As a trauma centre, there were improvements in time to definitive skeletal stabilisation (4.7 vs 2.2 days, p=0.06), skin coverage (8.3 vs 3.7 days, p=0.06), average number of operations (4.2 vs 2.3, p=0.002) and average length of hospital admission (26.6 vs 15.3 days, p=0.05).

CONCLUSIONS

The volume and management of open tibial fractures, independent of fracture grade, has been directly affected by the introduction of a trauma centre enabling early combined senior orthopaedic and plastic surgical input. Our data strongly support the benefits of trauma centres and the continuing development of trauma networks in the management of open tibial fractures.

What is the nature of polyps detected by the NHS bowel cancer screening pilots?

AIM

The NHS Bowel Cancer Screening Programme is currently being introduced following three rounds of pilot screening. The study outlines the important characteristics of polyps detected by pilot screening and compares the location of polyps with those of symptomatic cancers to challenge the circumstantial evidence for the adenoma carcinoma pathway.

METHOD

The first 100 patients with screen-detected polyps from University Hospitals Coventry and Warwickshire (UHCW) were identified from the colorectal cancer screening database. Important characteristics of the polyps were identified from the endoscopy reporting system and entered into a database. Polyp location was compared with the location of symptomatic cancers detected in the UHCW colorectal cancer database.

RESULTS

One hundred patients were selected for investigation and 202 polyps were detected. The average age of the patients with polyps was 61 years, 35% were under the age of 60. There were 67% male subjects. The average size of the largest polyp in each of the different patients was 13.5 mm. Eighty-five per cent of polyps were excised. Histology was available for 181 polyps of which 40% were tubulovillous, 33% tubular, 14% metaplastic and 1% villous. Eighty-eight per cent showed low-grade dysplasia and 8% high-grade one. The location of screen-detected polyps was significantly different from that of symptomatic cancers in our database, with proportionally more sigmoid and proportionally less rectal and caecal polyps detected.

CONCLUSION

The study outlines the important characteristics of screen-detected polyps. The significant difference in location of polyps from that of cancer suggests a variation in the malignancy potential of polyps depending on the location.

The antioxidant and chlorogenic acid profiles of whole coffee fruits are influenced by the extraction procedures

Commercial whole coffee fruit extracts and powder samples were analyzed for chlorogenic acids (CGA), caffeine and antioxidant activities. CGA and caffeine were characterized by LC-MS(n) and HPLC accordingly, and quantified by UV absorbance. ORAC, HORAC, NORAC, SORAC and SOAC (antioxidant capacities) were assessed. Three caffeoylquinic acids, three feruloylquinic acids, three dicaffeoylquinic acids, one p-coumaroylquinic acid, two caffeoylferuloylquinic acids and three putative chlorogenic lactones were quantified, along with a methyl ester of 5-caffeoylquinic acid (detected in one sample, the first such report in any coffee material). Multistep whole coffee fruit extracts displayed higher CGA content than single-step extracts, freeze-dried, or air-dried whole raw fruits. Caffeine in multistep extracts was lower than in the single-step extracts and powders. Antioxidant activity in whole coffee fruit extracts was up to 25-fold higher than in powders dependent upon the radical. Total antioxidant activity of samples displayed strong correlation to CGA content.

Does social environment affect arthritis patients' ability to remain on methotrexate treatment?

Focal points

Sugammadex for the reversal of muscle relaxation in general anaesthesia: a systematic review and economic assessment

BACKGROUND

Sugammadex (Bridion) is a newly developed agent for the reversal of neuromuscular blockade (NMB) induced by rocuronium or vecuronium. Sugammadex can reverse profound blockade and can be given for immediate reversal and its use would avoid the potentially serious adverse effects of the currently used agent, succinylcholine. Also, sugammadex can reverse NMB more quickly and predictably than existing agents.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of sugammadex for the reversal of muscle relaxation after general anaesthesia in UK practice following routine or rapid induction of NMB.

DATA SOURCES

Medical databases [including MEDLINE, EMBASE, CINAHL, Science Citation Index, BIOSIS and Cochrane Central Register of Controlled Trials (CENTRAL), conference proceedings, internet sites and clinical trials registers] were searched to identify published and unpublished studies. The main searches were carried out in May 2008 and supplemented by current awareness updates up until November 2008.

REVIEW METHODS

For the clinical effectiveness review, randomised controlled trials of sugammadex against placebo or an active comparator (neostigmine + glycopyrrolate) for the reversal of moderate or profound NMB and for immediate reversal (spontaneous recovery from succinylcholine-induced blockade) were included. The primary effectiveness outcome was speed of recovery from NMB, as measured by objective monitoring of neuromuscular function. For the cost-effectiveness review, a de novo economic assessment considered the routine induction of NMB and the rapid induction and/or reversal of NMB, and threshold analyses were carried out on a series of pairwise comparisons to establish how effective sugammadex needs to be to justify its cost.

RESULTS

The review of clinical effectiveness included four randomised active-control trials of sugammadex, nine randomised placebo-controlled trials and five studies in special populations. A total of 2132 titles and abstracts and 265 full-text publications were screened. The included trials indicated that sugammadex produces more rapid recovery from moderate or profound NMB than placebo or neostigmine. Median time to recovery from moderate blockade was 1.3-1.7 minutes for rocuronium + sugammadex, 21-86 minutes for rocuronium + placebo and 17.6 minutes for rocuronium + neostigmine. In profound blockade, median time to recovery was 2.7 minutes for rocuronium + sugammadex, 30 to > 90 minutes for rocuronium + placebo, and 49 minutes for rocuronium + neostigmine. Results for vecuronium were similar. In addition, recovery from NMB was faster with rocuronium reversed by sugammadex 16 mg/kg after 3 minutes (immediate reversal) than with succinylcholine followed by spontaneous recovery (median time to primary outcome 4.2 versus 7.1 minutes). The evidence base for modelling cost-effectiveness is very limited. However, assuming that the reductions in recovery times seen in the trials can be achieved in routine practice and can be used productively, sugammadex [2 mg/kg (4 mg/kg)] is potentially cost-effective at its current list price for the routine reversal of rocuronium-induced moderate (profound) blockade, if each minute of recovery time saved can be valued at approximately 2.40 pounds (1.75 pounds) or more. This is more likely to be achieved if any reductions in recovery time are in the operating room (estimated value of 4.44 pounds per minute saved) rather than the recovery room (estimated value of 0.33 pounds per minute saved). The results were broadly similar for rocuronium- and vecuronium-induced blockade. For rapid reversal of NMB it appeared that any reduction in morbidity from adopting sugammadex is unlikely to result in significant cost savings.

LIMITATIONS

The evidence base was not large and many of the published trials were dose-finding and safety studies with very small sample sizes. Also, some relevant outcomes, in particular patient experience/quality of life and resources/costs used, were either not investigated or not reported. In addition, it is likely that the patients included in the efficacy trials were relatively young and in good general health compared with the overall surgical population. Regarding the economic evaluation, there appears to be no evidence linking measures of clinical efficacy to patients' health-related quality of life and mortality risks.

CONCLUSIONS

Sugammadex may be a cost-effective option compared with neostigmine + glycopyrrolate for reversal of moderate NMB and also provides the facility to recover patients from profound blockade. Rocuronium + sugammadex could be considered as a replacement for succinylcholine for rapid induction (and reversal) of NMB, although this may not be a cost-effective option in some types of patient at current list prices for sugammadex. Considerable uncertainties remain about whether the full benefits of sugammadex can be realised in clinical practice.

Mechanical thrombectomy of an infected deep venous thrombosis: a novel technique of source control in sepsis

A young i.v. drug abuser presented with an extensive iliofemoral deep vein thrombosis and signs of severe sepsis. Subsequent investigations revealed multiple septic emboli in his lungs originating from infected thrombus in his leg. Despite systemic anti-coagulation and appropriate parenteral antibiotics, he continued to show signs of worsening acute infection. Percutaneous mechanical thrombectomy was performed successfully and resulted in an immediate improvement in his condition. In this report, we discuss the novel use of this technique for source control in a patient with septic shock secondary to infected thrombus.

Annealing c60+: synthesis of fullerenes and large carbon rings

Laser vaporization of graphite generates C(60)(+) cluster ions that are fullerenes and a mixture of roughly planar polycyclic polyyne ring isomers. Experimental studies of the annealing of the non-fullerene C(60)(+) ions indicate that they can be converted (in the gas phase) into the fullerene and an isomer that appears to be a large monocyclic ring. Some fragmentation is associated with conversion to the fullerene geometry, but the majority of the non-fullerene C(60)(+) isomers are cleanly converted into an intact fullerene. The emergence of the monocyclic ring (as the clusters are annealed) suggests that this is a relatively stable non-spheroidal form of these all carbon molecules. The estimated activation energies for the observed structural interconversions are relatively low, suggesting that these processes may play an important role in the synthesis of spheroidal fullerenes.