Tissue engineering and the trauma surgeon

The demands for repair and renewal of worn out or injured human tissue grow year on year<Eth> it is a demand that cannot be met from live human donors. A partial solution may be found from cadaveric or trans-species transplantation of tissue, but these approaches are steeped in the problems of disease transfer and ethical dilemma. Tissue engineering is a new technology that seeks to meet these increasing demands by utilizing novel cell culture methods in vitro to provide tissue replacements in vivo. This article reviews the current state of tissue engineering and its potential for use in the realms of trauma surgery.

Recent advances in topical agents for prehospital haemostasis

The prehospital treatment of severe extremity bleeding has remained unchanged for years and relies on compression with absorbent gauze dressings. Advances in haemostasis technology have identified several new methods of improving bleeding control. These are examined with a view to possible inclusion in a new prehospital dressing aimed at reducing the degree of exsanguination and associated mortality and morbidity from a major extremity injury.

Cerebrospinal fluid and plasma oxytocin concentrations are positively correlated and negatively predict anxiety in children

The neuropeptide oxytocin (OXT) exerts anxiolytic and prosocial effects in the central nervous system of rodents. A number of recent studies have attempted to translate these findings by investigating the relationships between peripheral (e.g., blood, urinary and salivary) OXT concentrations and behavioral functioning in humans. Although peripheral samples are easy to obtain in humans, whether peripheral OXT measures are functionally related to central OXT activity remains unclear. To investigate a possible relationship, we quantified OXT concentrations in concomitantly collected cerebrospinal fluid (CSF) and blood samples from child and adult patients undergoing clinically indicated lumbar punctures or other CSF-related procedures. Anxiety scores were obtained in a subset of child participants whose parents completed psychometric assessments. Findings from this study indicate that plasma OXT concentrations significantly and positively predict CSF OXT concentrations (r=0.56, P=0.0064, N=27). Moreover, both plasma (r=-0.92, P=0.0262, N=10) and CSF (r=-0.91, P=0.0335, N=10) OXT concentrations significantly and negatively predicted trait anxiety scores, consistent with the preclinical literature. Importantly, plasma OXT concentrations significantly and positively (r=0.96, P=0.0115, N=10) predicted CSF OXT concentrations in the subset of child participants who provided behavioral data. This study provides the first empirical support for the use of blood measures of OXT as a surrogate for central OXT activity, validated in the context of behavioral functioning. These preliminary findings also suggest that impaired OXT signaling may be a biomarker of anxiety in humans, and a potential target for therapeutic development in individuals with anxiety disorders.

The effect of perch availability during pullet rearing and egg laying on the behavior of caged White Leghorn hens

Enriched cages, compared with conventional cages, allow egg laying strains of chickens to meet some behavioral needs, including a high motivation to perch. The objective of this study was to determine if perch availability during rearing affected perch use as adults and if perch presence affected eating and drinking in caged White Leghorn hens. Chickens were assigned to 14 cages each with and without 2 round metal perches from hatch to 16.9 wk of age. At 17 wk of age, pullets were assigned to laying cages consisting of 1 of 4 treatments. Treatment 1 chickens never had access to perches (controls). Treatment 2 chickens only had access to 2 round metal perches during the laying phase (17 to 71 wk of age). Treatment 3 chickens only had access to 2 round perches during the pullet phase (0 to 16.9 wk of age). Treatment 4 chickens had access to the perches during both the pullet and laying phase. Each treatment during the adult phase consisted of 9 cages with 9 birds/cage for a total of 36 cages. Automatic infrared cameras were used to monitor behavior of hens in each cage for a 24-h period at 19, 24, 29, 34, 39, 44, 49, 54, 59, 64, and 69 wk of age. Behavior was also recorded twice weekly by an observer in the room where the hens were housed during photophase from 25 to 68 wk of age. Behavioral data were analyzed using ANOVA with repeated measures and the MIXED model procedure. A greater proportion of hens without perches as pullets used the rear perch more during both photophase and scotophase than hens with prior pullet perching experience. Eating and drinking activities of caged adult Leghorns were not impaired by their prior experience to perches as pullets or by the presence of perches in laying cages. It is concluded that providing perches in cages to White Leghorns during pullet rearing did not facilitate use of perches as adults.

The UK military experience of thoracic injury in the wars in Iraq and Afghanistan

INTRODUCTION

Thoracic injury during warfare is associated with a high incidence of morbidity and mortality. This study examines the pattern and mortality of thoracic wounding in the counter-insurgency conflicts of Iraq and Afghanistan, and outlines the operative and decision making skills required by the modern military surgeon in the deployed hospital setting to manage these injuries.

METHODS

The UK Joint Theatre Trauma Registry was searched between 2003 and 2011 to identify all patients who sustained battle-related thoracic injuries admitted to a UK Field Hospital (Role 3). All UK soldiers, coalition forces and local civilians were included.

RESULTS

During the study period 7856 patients were admitted because of trauma, 826 (10.5%) of whom had thoracic injury. Thoracic injury-related mortality was 118/826 (14.3%). There were no differences in gender, age, coalition status and mechanism of injury between survivors and non-survivors. Survivors had a significantly higher GCS, Revised Trauma Score and systolic blood pressure on admission to a Role 3 facility. Multivariable regression analysis identified admission systolic blood pressure less than 90, severe head or abdominal injury and cardiac arrest as independent predictors of mortality.

CONCLUSIONS

Blast is the main mechanism of thoracic wounding in the recent conflicts in Iraq and Afghanistan. Thoracic trauma in association with severe head or abdominal injuries are predictors of mortality, rather than thoracic injury alone. Deploying surgeons require training in thoracic surgery in order to be able to manage patients appropriately at Role 3.

Laparoscopically assisted repair of an acute traumatic diaphragmatic hernia

A 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit.

Can seeds help mice with the daily grind?

Some laboratory mice gnaw food pellets without ingesting much of the gnawed material, resulting in the production of waste material called ‘orts’. The fact that this food grinding behavior is not seen in all individuals of a particular strain suggests that it might be abnormal, and thus indicate a welfare concern. Furthermore, the increased rate of feed consumption and cage soiling is undesirable from a husbandry perspective. To try to determine possible motivations for the behavior, and identify potential treatments, outbred Crl:CD1(Icr) mice exhibiting food grinding were selected for one of three treatments placed in the feeder: no enrichment, a chewing device, or sunflower seeds. Both enrichment groups showed a significant decrease ( P < 0.05) in ort production when compared with baseline measurements, but only mice provided with sunflower seeds maintained the decreased rate of food wastage after the treatment was withdrawn. A relationship between body weight and ort production was also found, in that cages with greater average body weights had lower levels of ort production. This suggests that a simple need to gnaw cannot alone explain food grinding, and that a nutritional motivation may also be involved.

Anorectal injury in pelvic blast

The signature injury of the Afghanistan campaign has, amongst other things, included an increased incidence of destructive anorectal injury. There is no significant body of evidence about this type of injury on which to base management strategies. This review examines the historical military data, later civilian reports, many of which have challenged the military dogmas of Vietnam, and the spartan contemporaneous military data which does not particularly address pelviperineal blast injury. There is no evidence to support a move away from the doctrine of the four D's (diversion, distal washout, drainage and direct repair), but sound surgical judgement remains the mainstay of managing these challenging and highly morbid injuries.

Surgical management of primary appendiceal malignancy

AIM

Primary appendiceal neoplasms are rare, with carcinoid being more common than carcinoma. Preoperative diagnosis is infrequent. We report a series of 24 primary appendiceal neoplasms treated over a 5-year period.

METHOD

All primary appendiceal neoplasms diagnosed in a university teaching hospital between April 2003 and June 2008 were identified from the prospective histopathology database. Patient records were reviewed for clinical, operative and pathological data.

RESULTS

Fourteen carcinomas and 10 carcinoids were identified in the 5-year period. The former presented at median age 55.8 years with median symptom duration of 35 days, compared with 48 years and 3 days, respectively, for carcinoids. An abdominal mass was commoner in carcinomas (8/14 vs 1/10). Six patients with carcinoma underwent appendicectomy followed by completion right-hemicolectomy, two of whom had residual disease; seven underwent primary right-hemicolectomy and one had abscess drainage. Five patients with appendiceal carcinoma died of the disease during a median follow-up of 633 (256-1158) days. Six patients underwent appendicectomy for acute appendicitis, one had a primary right-hemicolectomy for a caecal mass. Three had a subsequent right-hemicolectomy for a high-risk carcinoid. An appendiceal carcinoid was an incidental finding in three right-hemicolectomy specimens removed for other indications. No metastases or deaths were recorded at median follow-up 451 (51-975) days.

CONCLUSION

Appendiceal carcinomas follow a more protracted clinical course than carcinoids, which usually present as acute appendicitis. Caution is needed when diagnosing simple appendicitis in older patients with longer symptom duration, particularly if a mass is present. Patients with appendiceal carcinoma should be offered completion right-hemicolectomy. Carcinoma has a poor prognosis.

Non-operative management of liver trauma

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.

The effect of cage and house design on egg production and egg weight of White Leghorn hens: an epidemiological study

Hen performance can be affected by many interacting variables related to cage design, such as floor area, height, tier arrangement, and feeder and drinker type and placement within the cage. Likewise, features of house design such as waste management and lighting can also affect hen productivity. The influence of these design aspects on hen performance has not been fully assessed. Determining the effects of numerous, interacting variables is impractical in a traditional experiment; therefore, an epidemiological approach, using variability in cage and house design among and within commercial producers, was employed to identify features that affect egg production and egg weight. A universal cage measurement system was created to calculate cage design variables. A database for recording information on cage design, resource location, waste management, environmental conditions, and hen productivity was developed. Production outcomes were assessed from placement to 60 wk of age in White Leghorns (n = 165-168 houses). Using GLM, a statistical model was identified that best described the variance in egg traits. Eggs/hen-housed increased with greater feeder space allocation (P = 0.031); taller cages (P = 0.029); rear (vs. front) drinker location in vertical cages (P = 0.026); and regular removal of manure from the house (P = 0.005). Case weight of eggs was greater in A-frame houses where manure was removed regularly instead of being left in the house (P < 0.001); with increasing cage floor slope (P = 0.001); in cages where drinkers were placed more toward the front or back of the cage as compared with the middle of the cage (P < 0.001); with more space/hen (P = 0.024); and with higher caloric intake (P < 0.001). Perhaps because of its negative correlation with egg production, case weight of eggs increased with less feeder space allocation (P = 0.004) and shorter cage heights (P < 0.001). These results reveal important effects of feeder space, floor space, cage height, drinker position, and waste management on hen productivity.

Abdominal trauma in primary blast injury

BACKGROUND

Blast injury is uncommon, and remains poorly understood by most clinicians outside regions of active warfare. Primary blast injury (PBI) results from the interaction of the blast wave with the body, and typically affects gas-containing organs such as the ear, lungs and gastrointestinal tract. This review investigates the mechanisms and injuries sustained to the abdomen following blast exposure.

METHODS

MEDLINE was searched using the keywords 'primary blast injury', 'abdominal blast' and 'abdominal blast injury' to identify English language reports of abdominal PBI. Clinical reports providing sufficient data were used to calculate the incidence of abdominal PBI in hospitalized survivors of air blast, and in open- and enclosed-space detonations.

RESULTS

Sixty-one articles were identified that primarily reported clinical or experimental abdominal PBI. Nine clinical reports provided sufficient data to calculate an incidence of abdominal PBI; 31 (3·0 per cent) of 1040 hospitalized survivors of air blast suffered abdominal PBI, the incidence ranging from 1·3 to 33 per cent. The incidence for open- and enclosed-space detonations was 5·6 and 6·7 per cent respectively. The terminal ileum and caecum were the most commonly affected organs. Surgical management of abdominal PBI is similar to that of abdominal trauma of other causes.

CONCLUSION

Abdominal PBI is uncommon but has the potential for significant mortality and morbidity, which may present many days after blast exposure. It is commoner after blast in enclosed spaces and under water.

Emergency thoracotomy--the indications, contraindications and evidence

Emergency thoracotomy is a dramatic and controversial intervention which may be life saving after major torso trauma. Success rates are variable and differ widely according to mechanism of injury. This article outlines the current indications and contraindications to emergency thoracotomy and examines the evidence to support it accumulated over 40 years.

Self assessment questions in general surgery

The advent of Modernising Medical Careers has meant that many more junior doctors are coming into contact with general surgical patients either as part of Foundation Year 2 or Core Training rotation or during the course of cross covering other specialities due to the hours constraints of the European Working Time Directive. These scenarios are all common general surgical cases that such a junior doctor may be expected to manage.

Development of a large animal model for investigating resuscitation after blast and hemorrhage

BACKGROUND

Blast injuries are an increasing problem owing to the widespread terrorist threat, but hemorrhage remains the second leading cause of civilian trauma death. Against this background, increasing numbers of prehospital and military trauma organizations are advocating a hypotensive approach to resuscitation of the hypovolemic casualty, deliberately aiming not to achieve a normal blood pressure so as not to disturb any newly formed blood clots at the site of a vascular injury.

METHODS

There are no data available to guide clinicians as to how best to resuscitate the blast-injured casualty who has also suffered a hemorrhagic injury. A large-scale program was initiated to examine this question and to offer clinical guidance on the optimal resuscitation strategy in such circumstances in terms of volume, type of fluid, speed of resuscitation, and appropriate endpoints. Before such experiments could be undertaken, a novel large animal model of blast and hemorrhage had to be devised and validated. This study outlines the derivation of such a large animal model utilizing terminally anesthetized Large White pigs exposed to a standardized primary blast wave followed by a controlled hemorrhage of 30% of the total blood volume.

RESULTS AND CONCLUSION

The preliminary results confirm the reliability and reproducibility of this model.

The effect of feeder space allocation on productivity and physiology of Hy-Line W-36 hens housed in conventional cages

Insufficient feeder space for laying hens could increase competition at the feed trough, leading to disrupted feeding, inadequate nutrient intake, stress, and reduced productivity. The effects of feeder space allocation (FSA) on physiology and productivity were evaluated in beak-trimmed Hy-Line W-36 hens (n=480). They were obtained at 16.5 wk of age and housed on 4 tiers of shallow conventional cages. Five pullets/cage were housed at a stocking density of 434 cm2/hen and a feeder space of 12.2 cm/hen. After 1.5 wk of acclimation, baseline measurements were taken for feed utilization, bone mineralization, and heterophil:lymphocyte ratios. At 20 wk of age, pullets were given 5.8, 7.1, 8.4, 9.7, 10.9, or 12.2 cm of feeder space/bird (16 cages/treatment). Physiological and production measures were calculated monthly or twice a month for 12 mo. The heart, spleen, and right adrenal gland were collected from each hen at the end of the study. Data were analyzed using a repeated measures GLM incorporating cage, tier, FSA, and hen age. There were no effects of FSA on total egg production, bone mineral density, bone mineral content, heterophil:lymphocyte ratios, or organ weights. Hens with reduced FSA utilized more feed (P<0.001), had poorer feed conversion (P<0.001), and laid eggs with slightly thicker and heavier shells (P<0.001). There were effects of FSA on total egg weight (P<0.001) and hen-day egg production (P<0.001), but they were of low magnitude and not linear (P>0.05). Because BW was similar among FSA treatments, the results suggest that reduced feeder space did not limit feed intake. In addition, reduced FSA did not lower bone mineralization or cause physiological stress in W-36 hens housed in shallow cages, suggesting that it did not impair hen welfare. However, it did result in poorer feed efficiency, possibly related to greater feed wastage, predictive of an adverse economic effect from reducing feeder space.

Abdominal compartment syndrome — the new killer

Abdominal compartment syndrome (ACS) results from an increase in intra-abdominal pressure (IAP) within the relatively fixed confines of the abdominal cavity. This increase in abdominal pressure can have deleterious consequences on multiple organ systems and amongst the intensive care population is associated with increased morbidity and mortality. Trauma victims commonly have multiple risk factors for the development of ACS, yet in the past routine measurement of IAP in intensive care patients in the UK has been variable. Recent consensus guidelines have helped to clarify the identification, diagnosis and management of patients at risk of ACS.

The cost of ignoring acute cholecystectomy

INTRODUCTION

Biliary symptoms whilst awaiting elective cholecystectomy are common, resulting in hospital admission, further investigation and increased hospital costs. Immediate cholecystectomy during the first admission is safe and effective, even when performed laparoscopically, but acute laparoscopic cholecystectomy has only recently become increasingly commonplace in the UK. This study was designed to quantify this problem in our hospital and its cost implications.

PATIENTS AND METHODS

The case notes of all patients undergoing laparoscopic cholecystectomy in our hospital between January 2004 and June 2005 were examined for details of hospital admissions with biliary symptoms or complications whilst waiting for elective cholecystectomy. Additional bed occupancy and radiological investigations were recorded and these costs to the trust calculated. We compared the potential tariff income to the hospital trust for the actual management of these patients and if a policy of acute laparoscopic cholecystectomy on first admission were in place.

RESULTS

In the 18-month study period, 259 patients (202 females) underwent laparoscopic cholecystectomy. Of these, 147 presented as out-patients and only 11% required hospital admission because of biliary symptoms whilst waiting for elective surgery. There were 112 patients who initially presented acutely and were managed conservatively. Twenty-four patients were re-admitted 37 times, which utilised 231 hospital bed-days and repeat investigations costing over 40,000 pounds. There would have been a marginal increase in tariff income if a policy of acute laparoscopic cholecystectomy had been in place.

CONCLUSIONS

Adoption of a policy of acute laparoscopic cholecystectomy on the index admission would result in substantial cost savings to the trust, reduce elective cholecystectomy waiting times and increase tariff income.

The Effects of Different Bill-Trimming Methods on the Well-Being of Pekin Ducks

Pekin ducks are often bill-trimmed to prevent feather pecking and cannibalism, but this practice has been criticized because of the resulting potential for acute and chronic pain. The goal of this experiment was to compare 2 different bill-trimming methods, hot blade trimming with cautery (TRIM) and cautery only (tip-searing; SEAR), on the behavior, bill morphology, and weight gain of Pekin ducks. Ducklings (n = 192, 96 per sex) were trimmed at the hatchery and assigned to 12 floor pens (3.66 x0.91 m) by treatment. Behavior was evaluated by scan sampling, and plumage condition was scored using a 0 to 3 scoring system. Thirty-six ducks were randomly euthanized at 3 and 6 wk of age, and their bills were collected for examination. Following fixation and decalcification, the bills were embedded in paraffin wax and sectioned longitudinally. Alternate sections were stained with hematoxylin and eosin and Masson's trichrome for the connective tissues, and with Bielschowsky's silver impregnation, Bodian's staining, and Holmes' staining for the nerve fibers. Trimmed ducks engaged in fewer bill-related behaviors and rested more than untrimmed ducks (NOTRIM) during the first 2 wk posttrim. Ducks in the SEAR and NOTRIM groups showed similar patterns of weight gain, but those in the TRIM group had a lower rate of gain than ducks in the SEAR group during the first week posttrim and had a lower rate of gain than those in the NOTRIM group for 2 wk posttrim. Feather scores of ducks in the NOTRIM group were significantly worse than those in the TRIM or SEAR group by 18 d, and scores continued to deteriorate at a greater rate than those of trimmed ducks throughout the study. Both trimming methods caused connective tissue proliferation in the bill stumps, but the TRIM method caused thicker scar tissue than the SEAR method. No neuromas were found with either trimming method, but there were more nerve fibers in bill stumps of the SEAR ducks than the TRIM ducks. These results suggest that acute pain is associated with both trimming methods, but that SEAR may be a preferable method, causing less check in weight gain and fewer bill morphological changes while still being effective in minimizing feather pecking damage.

Psoas abscess - not as rare as we think?

OBJECTIVE

Iliopsoas abscess (IPA) is a rare condition with a reported worldwide incidence of 12 new cases per year with primary abscesses now predominating. The presentation is often vague and the diagnosis not considered.

METHOD

The medical records of 15 consecutive patients presenting to our hospital in a 3-year period with IPA were reviewed. Demographic data, presenting features, predisposing factors and the investigations performed were recorded. Abscesses were classified as primary or secondary and the treatment provided and eventual outcomes were analysed.

RESULTS

Fifteen patients (eight males) were included. Nine patients were pyrexial on admission, 14 were anaemic and all had raised inflammatory markers. Only five patients presented with the classical triad of pain, fever and limp. The median time to diagnosis was 3 days with a median hospital stay of 27 days (range 7-243 days). Fourteen patients were diagnosed by computed tomographic scan. Three patients were treated with antibiotics alone whilst 11 received percutaneous drainage (PCD) as well. Of these, five had recurrence following initial drainage, needing further PCD procedures but none needed open drainage. Only one patient underwent open drainage initially. The mortality rate was 20%.

CONCLUSION

The incidence of IPA is probably under-reported. The vague presentation leads to delays in diagnosis and increases morbidity and a high index of suspicion is the key to early diagnosis. Percutaneous drainage with antibiotics is the first line of treatment although recurrence rate is high. Open drainage allows simultaneous treatment of underlying pathology in secondary abscesses.

Abdominal actinomycosis

Abdominal actinomycosis has been recognised for over 150 years yet remains largely unknown to most clinicians. It's varied presentations are usually considered to represent malignancy rather than an infective process - and was once described as 'the most misdiagnosed disease'. Actinomyces are gram positive bacilli of the Actinomycetales genus, and A. israelii is responsible for the majority of human disease. They are normal commensal inhabitants of the human bronchial and gastrointestinal tracts and seem to only cause pathological infection after preceding mucosal breakdown. Patients who have undergone appendicectomy, have had a missed perforated appendicitis or women with a history of intrauterine contraceptive device use are at an increased risk. Florid abscess formation with fistulation, abundant granulation and dense surrounding fibrosis are common. Diagnosis prior to, or even during, surgery is rare and the findings are usually mistaken for acute inflammatory pathologies or malignancy. The treatment of choice is prolonged antibiotic therapy, usually with penicillin to which the organisms remain exquisitely sensitive, although delayed recurrence is possible. This review outlines the historical background of actinomyceal infection and considers the epidemiology, pathophysiology and clinical features of abdominal actinomycosis.

Sub-specialization in general surgery: the problem of providing a safe emergency general surgical service

BACKGROUND

The increasing subspecialization of general surgeons in their elective work may result in deskilling and create problems in providing expert care for emergency cases. To evaluate the size of the problem this study determined how often complex emergency surgical cases are treated by general surgeons working outside their own elective subspecialty.

METHOD

In a district general hospital in the south of the UK serving a population of 550 000 where there is almost complete subspecialization within general surgery, 1554 patients having emergency general surgical operations were studied in a one-year review. The time an operation occurred, the seniority of the operating surgeon, the subspecialty interest of the consultant responsible for the case compared with the specialist nature of the operation was determined.

RESULTS

Of 1554 patients having emergency general surgical operations, 23% (352/1554) were of a high category of complexity. Ninety were vascular procedures and were dealt with by specialist vascular surgeons on a separate rota. Of the remaining 262 operations, 78 (30%) did not match the subspecialty of the consultant surgeon responsible for their care; 56 (72%) of these occurred out of hours of which 14 (18%) had a consultant surgeon present and scrubbed in the theatre; one per month of the study. Seventy-three percent (57/78) of these were complex colorectal operations.

CONCLUSION

The mismatch between the subspecialist elective interests of the consultant general surgeon and out of hours specialist major surgery needing consultant involvement occurred infrequently, and was mainly due to major lower gastrointestinal cases managed by upper gastrointestinal and breast surgeons. This has important implications for the future training of general surgeons and the provision of an emergency nonvascular general surgical service.

Effect of sand and wood-shavings bedding on the behavior of broiler chickens

The purpose of this study was to determine the effect of 2 different bedding types, sand and wood shavings, on the behavior of broiler chickens. In experiment 1, 6 pens were divided down the center and bedded half with sand and half with wood shavings. Male broilers (10/pen) were observed by scan sampling at 5- or 12-min intervals throughout the 6-wk growth period during the morning (between 0800 to 0900 h), afternoon (1200 to 1500 h), and night (2300 to 0600 h). There was a significant behavior x substrate x week interaction during the day (P < 0.0001) and at night (P < 0.0002). Drinking, dustbathing, preening, and sitting increased in frequency on the sand side but decreased on the wood shavings side during the day, as did resting at night. In general, broilers performed a greater proportion of their total behavioral time budget on the sand (P < 0.0001) as they aged. Broilers used the divider between the 2 bedding types to perch; perching behavior peaked during wk 4. In experiment 2, male broilers were housed in 8 pens (50 birds/pen) bedded only in sand or wood shavings. Bedding type had no effect on behavioral time budgets (P = 0.8946), although there were age-related changes in behavior on both bedding types. These results indicate that when given a choice, broilers increasingly performed many of their behaviors on sand, but if only one bedding type was provided they performed those behaviors with similar frequency on sand or wood shavings.

Cerium nitrate in the management of burns

BACKGROUND

The introduction of early excision of the burn eschar has contributed to a reduction in burn-related mortality but is not appropriate in all circumstances. Cerium nitrate has been used since 1976, usually in combination with silver sulphadiazine, to improve outcome where early excision is not performed. However, has still not gained universal acceptance. The evidence for its use is reviewed.

METHODS

A MEDLINE search was performed for the years 1966-2003 using keywords 'cerium', 'sulphadiazine', 'Flammacerium', 'lanthanides' and 'topical therapy for burns'. The reference lists of key articles were then sifted for other relevant articles.

RESULTS

Cerium has been shown to reduce mortality and morbidity in the treatment of severe burns. This benefit is derived from its action on the burn eschar. It binds and denatures the lipid protein complex liberated from burnt skin that is responsible for the profound immunosuppression associated with major cutaneous burns. It has only limited antimicrobial properties.

CONCLUSIONS

Cerium nitrate is an excellent topical treatment for most cutaneous burns not undergoing immediate excision and closure.

Is herniography useful?

Herniography has been used for 25 years in the diagnosis of occult herniation but has not gained widespread acceptance in the UK, despite studies confirming its high sensitivity and specificity for occult hernias and an excellent record of safety and patient acceptability. The traditional approach in the UK to suspected occult groin herniation has been surgical exploration. This study examined the use of herniography in a single district general hospital to assess its impact in limiting unnecessary groin explorations and allowing discharge of patients without hernias. The case notes of 90 successive patients referred for herniography by the department of general surgery in a single UK district general hospital over an 18-month period were reviewed. Eighty-seven completed examinations were analysed in which 23 hernias were diagnosed in 20 patients. Thirteen patients have undergone hernia repair with resolution of symptoms. There were no false positive examinations, although two inguinal hernias were incorrectly diagnosed radiologically as femoral hernias; there were two false negative examinations where additional hernias were found at laparoscopic repair. There were no reported complications. Twenty-four patients were discharged directly from the surgical clinic after a negative herniogram. Thirty patients were referred to other specialities. No patient had undergone groin exploration after a negative herniogram. Herniography is a useful tool in assessing obscure groin pain and potential occult herniation. It can reliably rule out the presence of a hernia and avoid the need for surgical exploration. Many patients with a negative herniogram can be reassured and discharged, whilst others may be referred on to other specialities safe in the knowledge that an occult hernia has been excluded.

The use of Flammacerium in British Burns Units

INTRODUCTION

Flammacerium (cerium nitrate-silver sulphadiazine) is marketed throughout Europe, but is only available in UK on a named patient basis. Anecdotally it is widely used in civilian burns units across the country despite the regulatory constraint, although little literature exists regarding its use in UK. We designed a postal survey to assess the use of Flammacerium countrywide and whether its 'named patient only' designation causes problems in treating burns patients.

METHODS

Postal questionnaires were sent to the directors of the 18 adult burns units listed by the British Burns Association, requesting information on the use of Flammacerium. The indications and limitations of its use were recorded, as were any problems obtaining supplies. Finally, burns units were asked if they would like to see Flammacerium fully licensed in this country.

RESULTS

Replies were received from 14 units (response rate=78%). Six units use Flammacerium frequently, six occasionally and two units never use it. It is used in those patients not undergoing early wound excision and closure because of co-morbidity, general age or frailty, paucity of donor sites or mixed depth pattern burns. It was generally used in the belief that it reduces the inflammatory response to burn injury (8/12), decreases bacterial colonization (10/12) and provides a firm eschar for easier wound management (11/12). Although 8 units had no problems with supplies of the agent, 10 respondents indicated they would like to see Flammacerium fully licensed in UK.

A comparative study of envelope mastectomy and immediate reconstruction (EMIR) with standard latissimus dorsi immediate breast reconstruction

BACKGROUND

Latissimus dorsi breast reconstruction has problems with scars at the donor site and on the reconstructed breast. We report the feasibility and aesthetic results of Envelope Mastectomy and Immediate Reconstruction (EMIR), which utilises a single lateral mammary fold incision.

PATIENTS AND METHODS

Between 2001 and 2002, 20 EMIRs were performed in 19 patients, one as a staged bilateral procedure. Twenty consecutive patients, matched for body habitus, who had undergone standard latissimus dorsi breast reconstruction by the same surgeon from 1996 to 2000 were used as controls. Patient satisfaction was assessed using a validated Body Image Scale. Standard post-operative photographs were scored by three independent observers.

RESULTS

Length of stay and complication rates were equivalent between both groups. Cosmetic self-assessment scores on the Body Image Scale and scores by the independent observers were satisfactory for both groups but no statistically significant difference was observed between groups.

CONCLUSIONS

EMIR is a technically feasible and cosmetically acceptable method of immediate breast reconstruction.

Environmental enrichment and development of cage stereotypy in Orange-winged Amazon parrots (Amazona amazonica)

Stereotypies are abnormal repetitive behaviors that often develop in animals housed in impoverished environments. Stereotypy represents the interaction of several complex developmental phenomena. To characterize the temporal nature of stereotypy increase (escalation) and decrease (attenuation), we monitored changes in stereotypy performance in young Orange-winged Amazon parrots reared either in barren cages or cages provided with enrichments designed to facilitate foraging and locomotion. Unenriched parrots developed significantly more stereotypy than enriched parrots, and the mean time to stereotypy onset and the rate and magnitude of stereotypy increase also differed between the two groups. We then provided enrichment to the birds that had been reared in the barren cages. Following a 4-week delay, stereotypy was significantly reduced. These results show that stereotypy can be both prevented and reversed with appropriate environmental modification and illustrate how studying this behavior at many points over time can provide insights into its ontogeny.

Tissue engineering in surgery

The demands for repair and renewal of worn out or injured human tissue continue to increase and it is now apparent that this demand cannot be met from human donors. A partial solution may be found in living related and trans-species transplantation but these approaches invoke the problems of disease transfer and ethical dilemmas. Tissue engineering is a new technology that seeks to meet these increasing demands by utilising novel cell culture methods in vitro to provide tissue replacements in vivo. This article reviews the current state of tissue engineering and its potential for use in surgery.

Varicose veins--an old dog and some new tricks

There are many new methods to treat varicose veins being tried and tested around the world, many using patented techniques. They would appear to demonstrate many of the features a military surgeon might deem beneficial for treating a service population, a rapid return to duties amongst them. There are some significant drawbacks. All of these modalities need to offer long-term evidence of efficacy to demonstrate advantage over current standard. The endovenous therapies utilise expensive equipment that limit their introduction and provide a potential for novel complications as well as novel therapy. Modified sclerotherapy as described here has many advantages; it is incredibly cheap, minimally invasive and easily repeatable--in fact planned re-intervention is used in some protocols. Until long-term results are available, it would seem premature to recommend any of these new treatments for use in service personnel with primary varicose veins. Military vascular surgeons will await these results with interest, as the service population would have much to gain from a modality that reliably treats the veins and ensures a swift return to service.

Froelich, fertility and a French emperor. Commentary on 'Napoleon's sex life' by Maj Gen F M Richardson

This article, some forty-odd years old now sheds an interesting light on one of the great men of history; whether he was homosexual or not I think matters little, as he will be remembered for his Empire building and battles far more than his penis and prowess. The fact that a medical condition can tentatively be put forward as a mitigating circumstance against his less laudable behaviours, is of interest more for the value of the medical detective work that was involved, than the expunging of the blemishes from his legend. As a testament to the breadth of interest portrayed by the Journal all those years ago I feel it is a splendid reminder that articles other than randomised controlled trials or evidence based guidelines still make for enjoyable, if not directly practical, relevant reading.

The lateral accessory saphenous vein - a common cause of recurrent varicose veins

BACKGROUND

Varicose veins commonly recur after surgery and present a large burden to the NHS. The aim of this study was to demonstrate that the lateral accessory saphenous vein is the commonest cause of groin recurrence of varicose veins and we discuss a possible anatomical reason for this.

PATIENTS AND METHODS

The case notes of all patients presenting to two vascular surgeons with recurrent varicose veins over a 3-year period were studied. All limbs were assessed by duplex ultrasound scanning. These scans were reviewed to identify the site of recurrence. When recurrence occurred in the groin, the scans were further evaluated to identify the cause of groin recurrence.

RESULTS

A total of 216 limbs in 186 patients were evaluated over a 36-month period. Of these, 141 (65%) demonstrated a recurrence in the groin: 56 (26%) recurrences were due to either incompetent thigh or calf perforators and there were 19 (9%) cases of saphenopopliteal or short saphenous vein incompetence. Out of 141 groin recurrences, 61 (43%) were due to a persistent lateral accessory saphenous vein.

CONCLUSIONS

The lateral accessory saphenous vein is the commonest cause of recurrence in the groin of varicose veins. It should be looked for specifically during pre-operative assessment duplex scanning and at primary surgery. If identified at operation, we believe it should be either stripped or avulsed to reduce the risk of recurrence.

Some recollections of Porton in World War 1. Commentary

Chemical weapons now regularly feature in news reports and the threat from them has become widely recognised by the public at large. Terrorist actions such as the Tokyo subway incident in 1995, coupled with the persistent use of agents such as sulphur mustard and Sarin by the Iraqi regime over the last 20 years in the Iran/Iraq war and against the Kurds of Northern Iraq, make it easy to think that chemical weapons are a new phenomenon. This paper reminds us that many chemical agents were developed during WWI; indeed the first use of a chemical agent was the release of chlorine gas--a choking agent--by the Germans over the battlefields of Ypres in 1915. Porton Down remains at the very heart of chemicals and biological weapons research, albeit in a purely defensive capacity; few of the old buildings remain and the idyllic lifestyle in the Officer's Mess at Idmiston Manor has long since disappeared. These recollections provide a fascinating insight into scientific research at the time of World War I.

Organise a clinical trial

Organising a clinical trial is a major undertaking involving a lot of hard work before during and after the study takes place and such trials are one endeavour where there are no short cuts. Cutting corners in an effort to save time, money or effort is usually quite obvious to the assiduous journal reader who will rubbish the conclusions and tarnish one's reputation for scientific validity. By taking time to carefully think through each stage and possible eventuality of ones plans it is possible to avoid many of the stumbling blocks that interfere with the conduct of a successful trial. Consideration of the contents of this article may help to clarify matters when organising ones first clinical trial or one may wish to attend one of a growing number of courses that give instruction in many of these matters.

Prepare for an SpR interview

By the time you attend an interview for a military SpR number you should have no real problems but it pays to be prepared. Begin preparations early, reading widely and talk to as many people as possible. Your consultants will have a useful viewpoint on the proceedings and may be able to help you refine your answers to the common questions. Arrive at your interview in a smart and timely fashion and answer questions with confidence and common sense. Avoid confrontation and bluff and be courteous at all times, whatever you may be feeling inside and thank the interview panel as you leave.

The medical and surgical management of chronic anal fissure

Major advances in our understanding of the mechanisms involved in chronic anal fissure have allowed the introduction of many new medical therapies for this condition. The literature about current treatment modalities licensed for anal fissure and those novel therapies still under evaluation has been reviewed. These new treatments are examined in the context of traditional surgical management of the disease and a future treatment algorithm suggested.

Reliability and validity of a modified gait scoring system and its use in assessing tibial dyschondroplasia in broilers

1. The gait scoring system for broilers developed by Kestin et al. (Veterinary Record, 131: 190-194, 1992) has been widely used to evaluate leg problems. The many factors and measures associated with this scale have empirically established its external (biological) validity. However, published test-retest (within-observer) reliabilities are poor, and inter-observer reliabilities are unknown. We evaluated several modifications to this scale aimed at improving its objectivity and reliability. 2. Eighteen naïve observers scored a standardised video of birds exhibiting varying degrees of lameness, either using Kestin et al.'s system, or our modified system. 3. Test-retest reliability (0.906) for Kestin et al.'s system was higher than previously reported. Inter-rater reliability was also good (0.892). The modified system offered significantly better test-retest (0.948) and inter-rater reliabilities (0.943), without incurring costs in terms of time taken or difficulty of use. The systems were consistent, assigning individual birds the same score on average. 4. It is concluded that the modified system offers the advantages of reduced error within and between studies. 5. In a second experiment, we used our modified scoring system to examine the relationship between tibial dyschondroplasia (TD) and gait score in 267 selected broilers. 6. Neither the presence nor severity of TD affected gait score, suggesting that, at least in this strain of broilers, other leg problems like slipped tendons or torsional deformities had more influence on gait impairment than did TD.