The malignant epidemic-changing patterns of trauma

Objectives and Setting. The worldwide burden of trauma is increasing, but is unequally distributed between nations. Trauma in South Africa targets the young and productive in society and imposes a major burden on the health infrastructure. We undertook a review of injury trends among patients attending the Johannesburg Hospital Trauma Unit (JHTU) and the Johannesburg Medicolegal Laboratory (JMLL) in order to document the evolution in patterns of trauma over a 17-year period of great social and political change. Design, subjects and outcome measures. This was a retrospective review of all priority-one patients attending the JHTU from January 1985 to December 2001. The JHTU trauma database was used to retrieve information on patient demographics, wound mechanism and injury severity. The database at the JMLL, maintained since 1996, was examined and the manner and place of death were analysed.Results. The JHTU has seen an unprecedented increase in the number of trauma patients over the last 17 years. The patients' demographic profiles have altered and injury is now predominantly due to interpersonal violence. Unnatural deaths examined at the JMLL have declined by 19% since 1996; however, the proportion of those deaths due to gunshot wounds has risen.Conclusions. The social and political changes in South Africa in recent years have led to changes in the injury profiles seen at the JHTU. Part of the increase can be explained by desegregation and a reduction in the provision of local hospital services; however, the impact of urbanisation within South Africa, cross-border migration and the high incidence of substance abuse are recognised. Evidence supports the implementation of legislative, environmental, social and behavioural interventions to contain and reduce the incidence and impact of violence and injury. Concerted efforts must be made at all levels to curb South Africa's  trauma  epidemic

The BCD Triage Sieve outperforms all existing major incident triage tools:comparative analysis using the UK national trauma registry population

BACKGROUND: Natural disasters, conflict, and terrorism are major global causes of death and disability. Central to the healthcare response is triage, vital to ensure the right care is provided to the right patient at the right time. The ideal triage tool has high sensitivity for the highest priority (P1) patients with acceptably low over-triage. This study compared the performance of major incident triage tools in predicting P1 casualty status in adults in the prospective UK Trauma Audit and Research Network (TARN) registry. METHODS: TARN patients aged 16+ years (January 2008-December 2017) were included. Ten existing triage tools were applied using patients’ first recorded pre-hospital physiology. Patients were subsequently assigned triage categories (P1, P2, P3, Expectant or Dead) based on pre-defined, intervention-based criteria. Tool performance was assessed by comparing tool-predicted and intervention-based priority status. FINDINGS: 195,709 patients were included; mortality was 7·0% (n=13,601); median Injury Severity Score (ISS) was 9 (IQR 9–17); 97·1% sustained blunt injuries. 22,144 (11·3%) patients fulfilled intervention-based criteria for P1 status, exhibiting higher mortality (12·8% vs. 5·0%, p<0.001), increased intensive care requirement (52·4% vs 5·0%, p<0.001), and more severe injuries (median ISS 21 vs 9, p<0.001) compared with P2 patients. In 16–64 year olds, the highest performing tool was the Battlefield Casualty Drills (BCD) Triage Sieve (Prediction of P1 status: 70·4% sensitivity, over-triage 70·9%, area under the receiver operating curve (AUC) 0·068 [95%CI 0·676–0·684]). The UK National Ambulance Resilience Unit (NARU) Triage Sieve had sensitivity of 44·9%; over-triage 56·4%; AUC 0·666 (95%CI 0·662–0·670). All tools performed poorly amongst the elderly (65+ years). INTERPRETATION: The BCD Triage Sieve performed best in this nationally representative population; we recommend it supersede the NARU Triage Sieve as the UK primary major incident triage tool. Validated triage category definitions are recommended for appraising future major incidents. FUNDING: This study is funded by the National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre. GVG also acknowledges support from the MRC Heath Data Research UK (HDRUK/CFC/01). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the Ministry of Defence

Novel Textbook Outcomes following emergency laparotomy:Delphi exercise

Background: Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy. Methods: A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1–5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round. Results: A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into ‘early’ and ‘longer-term’. For non-trauma patients the proposed early Textbook Outcome was ‘Discharged from hospital without serious postoperative complications (Clavien–Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was ‘Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien–Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)’. The longer-term Textbook Outcome for both non-trauma and trauma was ‘Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year’. Conclusion: Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.</p

Tongue tie: the evidence for frenotomy.

Tongue tie or ankyloglossia is a congenital variation characterised by a short lingual frenulum which may result in restriction of tongue movement and thus impact on function. Tongue tie division (frenotomy) in affected infants with breastfeeding problems yields objective improvements in milk production and breastfeeding characteristics, including objective scoring measures, weight gain and reductions in maternal pain. For the majority of mothers, frenotomy appears to enhance maintenance of breastfeeding. Tongue tie division is a safe procedure with minimal complications. The commonest complication is minor bleeding. Recurrence leading to redivision occurs with rates of 0.003-13% reported; this appears to be more common with posterior than anterior ties. There are limited reports indicating that prophylactic frenotomy may promote subsequent speech development; however, evidence is currently insufficient to condone this practice and further good quality research into this area is warranted

Fifteen-minute consultation: the infant with a tongue tie.

Tongue tie is an increasingly common cause for referral of infants to our general paediatric surgery service. In this article, we will explore the indications for tongue tie division in the newborn child, the practicalities of the procedure and the supporting evidence