The surgeon and his tools-the case for a focused orthopaedic theatre induction programme

<p>Abstract</p> <p>Background</p> <p>Induction programme for trainee doctors in the UK generally do not focus on the surgical aspects of their jobs. In this context we decided to conduct a telephonic survey among the hospitals belonging to three orthopaedic training regions in the UK from the point of view of the diversity of instrumentations and implants used for index procedures.</p> <p>Results</p> <p>We chose four index trauma & orthopaedic procedures (Total hip replacement, total knee replacement, intramedullary nailing and external fixator systems for long bone fractures). A telephonic survey was done in six NHS trust hospitals which were part of an orthopaedic training rotation (2 from England, 2 from Wales and 2 from Scotland). In total there were 39 different instrumentation systems for these 4 index procedures in the 6 trusts (see table <tblr tid="T1">1</tblr>). These comprise 12 Total hip replacement (THR) systems, 14 total knee replacement (TKR) systems, 9 intra-medullary nailing systems, and 4 external fixator systems. The number of different systems for each trust ranged from 7 to 19. There is a vast array of implants and instrumentation systems in each trust, as highlighted by our survey. The surgical tools are not the same in each hospitals. This situation is more complicated when trainees move to new hospitals as part of training rotations.</p> <tbl id="T1"> <title> <p>Table 1</p> </title> <caption> <p>Number of implants/instrumentations used in each of the 6 UK trusts (3 training regions).</p> </caption> <tblbdy cols="7"> <r> <c ca="left"> <p>IMPLANT</p> </c> <c ca="center"> <p>E1</p> </c> <c ca="center"> <p>E2</p> </c> <c ca="center"> <p>W1</p> </c> <c ca="center"> <p>W2</p> </c> <c ca="center"> <p>S1</p> </c> <c ca="center"> <p>S2</p> </c> </r> <r> <c cspan="7"> <hr/> </c> </r> <r> <c ca="left"> <p><it>Total Knee Replacement</it></p> </c> <c ca="center"> <p>4</p> </c> <c ca="center"> <p>5</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>4</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>2</p> </c> </r> <r> <c ca="left"> <p><it>Total Hip Replacement</it></p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>4</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>6</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>3</p> </c> </r> <r> <c ca="left"> <p><it>Intramnedullary nailing</it></p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>1</p> </c> <c ca="center"> <p>1</p> </c> <c ca="center"> <p>6</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>3</p> </c> </r> <r> <c ca="left"> <p><it>External fixators</it></p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>3</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>2</p> </c> <c ca="center"> <p>1</p> </c> <c ca="center"> <p>1</p> </c> </r> <r> <c cspan="7"> <hr/> </c> </r> <r> <c ca="left"> <p><it>TOTAL</it></p> </c> <c ca="center"> <p>11</p> </c> <c ca="center"> <p>13</p> </c> <c ca="center"> <p>8</p> </c> <c ca="center"> <p>18</p> </c> <c ca="center"> <p>9</p> </c> <c ca="center"> <p>9</p> </c> </r> </tblbdy> <tblfn> <p>E = England, W = Wales, S = Scotland</p> </tblfn> </tbl> <p>Conclusion</p> <p>In view of this we feel that more focused theatre based induction programmes for higher surgical trainees is advocated in each hospital trust so trainees can familiarise themselves with the tools available to them. This could include discussion with the consultants and senior theatre staff along with representatives from the companies supplying the implants and instrumentation systems.</p

The astrobiology primer: An outline of general knowledge - Version 1, 2006

Peer reviewe

Global urban environmental change drives adaptation in white clover

Urbanization transforms environments in ways that alter biological evolution. We examined whether urban environmental change drives parallel evolution by sampling 110,019 white clover plants from 6169 populations in 160 cities globally. Plants were assayed for a Mendelian antiherbivore defense that also affects tolerance to abiotic stressors. Urban-rural gradients were associated with the evolution of clines in defense in 47% of cities throughout the world. Variation in the strength of clines was explained by environmental changes in drought stress and vegetation cover that varied among cities. Sequencing 2074 genomes from 26 cities revealed that the evolution of urban-rural clines was best explained by adaptive evolution, but the degree of parallel adaptation varied among cities. Our results demonstrate that urbanization leads to adaptation at a global scale

Identification of extracolonic pathologies by computed tomographic colonography in colorectal cancer symptomatic patients

BACKGROUND & AIMS: Symptoms suggestive of colorectal cancer may originate outside the colorectum. Computed tomographic colonography (CTC) is used to examine the colorectum and abdominopelvic organs simultaneously. We performed a prospective randomized controlled trial to quantify the frequency, nature, and consequences of extracolonic findings. METHODS: We studied 5384 patients from 21 UK National Health Service hospitals referred by their family doctor for the investigation of colorectal cancer symptoms from March 2004 through December 2007. The patients were assigned randomly to groups that received the requested test (barium enema or colonoscopy, n = 3574) or CTC (n = 1810). We determined the frequency and nature of extracolonic findings, subsequent investigations, ultimate diagnosis, and extracolonic cancer diagnoses 1 and 3 years after testing patients without colorectal cancer. RESULTS: Extracolonic pathologies were detected in 959 patients by CTC (58.7%), in 42 patients by barium enema analysis (1.9%), and in no patients by colonoscopy. Extracolonic findings were investigated in 142 patients (14.2%) and a diagnosis was made for 126 patients (88.1%). Symptoms were explained by extracolonic findings in 4 patients analyzed by barium enema (0.2%) and in 33 patients analyzed by CTC (2.8%). CTC identified 72 extracolonic neoplasms, however, barium enema analysis found only 3 (colonoscopy found none). Overall, CTC diagnosed extracolonic neoplasms in 72 of 1634 patients (4.4%); 26 of these were malignant (1.6%). There were significantly more extracolonic malignancies detected than expected 1 year after examination, but these did not differ between patients evaluated by CTC (22.2/1000 person-years), barium enema (26.5/1000 person-years; P = .43), or colonoscopy (32.0/1000 person-years; P = .88). CONCLUSIONS: More than half of the patients with symptoms of colorectal cancer are found to have extracolonic pathologies by CTC analysis. However, the proportion of patients found to have extracolonic malignancies after 1 year of CTC examination is not significantly greater than after barium enema or colonoscopy examinations. International Standard Randomised Controlled Trials no: 95152621.isrctn.com

Predictors of Enteral Autonomy in Children with Intestinal Failure: A&nbsp;Multicenter Cohort Study

ObjectivesIn a large cohort of children with intestinal failure (IF), we sought to determine the cumulative incidence of achieving enteral autonomy and identify patient and institutional characteristics associated with enteral autonomy.Study designA multicenter, retrospective cohort analysis from the Pediatric Intestinal Failure Consortium was performed. IF was defined as severe congenital or acquired gastrointestinal diseases during infancy with dependence on parenteral nutrition (PN) &gt;60 days. Enteral autonomy was defined as PN discontinuation &gt;3 months.ResultsA total of 272 infants were followed for a median (IQR) of 33.5 (16.2-51.5) months. Enteral autonomy was achieved in 118 (43%); 36 (13%) remained PN dependent and 118 (43%) patients died or underwent transplantation. Multivariable analysis identified necrotizing enterocolitis (NEC; OR 2.42, 95% CI 1.33-4.47), care at an IF site without an associated intestinal transplantation program (OR 2.73, 95% CI 1.56-4.78), and an intact ileocecal valve (OR 2.80, 95% CI 1.63-4.83) as independent risk factors for enteral autonomy. A second model (n = 144) that included only patients with intraoperatively measured residual small bowel length found NEC (OR 3.44, 95% CI 1.36-8.71), care at a nonintestinal transplantation center (OR 6.56, 95% CI 2.53-16.98), and residual small bowel length (OR 1.04 cm, 95% CI 1.02-1.06 cm) to be independently associated with enteral autonomy.ConclusionsA substantial proportion of infants with IF can achieve enteral autonomy. Underlying NEC, preserved ileocecal valve, and longer bowel length are associated with achieving enteral autonomy. It is likely that variations in institutional practices and referral patterns also affect outcomes in children with IF