Practical guides for health and wellbeing boards
These publications aim to help support the establishment of well-functioning health and wellbeing boards. They cover a range of themes including integration, criminal justice, improving population health and patient and public engagement.
The clinical effectiveness of permissive hypotension in blunt abdominal trauma with hemorrhagic shock but without head or spine injuries or burns: A systematic review:
Open Access Emergency Medicine, May 2012, vol./is. 4/(21-29), 1179-1500 (23 May 2012)
Author(s): Alsawadi A.
Abstract: Trauma is a major cause of death and disability. The current trend in trauma management is the rapid administration of fluid as per the Advanced Trauma Life Support guidelines, although there is no evidence to support this and even some to suggest it might be harmful. Some guidelines, protocols, and recommendations have been established for the use of permissive hypotension although there is reluctance concerning its application in blunt injuries.
Objectives: The aim of this review is to determine whether there is evidence of the use of permissive hypotension in the management of hemorrhagic shock in blunt trauma patients. This review also aims to search for any reason for the reluctance to apply permissive hypotension in blunt injuries.
Methods: This systematic review has followed the steps recommended in the Cochrane Handbook for Systematic Reviews of Interventions. It is also being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement and checklist. Database searches of MEDLINE, EMBASE, the Centre for Reviews and Dissemination databases and the Cochrane Library were made for eligible studies as well as journal searches. Inclusion criteria included systematic reviews that have similar primary questions to this review and randomized controlled trials where patients with
blunt torso injuries and hemorrhagic shock were not excluded. Rapid or early fluid administration was compared with controlled or delayed fluid resuscitation and a significant outcome was obtained. Results: No systematic reviews attempting to answer similar questions were found. Two randomized controlled trials with mixed types of injuries in the included patients found no significant difference between the groups used in each study. Data concerning the question of this review was sought after these papers were appraised.
Conclusion: The limited available data are not conclusive. However, the
supportive theoretical concept and laboratory evidence do not show any reason for treating blunt injuries differently from other traumatic injuries. Moreover, permissive hypotension is being used for some nontraumatic causes of hemorrhagic shock and in theater. Therefore, this should encourage interested researchers to continue clinical work in this important field.
Publication Type: Journal: Review
This article “Faecal pyruvate kinase isoenzyme type M2 for colorectal cancer screening: A meta-analysis” by Carolin Tonus, Markus Sellinger, Konrad Koss and Gero Neupert was published earlier this month.
AIM: To present a critical discussion of the efficacy of the faecal pyruvate kinase isoenzyme type M2 (faecal M2-PK) test for colorectal cancer (CRC) screening based on the currently available studies.
METHODS: A literature search in PubMed and Embase was conducted using the following search terms: fecal Tumor M2-PK, faecal Tumour M2-PK, fecal M2-PK, faecal M2-PK, fecal pyruvate kinase, faecal pyruvate kinase, pyruvate kinase stool and M2-PK stool.
RESULTS: Stool samples from 704 patients with CRC and from 11 412 healthy subjects have been investigated for faecal M2-PK concentrations in seventeen independent studies. The mean faecal M2-PK sensitivity was 80.3%; the specificity was 95.2%. Four studies compared faecal M2-PK head-to-head with guaiac-based faecal occult blood test (gFOBT). Faecal M2-PK demonstrated a sensitivity of 81.1%, whereas the gFOBT detected only 36.9% of the CRCs. Eight independent studies investigated the sensitivity of faecal M2-PK for adenoma (n = 554), with the following sensitivities: adenoma < 1 cm in diameter: 25%; adenoma > 1 cm: 44%; adenoma of unspecified diameter: 51%. In a direct comparison with gFOBT of adenoma > 1 cm in diameter, 47% tested positive with the faecal M2-PK test, whereas the gFOBT detected only 27%.
CONCLUSION: We recommend faecal M2-PK as a routine test for CRC screening. Faecal M2-PK closes a gap in clinical practice because it detects bleeding and non-bleeding tumors and adenoma with high sensitivity and specificity.
Acknowledgements were made to Beverley Jones, Susan Knight, and Deborah Symmons (Macclesfield District General Hospital), in this publication.
UK Primary Sjögren’s Syndrome Registry
by Wan-Fai Ng
Musculoskeletal Research Group
Institute of Cellular Medicine
Introduction: Primary Sjögren’s syndrome (pSS) is a chronic multisystem disease affecting 0.3%–0.5% of the adult population.1, 2 Women are nine times more likely to be affected than men.1–4 The disease is characterized by oral and ocular dryness, fatigue, and musculoskeletal pain. PSS can affect other organ systems including the skin, nervous system, lungs, and kidneys.3, 4 Patients with pSS have a greater than 40-fold increased risk of developing B-cell mucosa-associated lymphoid tissue (MALT) lymphoma.4, 5 Patients with PSS have poor health-related quality of life and a significant proportion of PSS patients are unable to work due to their condition.2, 6–17 Both direct and indirect health care costs are higher in PSS than in the general population.17, 18 PSS is not, therefore a benign condition, but has a significant health and economic burden to patients and society.
Comparison between aptus and DVR plate as the preferred method of distal radius fracture fixation. This article was submitted for publication by Drs’ R Singhal, M Shakeel, S Dheerendra, S Morapudi, M Waseem of MDGH and P Ralte.
J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XXXVI 66
Background Volar locking plates have revolutionised the treatment for distal radius fractures. The DVR (Depuy) plate was one of the earliest locking plates which were used and they provided fixed angle fixation. Recently, newer volar locking plates, such as the Aptus (Medartis), have been introduced to the market that allow the placement of independent distal subchondral variable-angle locking screws to better achieve targeted fracture fixation. The aim of our study was to compare the outcomes of DVR and Aptus volar locking plates in the treatment of distal radial fractures.
Methods Details of patients who had undergone open reduction and internal fixation of distal radii from October 2007 to September 2010 were retrieved from theatre records. 60 patients who had undergone stabilisation of distal radius fractures with either DVR (n=30) or Aptus (n=30) plate were included in the study.
Results Mean age of patients undergoing fixation using DVR plate was 56.6 years (n=30) with 22 females and 8 males. Fractures in this group included 20 type 23-C, three type 23-B and seven type 23-A. The patients were followed up for an average of 5.5 months (2-16 months). 3 patients underwent revision of fixation due to malunion (n=1), non-union (n=1) and failure of fixation (n=1). Four patients had reduced movements even after intensive physiotherapy necessitating removal of plate.
Mean age of patients undergoing Aptus volar locking plate fixation was 56.38 years (n=30) with 21 females and 9 males. There were 27 type 23-C, two type 23-B and one type 23-A fractures according to AO classification. The patients were followed up for an average of 4.1 months (2-11 months). 2 patients developed complex regional pain syndrome (CRPS) and 1 patient underwent removal of screws due to late penetration of screws into the joint.
Conclusion Complex and unstable fractures of the distal radius can be optimally managed with volar locking plates. Both systems are user friendly. Aptus plates provide an additional advantage of flexibility in implant positioning and enhanced intra-fragmentary fixation compared to the DVR plate. In our study Aptus plates had lower secondary surgical procedures compared to DVR plates.
Septic arthritis vs transient synovitis in children: a tertiary healthcare centre study by R Singhal of MDGH and D Perry, FN Khan, D Cohen, HL Stevenson, LA James, JS Sampath and CE Bruce
Background Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.
Method All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5 degrees C. The definition of SA was based upon microscopy and culture of the joint fluid collected at arthrotomy.
Results 311 hips were included within the study. Of these 282 were considered to have transient synovitis. 29 patients met criteria to be classified as SA based upon laboratory assessment of the synovial fluid. The introduction of CRP eliminated the need for a four variable model as the use of two variables (CRP and weight bearing status) had similar efficacy. An algorithm that indicated a diagnosis of SA in individuals who could not weight-bear and who had a CRP >20mg/L correctly classified SA in 94.8% individuals, with a sensitivity of 75.9%, specificity of 96.8%, positive predictive value of 71.0%, and negative predictive value of 97.5%. CRP was a significant independent predictor of septic arthritis.
A novel method of diagnosing autonomic dysfunction in carpal tunnel syndrome by SK Dheerendra, WS Khan, P Smitham and NJ Goddard
This article by SK Dheerendra of the Dept of Trauma and Orthopaedics and colleagues from other Trusts was published in J Bone Joint Surg Br
2012 vol. 94-B no. SUPP XXXVI 17
Background & Objectives Sensory and motor manifestations in carpal tunnel syndrome (CTS) are well documented, whereas the associated autonomic dysfunction is often overlooked. The aim of this study is to demonstrate that autonomic dysfunction of the CTS hands can be quantified by measuring skin capacitance.
Methods Patients with clinical and electrophysiological signs of idiopathic carpal tunnel syndrome meeting the inclusion criteria were recruited. The patients were also scored based on the Brigham carpal tunnel severity score. Skin capacitance was measured using Corneometer CM825 (C&K Electronic, GmbH). The measurements were taken from the palmar aspect of distal phalanx of the index and little finger of the affected hand. Normal healthy patients with no signs and symptoms of carpal tunnel syndrome were recruited as controls and skin capacitance was measured in a similar fashion as the CTS group.
Results The CTS group consisted of 25 patients (18 female & 7 male) and 35 hands with an average age of 59.2 years (33-83 years). The mean symptom severity score was 2.80 (1.27-4.18; SD 0.82) and functional status score was 2.53 (1-4.26; SD 1.08). The mean ratio of skin hydration between the index and little finger was 0.85 (0.6-1.25; SD 0.155). Using the paired t-test to determine paired differences between index and little finger measurements, the mean difference was 12.6 (p<0.001).