Douglas M. Bowley

Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

PURPOSE The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH). METHODS This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007. RESULTS Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001). CONCLUSION Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.

Volume and accreditation, but not specialty, affect quality standards in colonoscopy

The Global Rating Scale, defined by the Joint Advisory Group for Gastrointestinal Endoscopy, requires monitoring of endoscopic performance indicators. There are known variations in colonoscopic performance, and investigation of factors causing this is needed. This study aimed to analyse the impact of endoscopist specialty and procedural volume on the quality of colonoscopy.

Socioeconomic deprivation adversely affects survival of patients with rectal cancer

The aim was to examine the influence of socioeconomic deprivation on stage at presentation, perioperative mortality, permanent stoma rates and overall survival in patients with rectal cancer.

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.

Military surgery in the new curriculum: whither general surgery training in uniform?

Background The nature of general surgical training within the UK has undergone significant changes recently, including the evolution of the Intercollegiate Surgical Curriculum Programme (ISCP). In 2013, new task-specific goals tailored towards military surgery were incorporated into the general surgery curriculum. In order to meet the demands of training the next generation of military general surgeons, a new compendium of workplace-based assessments (WBAs) is now required. Addressing the need In 2013, the ISCP general surgery curriculum was revised to include new, military-specific WBAs to allow formative assessment of a trainees’ experience and preparedness for their future deployed role. Index procedures considered mandatory for a deployed military general surgeon to be effective in the field are now included in the general surgery curriculum. These will permit formative assessment of trainees and also permit revalidation of deployed skills among the consultant cadre. Conclusions General surgical training in the UK is in a transitional period, and the move towards increased sub-specialisation appears inexorable as evidenced by the split of Vascular Surgery into a separate specialty, along with its own training pathway and curriculum. With the ‘generalist’ demands on deployed surgeons in the Defence Medical Services, the task of training towards broader surgical competencies may appear daunting. Inclusion of defined military WBAs into the curriculum should help focus trainees and their trainers to identify the deployed general surgical skill set, identify the appropriate learning opportunities/placements required to enable the acquisition of relevant competencies and document their attainment and later retention.

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.

Engaging with Faith Councils to Develop Stoma-specific Fatawās: A Novel Approach to the Healthcare Needs of Muslim Colorectal Patients.

Intestinal stomas are common. Muslims report significantly lower quality of life following stoma surgery compared to non-Muslims. A fatwā is a ruling on a point of Islamic law according to a recognised religious authority. The use of fatawās to guide health-related decision-making has becoming an increasingly popular practice amongst Muslims, regardless of geographic location. This project aimed to improve the quality of life of Muslim ostomates by addressing faith-specific stoma concerns. Through close collaboration with Muslim ostomates, a series of 10 faith-related questions were generated, which were posed to invited local faith leaders during a stoma educational event. Faith leaders received education concerning the realities of stoma care before generating their fatawās. The event lead to the formulation of a series of stoma-specific fatawās representing Hanafi and Salafi scholarship, providing faith-based guidance for Muslim ostomates and their carers. Enhanced communication between healthcare providers and Islamic faith leaders allows for the delivery of informed fatawās that directly benefit Muslim patients and may represent an efficient method of improving health outcomes in this faith group.

Administration of hyoscine- n-butylbromide during colonoscopy: a survey of current UK practice

Objective Current British Society of Gastroenterology (BSG) guidelines suggest that hyoscine-n-butylbromide (Buscopan) should be avoided during colonoscopy in patients with a history of angle-closure glaucoma. Angle-closure glaucoma, however, is not very common, is asymptomatic before onset and is treated definitively by a single laser treatment (if spotted early). Open-angle glaucoma is not affected by hyoscine. The aim of this study was to assess the use of hyoscine among colonoscopists, with particular reference to glaucoma. Design and setting Following BSG endoscopy subcommittee approval, a short questionnaire was electronically administered to members of the BSG and the Association of Coloproctology of Great Britain and Ireland. Main outcome measures Hyoscine use among colonoscopists, and effect of glaucoma history upon prescribing practice. Results 188 colonoscopists responded to some or all of the questions. 123/183 (67.2%) of respondents claimed they were aware of the BSG guidelines. 160/187 (85.6%) sometimes or always use hyoscine, while 27/187 (14.4%) never do. 137/177 (77.4%) always enquire about glaucoma history prior to administration, although 147/176 (83.0%) make no differentiation between open-angle or angle-closure forms. 126/178 (70.8%) would (incorrectly) withhold hyoscine if the patient declares a history of any form of glaucoma. 140/179 (78.2%) do not substitute glucagon as an antispasmodic. 4/180 (2.2%) had encountered ophthalmic complications post-administration. Conclusions Current BSG guidelines pertaining to hyoscine use and glaucoma are inappropriate; the authors recommend revision. Patients undergoing colonoscopy who have received hyoscine should, instead, be advised to seek urgent medical advice if they develop ophthalmic symptoms.

CT Colonography after Colorectal Cancer Resection: A One-Stop Assessment of Metachronous Mucosal Lesions, Local Recurrence, and Distant Metastases

Summary of ADC Measurements for Fetuses with and without Placental Insuffi ciency ParameterRegion 1 * Region 2 † Fetuses with Placental Insuffi ciency ( n = 33)Fetuses without Placental Insuffi ciency ( n = 69)Fetuses with Placental Insuffi ciency ( n = 33)Fetuses without Placental Insuffi ciency ( n = 69) Mean 1.454 1.771 1.415 1.752 Median 1.461 1.773 1.397 1.767 Standard deviation 0.106 0.208 0.132 0.181 Confidence interval 1.428, 1.498 1.705, 1.805 1.358, 1.455 1.686, 1.818 Note.— All measurements are given in 10 2 9 m 2 /sec. The average measurements of both readers are given. * Region 1 is located 2 cm from the insertion of the umbilical cord. † Region 2 is loca ted 5 cm from the insertion of the umbilical cord. “Reduction in False-Positive Results after Introduction of Digital Mammography: Analysis from Four Population-based Breast Cancer Screening Programs in Spain.” Radiology 2011;258(2):388–395 Page 388, the affi liations at the bot-tom left should read as follows: From the

Radiation exposure during paediatric emergency CT: Time we took notice?

INTRODUCTION Concerns exist about radiation exposure during medical imaging. Comprehensive computerised tomography (CT) dose standards exist for adults, but are incomplete for children. We investigated paediatric CT radiation doses at a NHS Trust in order to define the extent of the risk. METHODS CT dose indicators (CTDI) were recorded for all scans on paediatric patients from January - December 2011 and benchmarked against American College of Radiologists reference levels (75 mGy for adult head, 25 mGy for adult abdomen, and 20 mGy for paediatric (5-year-old) abdomen). Size-specific dose estimates (SSDE) were calculated based on effective patient diameter as recommended by the American Association of Physicists in Medicine. Student t-test was used to compare CTDI and SSDE values for each anatomical region. RESULTS Of 53,648 paediatric emergency presentations, CT was requested in 211 (0.39%). One hundred fifty-four patients underwent 169 scans, with the rest being cancelled for clinical improvement or senior overrule. Indication for CT was trauma in 130/154 (90%), of which 55% were after falls, 19% following road traffic collisions, 12% after sporting injury, and 12% after alleged assault. CTDI values were available for 96/169 (57%) scans, with the rest lacking sufficient data. There was no significant difference between CTDI and derived SSDE values. 3% of head scans exceeded the adult head reference level. CONCLUSION There is wide variation in radiation exposure during paediatric trauma CT, with some scans delivering doses in excess of recommended adult values. There is an urgent need to define standards for radiation dose in paediatric CT for all ages and anatomical regions.