Nigel Tapiwa Mabvuure

Acute Compartment Syndrome of the Limbs: Current Concepts and Management

Acute compartment syndrome (ACS) of the limb refers to a constellation of symptoms, which occur following a rise in the pressure inside a limb muscle compartment. A failure or delay in recognising ACS almost invariably results in adverse outcomes for patients. Unrecognised ACS can leave patients with nonviable limbs requiring amputation and can also be life–threatening. Several clinical features indicate ACS. Where diagnosis is unclear there are several techniques for measuring intracompartmental pressure described in this review. As early diagnosis and fasciotomy are known to be the best determinants of good outcomes, it is important that surgeons are aware of the features that make this diagnosis likely. This clinical review discusses current knowledge on the relevant clinical anatomy, aetiology, pathophysiology, risk factors, clinical features, diagnostic procedures and management of an acute presentation of compartment syndrome.

The Role of Bioreactors in Cartilage Tissue Engineering

Cartilage tissue engineering is concerned with developing in vitro cartilage implants that closely match the properties of native cartilage, for eventual implantation to replace damaged cartilage. The three components to cartilage tissue engineering are cell source, such as in vitro expanded autologous chondrocytes or mesenchymal progenitor cells, a scaffold onto which the cells are seeded and a bioreactor which attempts to recreate the in vivo physicochemical conditions in which cartilage develops. Although much progress has been made towards the goal of developing clinically useful cartilage constructs, current constructs have inferior physicochemical properties than native cartilage. One of the reasons for this is the neglect of mechanical forces in cartilage culture. Bioreactors have been defined as devices in which biological or biochemical processes can be re-enacted under controlled conditions e.g. pH, temperature, nutrient supply, O2 tension and waste removal. The purpose of this review is to detail the role of bioreactors in the engineering of cartilage, including a discussion of bioreactor designs, current state of the art and future perspectives.

Twelve tips for introducing students to research and publishing: A medical student's perspective

Background: Medical students claim to have inadequate opportunities to conduct research, whilst some do not know how to make the initial steps. There is a need for medical educators to not only direct students to research opportunities but also to counsel them on the attitudes required for the students success in a research environment. Aim: This article gives educators 12 tips on guidance that might help motivated medical students when starting their research careers. The various opportunities for students to participate in research are also identified. Method: Tips were devised from personal experience and a review of the literature. Results: The 12 tips are: (1) Educate students on the benefits of research. (2) Encourage students to take the initiative to create opportunities for themselves. (3) Encourage students to undertake extracurricular research. (4) Encourage students to network with other researchers. (5) Encourage students to engage with student-selected components of their courses. (6) Encourage students to apply for summer research programmes. (7) Encourage students to attend scientific conferences. (8) Advise students to consider intercalated degrees. (9) Encourage students to do research during elective placements. (10) Make students aware of the MBPhD courses. (11) Emphasise research as a learning process and reduce focus on output. (12) Advise students to balance their academic and research interests. Conclusions: The 12 tips highlight important attitudes for students to take in research as well as highlighting various opportunities for research.

Staple line reinforcement during laparoscopic sleeve gastrectomy: Does it affect clinical outcomes?

Although laparoscopic sleeve gastrectomy (LSG) is safe and efficacious treatment for morbid obesity, this procedure is associated with major staple line complications including leakage and bleeding. Staple-line reinforcement (SLR) either through suturing or buttressing with biological or synthetic material has been suggested as a method to prevent these complications. A Best Evidence Topic was constructed to address the question of whether SLR reduced these and other complications. MEDLINE, EMBASE and CINAHL searches up to October 2012 returned 97 unique results, of which nine (one meta-analysis, two randomised controlled trials (RCTs), six prospective cohort studies) provided the best evidence to answer this clinical question. We conclude that current evidence suggests that staple-line reinforcement reduces the incidence of leakage and postoperative complications than non-reinforcement but does not significantly reduce bleeding complications. However, we cannot as yet recommend staple-line reinforcement as the strength of the presented evidence is limited by the variable quality of the published studies. The full-length publication of several abstracts of randomised, controlled trials presented at various recent conferences is awaited. This may provide more data on the effect of staple-line reinforcement on other outcomes largely neglected by currently available studies.

Current concepts of prophylactic antibiotics in trauma: a review.

Traumatic injuries cause 5.8 million deaths per year globally. Before the advent of antibiotics, sepsis was considered almost inevitable after injury. Today infection continues to be a common complication after traumatic injury and is associated with increases in morbidity and mortality and longer hospital stays. Research into the prevention of post-traumatic infection has predominantly focused on thoracic and abdominal injuries. In addition, because research on sepsis following musculoskeletal injuries has predominantly been on open fractures. There is a paucity of research into the prevention of soft tissue infections following traumatic injuries. This review analyses the evidence for the role of prophylactic antibiotics in the management of soft tissue injuries. Emphasis is placed on assessing the strength of the presented evidence according to the Oxford Level of Evidence scale.

External cardiac compression during cardiopulmonary resuscitation of patients with left ventricular assist devices

A best evidence topic was written according to a structured protocol to determine whether there is evidence that cardiopulmonary resuscitation (CPR) by compressing the chest is safe and effective in patients with left ventricular assist devices (LVADs). Manufacturers warn of a possible risk of device dislodgement if the chest is compressed. AMED, EMBASE, MEDLINE, BNI and CINAHL were searched from inception to March 2014. Animal studies, case reports, case series, case-control studies, randomized controlled studies and systematic reviews were eligible for inclusion. Opinion articles with no reference to data were excluded. Of 45 unique results, 3 articles merited inclusion. A total of 10 patients with LVADs received chest compression during resuscitation. There was no report of device dislodgement as judged by postarrest flow rate, autopsy and resumption of effective circulation and/or neurological function. The longest duration of chest compression was 150 min. However, there are no comparisons of the efficacy of chest compressions relative to alternative means of external CPR, such as abdominal-only compressions. The absence of high-quality data precludes definitive recommendation of any particular form of CPR, in patients with LVADs. However, data identified suggest that chest compression is not as unsafe as previously thought. The efficacy of chest compressions in this patient population has not yet been investigated. Further research is required to address both the safety and efficacy of chest compressions in this population. Urgent presentation and publication of further evidence will inform future guidance.

Is acupuncture beneficial in the treatment of Bell's palsy?: Best Evidence Topic (BET)

A best evidence topic in facial nerve surgery was written according to a structured protocol. The question addressed was: in [patients with Bells palsy], does [acupuncture] improve [facial nerve function and/or pain]? A total of 43 papers were identified using the reported search protocol, of which three articles represented the best available evidence to answer the clinical question. Two of these articles were review papers and together encompassed 13 primary articles. Publication details, type of study, patients studied, outcomes and results are tabulated. The two level 1 articles concluded that before firm conclusions can be drawn, better designed trials are required in order to establish whether acupuncture confers any benefit to patients with Bells palsy. The level 2 randomised controlled trial (RCT) suggested that two methods of acupuncture were associated with significant improvements in pain in Bells palsy, although the trial was poorly controlled and had risk of bias. Therefore, the clinical bottom line is that until well designed trials are able to clearly demonstrate a role for acupuncture in Bells palsy, its efficacy should be considered to remain unproven.

Implications of rationing and the European Working Time Directive on aesthetic breast surgery: A study of trainee exposure in 2005 and 2011

BACKGROUND There are concerns that current trainees may be lacking operative experience in aesthetic and functional breast surgeries. Reduced exposure to such cases during training may stem from rationing, EWTD compliance, and an increasingly consultant-led service. These issues are examined in a single NHS hospital, with analysis of trends over time, and are contrasted with the changes that have occurred in a related private hospital. METHODS A single NHS hospital trusts database was retrospectively analysed for all aesthetic breast surgeries from 2005 to 2011, noting the total number of cases and the grade of the principal surgeon. The analysis was repeated in a related private sector hospital in the same catchment area. RESULTS A statistically significant drop of 55% of NHS aesthetic breast surgeries performed in 2011 compared to 2005 was demonstrated with an increasing trend for consultant led procedures. The NHS caseload decline was matched by a corresponding increase of 57% within the private sector. CONCLUSIONS Current trainees in plastic surgery face a significant reduction in operative exposure to aesthetic breast surgeries compared to their predecessors due to the EWTD working hours, surgical rationing policies, and an increasingly consultant led service. Approaches to maintaining training standards are discussed.

Twelve tips for running successful junior doctor-led teaching programmes for medical students

Background: Medical students value teaching by junior doctors and find it comparable to consultant-led teaching. Although several junior doctor-led teaching programmes have been developed, there is insufficient information in the literature to guide junior doctors planning on developing such programmes. Aim: This article gives junior doctors 12 practical tips on how they might develop and run successful teaching programmes for medical students. Results: The 12 tips are (1) Clearly define the scope of your programme, (2) Ensure student-defined learning goals are included at an early stage, (3) Inform and involve your fellow junior doctors in teaching, (4) Plan teaching rotas in advance, (5) Learn to teach effectively by attending courses, (6) Promote your programme to medical students as widely as possible, (7) Use varied and interactive teaching methods, (8) Establish rapport with students, (9) Include assessment as part of the teaching programme, (10) Seek feedback from attendees and senior faculty, (11) Establish rules for tutorials and (12) Secure formal recognition for your scheme. Conclusions: These 12 tips may help junior doctors to develop and manage successful teaching programmes. It may also be a useful guide for senior faculty advising junior doctors who aspire to establish such teaching programmes.

Chondrogenesis and Developments in Our Understanding

Conditions affecting cartilage through damage or age-related degeneration pose significant challenges to individual patients and their healthcare systems. The disease burden will rise in the future as life expectancy increases. This has resulted in vigorous efforts to develop novel therapies to meet current and future needs. Due to the limited regenerative capacity of cartilage, in vitro tissue engineering techniques have emerged as the favoured technique by which to develop replacements. Tissue engineering is mainly concerned with developing cartilage replacements in the form of chondrocyte suspensions and three-dimensional scaffolds seeded with chondrocytes. One major limiting factor in the development of clinically useful cartilage constructs is our understanding of the process by which cartilage is formed, chondrogenesis. For example, techniques of culturing chondrocytes in vitro have been used for decades, resulting in chondrocyte-like cells which produce an extracellular matrix of similar composition to native cartilage, but with inferior physical properties. It has now been realised that one aspect of chondrogenesis which had been ignored was the physical context in which cartilage exists in vivo. This has resulted in the development of bioreactor systems which aim to introduce various physical stresses to engineered cartilage in a controlled environment. This has resulted in some improvements in the quality of tissue engineered cartilage. This is but one example of how the knowledge of chondrogenesis has been translated into research practice. This paper aims to review what is currently known about the process of chondrogenesis and discusses how this knowledge can be applied to tissue engineering.