Robert Morgan

Effective prevention of thromboembolic complications in emergency surgery patients using a quality improvement approach.

Objective To assess the effectiveness of a multifaceted intervention based on industrial process improvement to identify and sustainably correct deficiencies in thromboprophylaxis delivery. Summary background data Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in surgical patients, but effective prophylactic treatments are available. Ensuring reliable delivery of the intended thromboprophylaxis is, however, a long-standing problem. Methods Delivery of thromboprophylactic treatment on an emergency general surgery admissions ward was targeted during a multidisciplinary intervention to improve process reliability using industrial quality improvement approaches. Delivery was audited against guidelines before and after 3- month intervention. Clinical outcome was evaluated by reviewing all radiological investigations for suspected Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) from patients admitted to the unit in the 1 year immediately before and that immediately after intervention. Results Delivery of thromboprophylaxis according to guidelines was improved from 35% before to 87% 3 months after intervention (χ2=87.412, p<0.0001) and sustained at 86% 10 months after intervention. Radiologically identified thromboembolic events occurring up to 60 days after admission in patients admitted for over 48 h fell from 23/3075 (0.75%) before to 9/3080 (0.29%) after intervention (HR 0.39, CI 0.29 to 0.53, χ2=6.18, p=0.01292). The risk of thromboembolism in the two groups diverged during follow-up to 60 days, before converging again. Conclusions A quality improvement process resulted in major sustainable improvements in the delivery of thromboprophylaxis associated with a 61% reduction in radiologically detected clinical episodes of thromboembolism 2 months after admission. Further study of this approach to improving care quality is warranted.

Management of giant omphalocele: a case series.

Giant omphalocele (GO) is congenital abdominal wall defect measuring >6 cm and/or containing liver.1 The omphalocele sac consists of amnion and peritoneum, and is prone to rupture either in utero, during delivery or after birth. The surgical management of neonates with GO is challenging. Several operative and nonoperative strategies have been described although a traditional silo chimney with graduated visceral reduction is commonly used. In this case report, we describe four patients with GO in whom postnatal management was highly problematic. We used an acellular biological xenograft called Surgisis Biodesign (Cook Ltd.) to repair the GO.2 Surgisis Biodesign is derived from porcine small intestine submucosa and consists of an extracellular matrix containing collagens, glycoproteins glycosaminoglycans, proteoglycans, and growth factors.2Once implanted into tissue it provides a scaffold for epithelialization.

The Hermeneutical Significance of Four Gospels

The fact of four different Gospels can be faced as a theological opportunity rather than as a merely historical problem by the hermeneutic of an understanding of Christianity as based upon the christological dogma.

Exploratory laparotomy in the management of confirmed necrotizing enterocolitis

IntroductionNecrotizing enterocolitis (NEC) is a serious gastrointestinal emergency in newborn infants. Surgical management includes primary peritoneal drainage and/or exploratory laparotomy with bowel resection. This study describes obstetric complications, postnatal comorbidities, surgical care and intermediate postoperative outcomes in all infants with surgically and/or histologically proven NEC, who underwent exploratory laparotomy at our tertiary referral centre. Materials and methodsWe conducted a retrospective review between January 2005 and December 2010. Results are reported as median (range). Fisher’s exact test (two tailed) was used for statistical analysis. A P-value of 0.05 or less was considered statistically significant. ResultsA total of 71 infants had suspected (Bell’s stage≥1) NEC. Of them, 32 infants underwent laparotomy for stage 2–3 NEC. We excluded 11 infants with surgically and/or histologically proven spontaneous intestinal perforation. In the remaining 21 infants with confirmed NEC, median gestational age was 27 weeks (23–39 weeks) and median birth weight was 720 g (440–3510 g). NEC was suspected after a median 14 days of life (1–49 days of life). Fifteen patients (71%) were initially managed medically for a median total of 8 days (1–25 days). Laparotomy was performed after a median of 7 days (<1–35 days) from the suspicion of NEC. Eleven infants (52%) underwent bowel resection and enterostomy, four infants (19%) underwent bowel resection with primary anastomosis and one infant (5%) underwent proximal diverting jejunostomy. Bowel perforation was seen in seven patients (33%). Necrosis totalis was evident in five patients (24%). There were 12 postoperative deaths (57% mortality), and seven deaths (58%) occurred during the first 30 days. Infants who died were more likely to have had absent/reversed end-diastolic flow (n=5, P=0.64), intrauterine growth retardation (n=5, P=0.18) or a gestational birth weight between 501 and 750 g (n=9, P=0.08). In the surviving children (n=9), the median length of hospital stay was 134 days (87–190 days) and postoperative sequelae were frequently seen. ConclusionThe morbidity and mortality for infants with confirmed NEC who undergo laparotomy remain high in infants despite optimal medical and surgical care.

Sachkritik in Reception History

Sachkritik, or critical assessment of what a biblical text says in the light of the gospel that the author intended to communicate, became an issue in modern theology and scriptural interpretation in 1922—26 with Bultmann’s discussions of Barth’s theological exegesis of Romans and 1 Corinthians. Since the gospel is itself heard in and through the witness of scripture this implies a dialectic between them. Bultmann could override some of Paul’s formulations in the light of the apostle’s basic intention, and so find a contemporary Christian meaning in texts from a distant culture. His later demythologizing the New Testament applied the same principle to large swathes of the biblical language without calling it Sachkritik, but some of his followers used the word for their critical assessment of one biblical writer in the light of the gospel as understood from another. Finally, a few liberal theologians now use the word to express their rejection of parts of scripture in the light of their modern understandings of the gospel, which they admit are remote from those of any New Testament witness. Reception historians can see from these three strategies how all historically critical theologians claim either more or less continuity with their scriptures while recognizing that much in them is incredible, and inapplicable to modern Christian identity.

A leak too far - Gastro-pleural fistula mimicking recurrence of repaired congenital diaphragmatic hernia following fundoplication

Recurrence rate after a congenital diaphragmatic hernia repair is high especially after a patch repair. Recurrence can be asymptomatic, followed by respiratory or gastrointestinal symptoms and the diagnosis is usually confirmed radiologically. We present an unusual case of radiologically diagnosed recurrent left diaphragmatic hernia but at surgery was found to be a gastro-pleural fistula that occurred as a complication following fundoplication surgery.

Susannah Heschel’s Aryan Grundmann

This discussion of The Aryan Jesus (2008) welcomes its combating all antisemitism but questions whether it sufficiently distinguishes that from an also deplorable theological anti-Judaism. Heschel’s account of the Eisenach Institute (1939—42), which aimed to de-Judaize German Christianity, provides a one-sided impression of 1930s German church history. The book’s broader thesis that Christianity is racist depends on a failure to distinguish clearly between the churches and the völkisch movement that stands behind Nazi antisemitism. Criticisms made of individual biblical scholars confirm the responsibility to counter an anti-Judaism that was bound to fuel modern secular antisemitism. Both are different from the Christian antisemitism prevalent in the Middle Ages.

Gabler's Bicentenary

Vacation Te/7ll for Biblical Study This will be held at St Anne’s Collcge, Oxford, from 25 July to 8 August 1987. Thc main courscs in thc first week will be ‘A Subject Peoplc: The Jews under Persian Rule’ by Profcssor P. R. Ackroyd, and ’Coherence and Conflict in Earliest Christian Doctrinc’ by DrJ. B. Muddiman, and in thc second week ’Jesus, the Rich and the Poor’ hy Professor D. R. Catchpole, and ’Biblical Interpretation and the Church’s Attitude to Social Questions, 1860 to 1930’ by Dr D. Thompson. Dr. M. Merchant, the Revd.

Difficult texts: Mark 16.8:

The Roman lectionary solves the problem of anticlimax by cutting out the problem at verse 8 and stopping at Mark 16.7. This plays havoc with some commentators’ accounts of Mark’s intentions. The scenario suggested here implies that the liturgists may accidentally have got Mark right. If this reconstruction is entertained, their mutilation of Mark no longer spoils his literary and theological design.

How did Mark End his Narrative

The best explanations of Mark’s perplexing ending at 16:8 with the women’s disobedience to the angelic commands make v. 8b part of his motif of the male disciples’ failure to understand Jesus adequately during his ministry. That is questionable and anyone who is not persuaded but agrees that Mark is not just careless may be driven back to the once popular expedient of supposing that the present text is not how Mark intended to end. The older proposals made Mark intend more. This one suggests that the pre- and immediate post-history of 16:7–8 may have resulted in a combination of two alternative endings.