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1.  Survey of General Paediatric Surgery Provision in England, Wales and Northern Ireland 
INTRODUCTION
A survey was carried out to ascertain the current provision of general paediatric surgery (GPS) in all hospitals in England, Wales and Northern Ireland with 100% return rate. The provision of GPS is at a crossroads with a drift of these cases to the overstretched, tertiary referral hospitals.
METHODS
The regional representatives on the council of the Association of Surgeons of Great Britain and Ireland (ASGBI) obtained data from their regions. Any gaps in the data were completed by the author telephoning the remaining hospitals to ascertain their current provision.
RESULTS
A total of 325 acute hospitals are potentially available to admit elective and/or emergency paediatric patients, of which 25 hospitals provide a tertiary paediatric surgical service. Of the remaining ‘non-tertiary’ hospitals, 138 provide elective GPS and 147 provide emergency GPS. The ages at which GPS is carried out varies considerably, but 76% of non-tertiary hospitals provide elective GPS to those over the age of 2 years. The ages of emergency cases are 24% over the age of 2 years and 51.5% over the age of 5 years. The age at which surgery is carried out is dependent on the anaesthetic provision. Subspecialisation within each hospital has taken place with a limited number of surgeons providing the elective surgery. ‘Huband-spoke’ provision of GPS to a district general hospital (DGH) from a tertiary centre is embryonic with only 11 surgeons currently in post. An estimate of the annual elective case load of GPS based on the average number of cases done on an operation list works out at 23,000 cases done outwith the tertiary centres.
DISCUSSION
Almost 10 years ago, a change in the training of young surgeons took place. An increase in training posts in Tertiary centres was made available following advice from the British Association of Paediatric Surgeons (BAPS) but these posts were often not taken up. Many DGH surgeons became uncertain whether they should continue GPS training. A subtle change in the wording of the general guidance by the Royal College of Anaesthetists altered the emphasis on the age at which it was appropriate to anaesthetise children. Change in clinical practice, reducing need, and a drift towards tertiary centres has reduced DGH operations by 30% over a decade. Young surgeons are now seldom exposed to this surgery, and are not being trained in it. The large volume of these low-risk operations in well children cannot be absorbed into the current tertiary centres due to pressure on beds. The future provision of this surgery is at risk unless action is taken now. This survey was carried out to inform the debate, and to make recommendations for the future. The principal recommendations are that: (i) GPS should continue to be provided as at present in those DGHs equipped to do so; (ii) GPS training should be carried out in the DGHs where a high volume of cases is carried out; (iii) management of these cases should use a network approach in each region; (iv) hospital trusts should actively advertise for an interest in GPS as a second subspecialty; and (v) the SAC in general surgery develop a strategy to make GPS relevant to trainee surgeons.
doi:10.1308/003588408X285766
PMCID: PMC2430449  PMID: 18430332
Child; Surgical procedures; Elective; Hospitals; General
2.  Developing a placebo-controlled trial in surgery: Issues of design, acceptability and feasibility 
Trials  2011;12:50.
Background
Surgical placebos are controversial. This in-depth study explored the design, acceptability, and feasibility issues relevant to designing a surgical placebo-controlled trial for the evaluation of the clinical and cost effectiveness of arthroscopic lavage for the management of people with osteoarthritis of the knee in the UK.
Methods
Two surgeon focus groups at a UK national meeting for orthopaedic surgeons and one regional surgeon focus group (41 surgeons); plenary discussion at a UK national meeting for orthopaedic anaesthetists (130 anaesthetists); three focus groups with anaesthetists (one national, two regional; 58 anaesthetists); two focus groups with members of the patient organisation Arthritis Care (7 participants); telephone interviews with people on consultant waiting lists from two UK regional centres (15 participants); interviews with Chairs of UK ethics committees (6 individuals); postal surveys of members of the British Association of Surgeons of the Knee (382 surgeons) and members of the British Society of Orthopaedic Anaesthetists (398 anaesthetists); two centre pilot (49 patients assessed).
Results
There was widespread acceptance that evaluation of arthroscopic lavage had to be conducted with a placebo control if scientific rigour was not to be compromised. The choice of placebo surgical procedure (three small incisions) proved easier than the method of anaesthesia (general anaesthesia). General anaesthesia, while an excellent mimic, was more intrusive and raised concerns among some stakeholders and caused extensive discussion with local decision-makers when seeking formal approval for the pilot.
Patients were willing to participate in a pilot with a placebo arm; although some patients when allocated to surgery became apprehensive about the possibility of receiving placebo, and withdrew. Placebo surgery was undertaken successfully.
Conclusions
Our study illustrated the opposing and often strongly held opinions about surgical placebos, the ethical issues underpinning this controversy, and the challenges that exist even when ethics committee approval has been granted. It showed that a placebo-controlled trial could be conducted in principle, albeit with difficulty. It also highlighted that not only does a placebo-controlled trial in surgery have to be ethically and scientifically acceptable but that it also must be a feasible course of action. The place of placebo-controlled surgical trials more generally is likely to be limited and require specific circumstances to be met. Suggested criteria are presented.
Trial registration number
The trial was assigned ISRCTN02328576 through http://controlled-trials.com/ in June 2006. The first patient was randomised to the pilot in July 2007.
doi:10.1186/1745-6215-12-50
PMCID: PMC3052178  PMID: 21338481
3.  Diabetes services in the UK: third national survey confirms continuing deficiencies 
Aims: To determine the current level of diabetes services and to compare the results with previous national surveys.
Methods: A questionnaire was mailed to all paediatricians in the UK identified as providing care for children with diabetes aged under 16 years. Information was sought on staffing, personnel, clinic size, facilities, and patterns of care. Responses were compared with results of two previous national surveys.
Results: Replies were received from 244 consultant paediatricians caring for an estimated 17 192 children. A further 2234 children were identified as being cared for by other consultants who did not contribute to the survey. Of 244 consultants, 78% expressed a special interest in diabetes and 91% saw children in a designated diabetic clinic. In 93% of the clinics there was a specialist nurse (44% were not trained to care for children; 47% had nurse:patient ratio >1:100), 65% a paediatric dietitian, and in 25% some form of specialist psychology or counselling available. Glycated haemoglobin was measured routinely at clinics in 88%, retinopathy screening was performed in 87%, and microalbuminuria measured in 66%. Only 34% consultants used a computer database. There were significant differences between the services provided by paediatricians expressing a special interest in diabetes compared with "non-specialists", the latter describing less frequent clinic attendance of dietitians or psychologists, less usage of glycated haemoglobin measurements, and less screening for vascular complications. Non-specialist clinics met significantly fewer of the recommendations of good practice described by Diabetes UK.
Conclusions: The survey shows improvements in services provided for children with diabetes, but serious deficiencies remain. There is a shortage of diabetes specialist nurses trained to care for children and paediatric dietitians, and a major shortfall in the provision of psychology/counselling services. The services described confirm the need for more consultant paediatricians to receive specialist training and to develop expertise and experience in childhood diabetes.
doi:10.1136/adc.88.1.53
PMCID: PMC1719265  PMID: 12495963
4.  Intravenous postoperative fluid prescriptions for children: A survey of practice 
BMC Surgery  2008;8:10.
Background
Postoperative deaths and neurological injury have resulted from hyponatraemia associated with the use of hypotonic saline solutions following surgery. We aimed to determine the rates and types of intravenous fluids being prescribed postoperatively for children in the UK.
Methods
A questionnaire was sent to members of the British Association of Paediatric Surgeons (BAPS) and Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) based at UK paediatric centres. Respondents were asked to prescribe postoperative fluids for scenarios involving children of different ages. The study period was between May 2006 and November 2006.
Results
The most frequently used solution was sodium chloride 0.45% with glucose 5% although one quarter of respondents still used sodium chloride 0.18% with glucose 4%. Isotonic fluids were used by 41% of anaesthetists and 9.8% of surgeons for the older child, but fewer for infants. Standard maintenance rates or greater were prescribed by over 80% of respondents.
Conclusion
Most doctors said they would prescribe hypotonic fluids at volumes equal to or greater than traditional maintenance rates at the time of the survey. A survey to describe practice since publication of National Patient Safety Agency (NPSA) recommendations is required.
doi:10.1186/1471-2482-8-10
PMCID: PMC2435100  PMID: 18541019
5.  Tonsillectomy and Adenoidectomy in Children with Sleep-Related Breathing Disorders: Consensus Statement of a UK Multidisciplinary Working Party 
During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons.
In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy.
As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children.
The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available.
Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time.
With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH.
BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a ‘concise, accurate and helpful document’.
The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.
doi:10.1308/003588409X432239
PMCID: PMC2758429  PMID: 19622257
Consensus statement; Children; Sleep-related breathing disorders; Tonsillectomy; Adenoidectomy
6.  Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation 
BMJ : British Medical Journal  2004;328(7436):379.
Objectives To investigate attitudes of cardiac surgeons and anaesthetists towards working immediately after an intraoperative death and to establish whether an intraoperative death affects the outcome of subsequent surgery.
Design Questionnaire on attitudes to working after an intraoperative death and matched cohort study.
Setting UK adult cardiac surgery centres and regional cardiothoracic surgical centre.
Participants 371 consultant cardiac surgeons and anaesthetists in the United Kingdom were asked to complete a questionnaire, and seven surgeons from one centre who continued to operate after intraoperative death.
Main outcome measures Outcome for 233 patients operated on by a surgeon who had experienced an intraoperative death within the preceding 48 hours compared with outcome of 932 matched controls. Hospital mortality and length of stay as a surrogate for hospital morbidity.
Results The questionnaire response rate was 76%. Around a quarter of surgeons and anaesthetists thought they should stop work after an intraoperative death and most wanted guidelines on this subject. Overall, there was no increased mortality in patients operated on in the 48 hours after an intraoperative death. However, mortality was higher if the preceding intraoperative death was in an emergency or high risk case. Survivors operated on within 48 hours after an intraoperative death had longer stay in intensive care (odds ratio 1.64, 95% confidence interval 1.08 to 2.52, P = 0.02) and longer stay in hospital (relative change 1.15, 1.03 to 1.24, P = 0.02).
Conclusion Mortality is not increased in operations performed in the immediate aftermath of an intraoperative death, but survivors have longer stays in intensive care and on the hospital ward.
doi:10.1136/bmj.37985.371343.EE
PMCID: PMC341385  PMID: 14734519
7.  Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England. 
British Heart Journal  1992;67(1):106-116.
The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.
PMCID: PMC1024713  PMID: 1739519
8.  Current practice in primary total hip replacement: results from the National Hip Replacement Outcome Project. 
As part of the National Study of Primary Hip Replacement Outcome, 402 consultant orthopaedic surgeons from three regions were contacted by postal questionnaire which covered all aspects of total hip replacement (THR). There was a 70% response rate of which 71 did not perform hip surgery, a further 33 refused to take part, leaving 181 valid responses. Preoperative assessment clinics were used by 89% of surgeons, but anaesthetists and rehabilitation services were rarely involved at this stage. Of respondents, 99% used routine thromboprophylaxis, with 79% using a combination of mechanical and chemical methods. Of surgeons, 84% routinely used stockings, whereas 95.5% used chemical prophylaxis, 63% employed low molecular weight heparins. Theatre facilities were shared with other surgical specialties by 6% of surgeons and 18% regularly used body exhaust suits for THR. Antibiotic loaded cement was used by 69% of surgeons, the majority (65%) used a single brand of normal viscosity cement with 9% using reduced viscosity formulations. Modern cementing techniques were commonly used at least in part, 87% used a cement gun and 94% a cement restrictor for femoral cementing. On the acetabulum, 47% pressurised the cement. In all, 36 different femoral stems and 35 acetabular cups were in routine use, but the majority of surgeons (55%) used Charnley type prostheses. Of the surgeons, 57% performed only cemented THR, while 3% exclusively used uncemented THR. Of consultants, 21% followed up their patients to 5 years, the majority discharge patients within the first year. Of concern is a large proportion of surgeons using low molecular weight heparins despite a lack of evidence with regard to reducing fatal pulmonary embolism, and also the small number of surgeons using prostheses of unproven value. Third generation cementing techniques have yet to be fully adopted. The introduction of a national hip register could help to resolve some of these issues.
PMCID: PMC2503116  PMID: 9849338
9.  Trauma care — a participant observer study of trauma centers at Delhi, Lucknow and Mumbai 
The Indian Journal of Surgery  2009;71(3):133-141.
Background
Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years.
Aim
To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India — Delhi (2 centres), Lucknow and Mumbai.
Setting and design
Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers.
Material and methods
Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables.
Results
Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning — anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute.
Conclusion
Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.
doi:10.1007/s12262-009-0037-0
PMCID: PMC3452474  PMID: 23133136
Trauma Care; India; Trauma Centers; Participant observer
10.  Attitudes to blood transfusion post arthroplasty surgery in the United Kingdom: A national survey 
International Orthopaedics  2007;32(3):325-329.
Five hundred orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty surgery. Seventy-two percent of surgeons and 73% of anaesthetists responded to the survey. In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below a haemoglobin (Hb) level of 8 g/dL. Surgeons tended to be more aggressive in their attitudes, with a mean transfusion threshold of 8.3 g/dL compared to 7.9 g/dL for anaesthetists (p < 0.01), and with 97% of surgeons transfusing two or more units compared to 78% of anaesthetists (p < 0.01). This threshold Hb increased if the patient was symptomatic (surgeons 9.3 g/dL, anaesthetists 8.8 g/dL, p < 0.05) or was known to have pre-existing ischaemic heart disease (surgeons 9.0 g/dL, anaesthetists 9.2 g/dL, p <  0.05). A wide variability in attitudes and practices is demonstrated, and the development and adoption of consensus guidelines needs to be encouraged if efforts to reduce the use of blood products are to succeed.
doi:10.1007/s00264-007-0330-0
PMCID: PMC2323427  PMID: 17396259
11.  What do trainees think about advanced trauma life support (ATLS)? 
Advanced trauma life support (ATLS) has become a desirable or even essential part of training for many surgeons and anaesthetists, but aspects of the ATLS course have attracted criticism. In the absence of published data on the views of trainees, this study sought their opinions in a structured questionnaire, which was completed by trainees in accident and emergency (A & E) (26), anaesthetic (82), general surgical (26), orthopaedic (42) and other (5) posts in different hospitals (response rate 66%). Of the trainees, 78% had done an ATLS course and, of these, 83% considered ATLS a 'major advantage' or 'essential' for practising their proposed specialty--100% for A & E, 94% for orthopaedics, 92% for general surgery, and 75% for anaesthetics. ATLS was considered a major curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%, respectively. Over 90% had positive attitudes towards ATLS, and 74% selected 'genuine improvement of management of trauma patients' as the most important reason for doing the course: 93% thought ATLS saved lives. Of the respondents, 83% thought that all existing consultants dealing with trauma patients should have done the course, and 41% thought it offered major advantages to doctors not involved in trauma. Funding problems for ATLS courses had been experienced by 14% trainees. This survey has shown that most trainees view ATLS positively. They believe that it provides genuine practical benefit for patients, and very few regard ATLS primarily as a career advantage or mandate.
PMCID: PMC2503502  PMID: 10932661
12.  Vestibular Schwannoma Management: Current Practice Amongst UK Otolaryngologists – Time for a National Prospective Audit 
INTRODUCTION
It is generally agreed that the successful management of a vestibular schwannoma (VS) usually involves close collaboration between a neuro-otologist and neurosurgeon. In addition, it is accepted that the experience of the team managing such tumours is one of the key determinants of outcome after surgical intervention. The aim of this study was to identify current practice in the management of such tumours amongst otolaryngologists in the UK and to observe whether such collaborative working practices exist.
MATERIALS AND METHODS
A cross sectional postal questionnaire survey of consultant members of the British Association of Otorhinolaryngologists – Head and Neck Surgeons (n = 542).
RESULTS
A total of 336 replies were received (62%). Of respondents, 299 consultants referred their patients to another surgeon for further management; 242 referred to another ENT surgeon (80.9%), 29 to a neurosurgeon (9.7%) and 28 to a combined team (9.4%). Twenty-eight of the responding otolaryngologists (8.6%) managed the tumours themselves, of whom 22 worked with a neurosurgeon. Of these 28 neuro-otologists, nearly two-thirds (64%) had been undertaking VS surgery for more than 10 years. The total number of patients with a VS referred to these 28 consultants during 2001 was 775, with a mean caseload of 29.8, median 23 and a range of 4 to 102 per surgeon. Seven of the 28 otolaryngologists chose their surgical approach entirely based on the size of the tumour. Eight consultants preferred the sub-occipital (SO) approach, 10 the trans-labyrinthine (TL) approach, three chose between SO and TL approaches. The majority of surgeons had a prospective, computer-based data collection and were willing to give further information about their outcomes and complications.
CONCLUSIONS
Amongst the otolaryngologists surveyed in the UK, we have identified 28 neuro-otologists who undertake VS surgery. The majority work with neurosurgical colleagues, confirming collaborative practice. The wide range in caseload raises the issue of training and maintaining standards and in the first instance we recommend a prospective national audit of VS management and outcomes with our neurosurgical colleagues. This would also be of value in manpower planning particularly if a minimum caseload could be identified below which results were seen to be less good.
doi:10.1308/003588406X114901
PMCID: PMC1964657  PMID: 17002858
Vestibular schwannoma; Acoustic neuroma; Audit; Management; Collaboration
13.  Mortality of doctors in different specialties: findings from a cohort of 20000 NHS hospital consultants. 
OBJECTIVES: To examine patterns of cause specific mortality in NHS hospital consultants according to their specialty and to assess these in the context of potential occupational exposures. METHODS: A historical cohort assembled from Department of Health records with follow up through the NHS Central Register involving 18,358 male and 2168 female NHS hospital consultants employed in England and Wales between 1962 and 1979. Main outcome measures examined were cause specific mortality during 1962-92 in all consultants combined, and separately for 17 specialty groups, with age, sex, and calendar year adjusted standardised mortality ratios (SMRs) for comparison with national rates, and rate ratios (RRs) for comparison with rates in all consultants combined. RESULTS: The 2798 deaths at ages 25 to 74 reported during the 30 year study period were less than half the number expected on the basis of national rates (SMR 48, 95% confidence interval (95% CI) 46 to 49). Low mortality was evident for cardiovascular disease, lung cancer, other diseases related to smoking, and particularly for diabetes (SMR 14, 95% CI 6 to 29). Death rates from accidental poisoning were significantly raised among male consultants (SMR 227, 95% CI 135 to 359), the excess being most apparent in obstetricians and gynaecologists (SMR 934); almost all deaths from accidental poisoning involved prescription drugs. A significantly raised death rate from injury and poisoning among female consultants was due largely to a twofold excess of suicide (SMR 215, 95% CI 93 to 423), the rate for this cause being significantly raised in anaesthetists (SMR 405). Compared with all consultants, significantly raised mortality was found in psychiatrists for all causes combined (RR 1.12), ischaemic heart disease (RR 1.18), and injury and poisoning (RR 1.46); in anaesthetists for cirrhosis (RR 2.22); and in radiologists and radiotherapists for respiratory disease (RR 1.68). There were significant excesses of colon cancer in psychiatrists (RR 1.67, compared with all consultants) and ear, nose, and throat surgeons (RR 2.25); melanoma in anaesthetists (RR 3.33); bladder cancer in general surgeons (RR 2.40); and laryngeal cancer in ophthalmologists (RR 7.63). CONCLUSIONS: Lower rates of smoking will have contributed substantially to the low overall death rates found in consultants, but other beneficial health related behaviours, and better access to health care, may have also played a part. The increased risks of accidental poisoning in male consultants, and of suicide in female consultants are of concern, and better preventive measures are needed. The few significant excesses of specific cancers found in certain specialties have no obvious explanation other than chance. A significant excess mortality from cirrhosis in anaesthetists might reflect an occupational hazard and may warrant further investigation.
PMCID: PMC1128798  PMID: 9245944
14.  Improved clinical practice but continuing service deficiencies following a regional audit of childhood diabetes mellitus 
Archives of Disease in Childhood  2000;82(4):302-304.
AIM—To assess the changes in services for children with diabetes in the south west of England between two regionwide audits performed in 1994 and 1998.
METHODS—Questionnaires were sent to consultant paediatricians, specialist diabetes nurses, dietitians, and Local Diabetes Service Advisory Groups. Information was gathered on consultant and nursing caseload, clinic structure, dietetic and psychological services, glycated haemoglobin use, and screening services.
RESULTS—In 1994 there were 21 consultant paediatricians caring for children with diabetes, only seven of whom fulfilled the British Paediatric Association definition of a specialist. By 1998 there were 14, 12 of whom fulfilled this definition. In 1994 a significant number of children were being seen in general paediatric clinics; by 1998 all centres stated that children were being seen in designated diabetes clinics. Between the two audits, despite a decrease in the average caseload of specialist diabetes nurses, nursing services in many centres remained deficient, as did dietetic and psychology services. Glycated haemoglobin use increased from 16 of 21 consultants to all consultants. In 1998 there was still patchy paediatric representation on Local Diabetes Service Advisory Groups.
CONCLUSIONS—The 1994 audit was followed by a change in clinical practice, in contrast to continuing deficiencies in resources, despite the availability of national recommendations and the widespread distribution of the audit report to those in a position of influence.


doi:10.1136/adc.82.4.302
PMCID: PMC1718294  PMID: 10735836
15.  Who cares for the patient with head injury now? 
Emergency Medicine Journal : EMJ  2001;18(5):352-357.
Objective—A recent report on head injury management from the Royal College of Surgeons of England suggests that surgeons are unsuited to the inpatient care of head injuries (ICHI) and should hand over responsibility entirely to neurosurgeons and accident and emergency (A&E) specialists. This prompted a survey of A&E consultants to establish their opinions on the current and future practice of head injury care.
Methods—Questionnaires were sent to consultant members of the British Association for Accident and Emergency medicine. Of a possible 256 A&E departments from Great Britain and Ireland with over 20 000 annual new attenders 206 (80%) replied.
Results—General surgeons contribute to ICHI for adults in 107 of 206 hospitals (52%) compared with orthopaedic surgeons in 73 of 206 (35%) and A&E consultants in 71 of 206 (34%). There was frequent criticism that surgeons are uninterested in head injury care. Fifty nine units (30%) commented on the lack of neurosurgery beds and difficulties experienced in getting patients accepted. Few hospitals seem to have well integrated rehabilitation or follow up services targeted at head injury. One in six patients with head injury admitted to a general hospital or observation ward remain after 48 hours and one in 20 stay beyond one week. Of the 132 A&E units without responsibility for ICHI 54 (41%) either wish to take on this responsibility or are willing to do so if the necessary resources are first put in place. The perceived net revenue cost required to allow 67 A&E units to take on ICHI is about 12.5 million pounds per year. This does not include the cost of further care after 48 hours, follow up or rehabilitation.
Conclusion—Only one third of A&E units at present have even part of the ICHI role recommended in the RCS report; another third are prepared to accept a new role if training and resources are provided and support is forthcoming from other specialists to take over the care after 48 hours; the remaining third are unwilling to accept responsibility for ICHI.
doi:10.1136/emj.18.5.352
PMCID: PMC1725681  PMID: 11559605
16.  Surgical checklists: the human factor 
Background
Surgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist.
Methods
Using the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital.
Results
Responses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process.
Conclusion
In order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.
doi:10.1186/1754-9493-7-14
PMCID: PMC3669630  PMID: 23672665
Surgical checklist; Surgery; Patient safety
17.  Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey 
PLoS Medicine  2010;7(3):e1000242.
In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.
Background
There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.
Methods and Findings
We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.
Conclusion
African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Infectious diseases remain the major killers in developing countries, but traumatic injuries, complications of childbirth, and other conditions that need surgery are important contributors to the overall burden of disease in these countries. Unfortunately, the provision of surgical services in low- and middle-income countries is often insufficient. There are many fewer operations per a head of population in developing countries than in developed countries, essential operations such as cesarean sections for complicated deliveries are not always available, and elective operations such as male and female sterilization can be difficult to obtain. Lack of funding for surgical procedures and shortages of trained health workers have often been blamed for the low rates of surgery in developing countries. For example, anesthesiologists (doctors who are trained to give anesthetics and other pain-relieving agents) and trained anesthetists (usually nurses and technicians) are rare in many African countries, as are surgeons and obstetricians (doctors who look after women during pregnancy and childbirth). To make matters worse, these specialists often work in tertiary referral hospitals in large cities. In district hospitals, which provide most of the primary health care needs of rural populations, basic surgical care is usually provided by “mid-level health care providers” (MLPs)—individuals with a level of training between that of nurses and physicians.
Why Was This Study Done?
Various organizations are currently working to improve emergency and essential surgical care in developing countries. For example, the Bellagio Essential Surgery Group (BESG) seeks to define, quantify, and address the problem of unmet surgical needs in sub-Saharan Africa. Importantly, however, before any programs can be introduced to improve access to surgical services in developing countries, better baseline data on existing surgical services needs to be collected—most of the available information on these services is anecdotal. In this study, the researchers (most of whom are members of the BESG) investigate the provision of surgical procedures and anesthesia in district hospitals in three sub-Saharan African countries and estimate the costs of surgery performed in the same hospitals.
What Did the Researchers Do and Find?
The researchers collected recent data on the number of doctors, MLPs, and nurses in two district hospitals in Tanzania and in Mozambique, and from four district hospitals in Uganda and information on each hospital's expenditure. Most of the health workers in these hospitals (which care for 3 million people between them) were nurses (77.5%), followed by MLPs not trained to provide surgical care (7.8%), and MLPs trained to provide surgical care (3.8%). The hospitals had between one and six medical doctors each (28 across all the hospitals), but there were no trained surgeons or anesthesiologists posted at any of the hospitals. About half of the major surgical procedures undertaken at these hospitals were performed by doctors but more than a third were done by MLPs although the exact pattern of personnel involved in surgery varied among the three countries. Anesthesia was mostly provided by nurses and doctors; again the pattern of anesthesia provision varied among countries and hospitals. Only 7%–14% of overall hospital expenditure was allocated to surgical care and most of this allocation was used for obstetric services. Finally, the researchers estimate that, on the basis of district populations, the district hospitals spent between US$0.05 and US$0.14 per head on surgical services.
What Do These Findings Mean?
These findings indicate that, in the district hospitals investigated in this study, physicians, MLPs, and nurses provide most of the surgical care. Furthermore, although all the hospitals in the study provide some surgical care, it accounts for a small part of the hospitals' overall operating costs. These findings may not be generalizable to other district hospitals in sub-Saharan Africa and provide no information about the unmet needs for surgical care. Nevertheless, these findings and those of a separate paper that investigates the range and volume of surgical procedures undertaken in the same district hospitals provide a valuable baseline for planning the expansion of health care services in Africa. They also suggest that increasing the funds allocated to surgery and formalizing the training of MLPs might be a cost-effective way of increasing access to surgical care in sub-Saharan Africa and other developing regions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000242.
The range and volume of surgery in the same hospitals is investigated in a PLoS Medicine Research Article by Moses Galukande et al.
Information on the Bellagio Essential Surgery Group is available
WHO's Global initiative for Emergency and Essential Surgical Care plans to take essential emergency, basic surgery and anesthesia skills to health care staff in low- and middle-income countries around the world; WHO also has a page describing the importance of emergency and essential surgery in primary health care
doi:10.1371/journal.pmed.1000242
PMCID: PMC2834706  PMID: 20231869
18.  A survey of surgical team members’ perceptions of near misses and attitudes towards Time Out protocols 
BMC Surgery  2013;13:46.
Background
Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.
Methods
This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.
Results
In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.
Conclusion
The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.
doi:10.1186/1471-2482-13-46
PMCID: PMC3851944  PMID: 24106792
Surgery; Operating room; Near misses; Medical errors; Checklist
19.  The Incidence and Reporting Rates of Needle-Stick Injury Amongst UK Surgeons 
INTRODUCTION
Needle-stick injuries are common. Such accidents are associated with a small, but significant, risk to our career, health, families and not least our patients. National guidelines steer institution-specific strategies to provide a consistent and safe method of dealing with such incidents. Surgeon-specific guidelines are not currently available. We have observed that hospital sharps policy is often considered cumbersome to the surgeon, resulting in on-the-spot decision making with potential long-term implications. By their essence, these decisions are inconsistent, not reproducible and, thus, we believe them to be unsafe. The under-reporting to occupational health departments is well documented. Current surgical practice has the potential to expose the surgeon to unnecessary risk. The aims of this study were to establish the true incidence of contaminations caused by needle-stick injury in our hospital and to assess how well current protocols are really implemented.
SUBJECTS AND METHODS
We identified all surgeons of consultant, non-career staff grade (NCSG) and registrar grade working in a large 687-bed district general hospital serving a population of 550,000, in the UK. We designed a retrospective, anonymous 30-second survey. Surgeons' awareness and opinion of local policy was sought in a free-text section.
RESULTS
Of the 98 surgeons in the hospital, 77% responded to the questionnaire and 44% anonymously admitted to having a needle-stick injury. Only 3 of the 33 (9%) who sustained an needle-stick injury said that they followed the agreed local policy. Twenty-three surgeons (70%) performed first aid type procedures such as informing scrub nurse, changing needle and gloves. Seven surgeons (21%) simply ignored the incident and continued. Forty-three surgeons commented on the policy's nature with only 9 who regarded it as ‘user friendly’.
CONCLUSIONS
Needle-stick injury is still a common problem, particularly in the surgical cohort and remains significantly under-reported. The disparity between hospital sharps policy and actual surgical practice is considered and an explanation for the difference sought. Without this awareness of ‘real-life’ surgical practice, the occupational health figures for sharps injury will always tell a rosy story under-estimating a real problem. We strongly advocate universal precautions in the operating theatre. However, we acknowledge that sharps injuries will occur. We should remain vigilant and act upon contaminations without surgical bravado but with mater-of-fact professionalism. This includes regular review of policy and, particularly, promotion of surgical awareness.
doi:10.1308/003588409X359213
PMCID: PMC2752234  PMID: 18990263
Needle-stick injury; Sharps injury; Surgical contamination; Blood-borne viruses; Reporting rates
20.  Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK 
Heart  2002;88(Suppl 1):i1-i14.
The size of the national population of patients with grown-up congenital heart disease (GUCH) is uncertain, but since 80–85% of patients born with congenital heart disease now survive to adulthood (age 16 years), an annual increase of 2500 can be anticipated according to birth rate. Organisation of medical care is haphazard with only three of 18 cardiac surgical centres operating on over 30 cases per annum and only two established specialised units fully equipped and staffed.
Not all grown-ups with congenital heart disease require the same level of expertise; 20–25% are complex, rare, etc, and require life long expert supervision and/or intervention; a further 35–40% require access to expert consultation. The rest, about 40%, have simple or cured diseases and need little or no specialist expertise. The size of the population needing expertise is small in comparison to coronary and hypertensive disease, aging, and increasing in complexity. It requires expert cardiac surgery and specialised medical cardiology, intensive care, electrophysiology, imaging and interventions, "at risk" pregnancy services, connection to transplant services familiar with their basic problem, clinical nurse specialist advisors, and trained nurses.
An integrated national service is described with 4–6 specialist units established within adult cardiology, ideally in relation or proximity to university hospital/departments in appropriate geographic location, based in association with established paediatric cardiac surgical centres with designated inpatient and outpatient facilities for grown-up patients with congenital heart disease. Specialist units should accept responsibility for educating the profession, training the specialists, cooperative research, receiving patients "out of region", sharing particular skills between each other, and they must liaise with other services and trusts in the health service, particularly specified outpatient clinics in district and regional centres. Not every regional cardiac centre requires a full GUCH specialised service since there are too few patients. Complex patients need to be concentrated for expertise, experience, and optimal management. Transition of care from paediatric to adult supervision should be routine, around age 16 years, flexibly managed, smooth, and explained to patient and family. Each patient should be entered into a local database and a national registry needs to be established. The Department of Health should accept responsibility of dissemination of information on special needs of such patients. The GUCH Patients' Association is active in helping with lifestyle and social problems.
Easy access to specialised care for those with complex heart disease is crucial if the nation accepts, as it should, continued medical responsibility to provide optimal medical care for GUCH patients.
doi:10.1136/heart.88.suppl_1.i1
PMCID: PMC1876264  PMID: 12181200
21.  The changing interface between district hospital cardiology and the major cardiac centres 
Heart  1997;78(5):519-523.
The national priority for reducing mortality and morbidity from cardiovascular disease, the resulting expansion in the number of consultant cardiologists, and the reforms of the National Health Service have produced significant changes in delivery of care for cardiac patients and in the relations between district general hospitals (DGH) and the old regional cardiac centres. 1.2 The British Cardiac Society, the Medical Royal Colleges of Physicians of London and Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow established a working group to make recommendations on the most appropriate evolution of these changes to secure high quality care in a cost-effective and professionally rewarding environment. The principal conclusions of the working group were: i) The establishment of new cardiac catheterisation laboratories in DGHs remote from a major cardiac centre should be encouraged provided the workload is adequate to ensure efficient use of the facility. ii) Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre. iii) Close liaison of the district cardiologist with a cardiac surgeon and interventionist is vitally important. iv) The centres will be required to provide tertiary care for emergency and urgent cases from their traditional catchment area, specialised expertise for the management of rare and difficult cases, and angioplasty. Some centres will also offer complex electrophysiology, and ablation techniques. v) The centres must also provide routine cardiology services for their local district, facilities for cardiac catheterisation for DGH cardiologists, and training for doctors, nurses, technicians, and radiographers. vi) Some centres will be linked with paediatric cardiology and paediatric cardiac surgical units. vii) District cardiac centres will be required to provide a full non-invasive diagnostic service and emergency care for patients referred by general practitioners and hospital colleagues as well as facilities for preventative and rehabilitation cardiology. Arrangements for invasive investigation and treatment of their patients will vary according mainly to the distance from the major centre. viii) Both the major centres and the district cardiac units should participate in training and research. 



PMCID: PMC1892294  PMID: 9415018
22.  Error, stress, and teamwork in medicine and aviation: cross sectional surveys 
BMJ : British Medical Journal  2000;320(7237):745-749.
Objectives:
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
Design:
Cross sectional surveys.
Setting:
Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
Participants:
1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
Main outcome measures:
Perceptions of error, stress, and teamwork.
Results:
Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Conclusions:
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
PMCID: PMC27316  PMID: 10720356
23.  Survey of clinical allergy services provided by clinical immunologists in the UK 
Journal of Clinical Pathology  2005;58(12):1283-1290.
Background: The UK National Health Service is failing to meet the need for diagnosis and treatment of allergic disorders, which are common and increasing in prevalence. The House of Commons select committee report on allergy services highlighted the inequalities and urgent need for investment.
Aim: To survey the allergy workload provided by clinical immunologists to inform service planning and resource allocation.
Methods: The allergy services performed by clinical immunologists during a 12 month period from 1 April 2003 to 31 March 2004 were surveyed by means of a questionnaire via supraregional audit groups.
Results: The immunology centres surveyed serve 32 million people and offer almost the complete repertoire of a specialised allergy service. There were large variations in clinic capacity, new referrals, appointment duration, and service configuration. Services were largely consultant delivered, but availability of joint clinics with paediatricians and anaesthetists was locally variable. Novel service delivery models utilising nurses and clinical assistants have been developed and merit further investigation.
Conclusion: Consultant immunologists and trainees currently make a major contribution to the development and provision of specialised allergy services. Consultant immunologists will probably remain key providers of tertiary level allergy care in the UK in the long term (in line with other countries) and will be pivotal in supporting and developing the provision of equitable national access to specialist allergy services in a timely manner. Rapid progress in developing the new specialty of allergy and securing better access to services for patients in the short term will be best served by strengthening the collaborative relationship between allergists and clinical immunologists.
doi:10.1136/jcp.2005.027623
PMCID: PMC1770782  PMID: 16311348
immunology; clinical allergy services; audit; workload
24.  Two Hundred Cases of Paralytic Foot Stabilization after the Method of Hoke 
Dr. Oscar Lee Miller was born on a farm in Franklin County, in northeast Georgia [6]. He obtained a teachers’ certificate and taught school several years after high school before he attended the University of Georgia and then graduated from the Atlanta College of Physicians and Surgeons (now Emory University School of Medicine) in 1912. He took postgraduate training in Atlanta, working with Dr. Michael Hoke (whose name is associated with hindfoot arthrodesis). He entered military service in 1917, then returned to private practice after the armistice. As with other first Presidents of the AAOS, foreign experience was important, and in 1921 he visited Sir Robert Jones and other British surgeons. Upon returning he moved to Gastonia, North Carolina and helped develop the North Carolina Orthopaedic Hospital, an institution focusing on crippled children. In 1923, he opened an office which eventually became the Miller Clinic in nearby Charlotte. (The Miller Clinic and Charlotte Orthopedic Specialists merged in 2005 to create OrthoCarolina.)
Dr. Miller was active in the AOA as well as the AAOS, and was a member of the Argentine Surgical Association. He became President of the AAOS in January, 1942, only days after the bombing of Pearl Harbor. In his Presidential address he emphasized the importance of the care of crippled children and urged a strong relationship with the Latin American orthopaedic community [1]. He served as Chair of a committee that created the Inter-American Orthopaedic Fellowship Program, for Latin American surgeons to visit training centers in the US. He also urged the AAOS to develop a library “as a repository for all pertinent records.” The Executive Committee outlined a program in June, 1941, to present a “motion picture exhibit,” a feature of the meeting which subsequently became the Instructional Course Lecture [2]. Under his leadership at that meeting, the AAOS passed a resolution regarding support of the country during the war years: “It is the desire of the American Academy of Orthopaedic Surgeons to offer its wholehearted support to our Country in this serious emergency.” A telegram with the resolution was sent to the President of the United States.
Miller had a lasting interest in foot surgery, undoubtedly influenced by Hoke. We reprint here Miller’s report of Hoke’s triple arthrodesis for paralytic feet [3]. Astonishingly, Miller states this was the only operation performed for paralytic feet in his clinic over a three-year period, yet he reported 200 cases in this short time; obviously the number of polio patients at the time was devastating. Among these 200 cases, 121 were of the “clubfoot type,” 62 had pes cavus (on which he wrote in 1927 [4]), and 17 pes calcaneus (on which he wrote in 1936 [5]). Miller reports eight cases of flail feet (although it is unclear whether these are additional cases, or fall within one of the three categories since the numbers of those categories add to 200). His focus is to describe the basic operations with indications for supplemental procedures including tendon transfers. As was often common practice in describing procedures at the time, he did not report the followup results and did not provide references [3]. Oscar Lee Miller, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
Heck CV. Commemorative Volume 1933–1983 Fifty Years of Progress. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Heck CV. Fifty Years of Progress: In Recognition of the 50th Anniversary of the American Academy of Orthopaedic Surgeons. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Miller O. Two hundred cases of paralytic foot stabilization after the method of Hoke. J Bone Joint Surg Am. 1925;7:85–97.Miller O. A plastic foot operation. J Bone Joint Surg Am. 1927;9:84–91.Miller O. Surgical management of pes calcaneus. J Bone Joint Surg Am. 1936;18:169–172.Oscar Lee Miller 1887–1970. J Bone Joint Surg Am. 1971;53:400–401.
doi:10.1007/s11999-007-0029-y
PMCID: PMC2505288  PMID: 18196377
25.  The feasibility of introducing advanced minimally invasive surgery into surgical practice 
Canadian Journal of Surgery  2007;50(4):256-260.
Background
This study investigates the feasibility of performing advanced minimally invasive surgery (MIS) in a nonspecialized practice environment.
Methods
We conducted a cross-sectional survey of all community general surgeons currently practising in Ontario.
Results
Few community surgeons perform a high volume (> 10 procedures per yr) of advanced MIS. Most (70%) believe it is important to acquire additional skills in advanced MIS. The most appropriate methods for learning advanced MIS are believed to be expert mentoring (79.7%), courses (77.2%) and a colleague mentor (63.9%). A total of 57.6% of respondents have attended a course in MIS while in practice, and most have access to a reasonable variety of instrumentation. Respondents believe that 57.6% of assistants, 54.8% of nurses and 43.4% of anaesthetists are relatively inexperienced with advanced MIS. Barriers to establishing advanced MIS include limited operating room access (50%), resources or equipment (45.2%) and limited expert mentoring (43.6%). Surgeons with less than 10 years of practice found lack of trained nursing staff (7.9% v. 4.2%, p = 0.01) and experienced assistants (12% v. 6.2%, p = 0.008) to be more important barriers than did those with over 10 years of practice, respectively.
Conclusion
Most general surgeons working in Ontario are self-taught with respect to MIS skills, and few perform a high volume of advanced MIS. Only one-half of all respondents have access to skilled MIS operating room nurses, surgical assistants or anesthesiology. Despite this, general surgeons perceive the greatest barriers to introducing advanced MIS procedures to be limited access to operating rooms, resources or equipment and limited mentoring. This study has shown that the role of the surgical team in advanced MIS may be underestimated by many general surgeons. These data have important implications in training general surgeons and in incorporating additional advanced MIS procedures into the armamentarium of general surgeons.
PMCID: PMC2386170  PMID: 17897513

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