Surgery

... Clinical Review. Lesson of the week. Useless and dangerous—fine needle aspiration of hepatic colorectal metastases. ... Rapid responses to this article. Biopsy of potentially operable hepatic colorectal metastases-not useless but certainly dangerous. ...

E ditor—We are delighted to have provoked such a lively debate with our article. The only weakness anticipated in advance of publication was that it perhaps represented rather “old news.” It is gratifying then to find that its message merited vigorous reiteration.

A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

This article considers two historical military casualties in the context of present day Advanced Trauma Life Support (ATLS) teaching. The death of Admiral Lord Nelson, Royal Navy, at the Battle of Trafalgar in 1805 has been well documented while that of Lieutenant Luke, an American aviator, U.S. Army Air Service, in France in 1918 has been almost disregarded. Both suffered a gunshot wound to the chest with the responsible weapon similarly sited. Nelson's dying was witnessed and recorded in detail by his surgeon. Luke's death was unwitnessed and has been the subject of considerable speculation. A recent monograph removes much of this speculation but cannot describe his last few minutes of life. This article describes both events and considers the mechanism of injury. It presents speculative radiological reconstructions and an outline of emergency management according to ATLS for both and further clinical speculation on Luke's demise.

St. John Ambulance Australia has used the performance of CPR for 10 min as a fitness test for its members. Recent changes in international guidelines for cardiopulmonary resuscitation caused concern that the new ILCOR protocol was more strenuous than the previous one. This study compared the two protocols to determine if there were significant differences and to allow an evidence-based decision on the continuation or modification of this practice. We studied 26 subjects performing single-rescuer cardiopulmonary resuscitation on a manikin. Every subject did 10 min cardiopulmonary resuscitation using each protocol. The study used a randomized cross-over design. The estimated maximum heart rate was calculated for each subject. Compression rate and effective ventilation (number and depth) were enforced by direct feedback. Subjective and objective measures of physical activity were recorded at regular intervals. The maximum percentage of estimated maximum heart rate achieved during 15:2 and 30:2 CPR was 76+/-2% and 79+/-2%, respectively (mean+/-standard error of mean; P<0.001). The rate pressure product at the end of 10 min cardiopulmonary resuscitation was 18,999+/-891 for 15:2 and 19,204+/-757 for 30:2 (ns) while the Borg rating of perceived exertion was 13.7+/-0.5 for 15:2 and 14.8+/-0.5 for 30:2 (P<0.05). The new protocol increases both objective and subjective measures of effort. While the absolute differences in workload are small, they are statistically significant. There are significant indicators of this difference in the first 3 min of assessment. Rescuers are more likely to be operating at a high-level of physical activity. To avoid increasing the demands of its mandatory fitness test, St. John should reduce the required performance time from its present 10 min.

The aim of this systematic review was to compare the safety and efficacy of laparoscopic live donor nephrectomy with the "gold" standard of open live donor nephrectomy. Three search strategies were devised to enable literature retrieval from the Medline, Current Contents, Embase, and Cochrane Library databases up until, and including, February 2000. Inclusion of a report was determined on the basis of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. English language reports were selected and acceptable study designs included randomized-controlled trials, controlled clinical trials, case series, or case reports. Each report was required to provide information on at least one of several safety and efficacy outcomes as detailed in the protocol. Twenty-five reports met the inclusion criteria. They were tabulated and critically appraised in terms of the methodology and design, sample size, outcomes, and the possible influence of bias, confounding, and chance. High level evidence comparing the safety and efficacy of laparoscopic live donor nephrectomy with open donor nephrectomy was not available at the time of this review. Limited low level evidence suggested that the laparoscopic approach might be advantageous regarding the donor's hospital stay, convalescence, pain, and resumption of employment. The ASERNIP-S Review Group concluded that the evidence-base for laparoscopic live donor nephrectomy was inadequate to make a safety and efficacy recommendation. Clinical and research recommendations were developed regarding the introduction and current practice of this procedure in Australia.

Latex allergy is a type I immediate hypersensitivity reaction to particular latex proteins in natural rubber latex. It must be differentiated from irritant dermatitis (not allergic) and allergic contact dermatitis (a type IV delayed hypersensitivity reaction). ◆ In the general, non-atopic population, the prevalence of latex allergy may be less than 1%, but in healthcare workers may be as high

First aid is the initial care of the ill or injured. It aims to preserve and protect life, prevent further injury or deterioration of illness, and help promote recovery. At major public events, there is a large gathering of people, physical spectacles, and equipment within a concentrated area, where organized first-aid care is provided. To analyze the demand for primary medical care at a public event by identifying the patients and initial symptoms that may predict that demand, and to use such information to improve the efficiency and delivery of medical care. A questionnaire was completed by St. John Operations Branch personnel after each patient consultation and a retrospective analysis of the data was conducted. A total of 1,276 questionnaires were returned. Mean patient presentation rate (PPR) was 1.9 +/- 0.47 per 1,000 show attendees. This correlated best with the maximum daily temperature (r = 0.715, p <0.02) and show day (r = 0.615, p <0.05). There was poor correlation ...

The reported case of a stab wound to the chest occurred in an isolated area with no specialized surgical care available. The need for transport and specifically by air, introduced particular questions in management. On a humanitarian basis and in line with its mandate, the Peace Monitoring Group, a United Nations endorsed entity in Bougainville, Papua New Guinea, provided transport to a facility with an appropriate standard of care. The questions of need for patient evacuation and chest drainage, with the timing of this maneuver are considered.

Latex allergy has become the epidemic of the 1990s for health care workers, as indicated by a remarkable increase in its prevalence. This literature review provides a brief background to the latex problem, strategies for prevention and management, a cost analysis of glove substitution in a clinical setting, and the implications for the military environment. Primary care providers must recognize the financial, medico-legal, occupational, and personal ramifications of latex allergy. Risk managers should realize that moving to a latex-free environment will reduce liability.