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Objectives & Background We identified that there is a cohort of people who attend our Emergency Department (ED) extremely frequently (>24 times per year) or who have frequent admissions (>12 per year). Analysing hospital clinical records identified that in many cases medically unexplained symptoms (MUS) drive the frequent presentation. The needs of these patients were not being met by a traditional dualistic approach in which people are seen in either physical or mental health settings. Indeed, despite frequent medical investigations/treatments, their symptoms persist, their problems are not resolved, they frequently complain and they keep coming back. This carries risk and distress for the patients, and heavy use of resources for the hospitals involved. Methods Each month we looked at attendance data for the previous 3 months (this identified people who in an acute phase of repeat presentations). By accessing patients clinical records we determined the main factors which appeared to drive their frequent attendance and admissions and identified those who presented with MUS. Care plans were developed and each patient was contacted and offered weekly Cognitive Behavioural Therapy (CBT) sessions to help them manage their symptoms. This was part of a case management approach in which coordinated, multidisciplinary reviews were undertaken resulting in an individualised care plan. Results Thus far the pilot has seen a reduction in attendances at ED for 100% of patients included in study (N=20). Crucially, all now attend less than once per month. In total 245 attends were saved after the CBT interventions Conclusion Providing a psychological intervention to this patient cohort is effective in reducing hospital costs by containing the most frequent attenders. CBT and care plans have reduced attendance to under once per month and subsequently reduced medical interventions and prescribing costs. 866Emerg Med J 2013;30(10):866-880

A best evidence topic was written according to a structured protocol. The question addressed was 'whether a sleeve lobectomy results in a better survival rate than a pneumonectomy in suitable patients?' Altogether, more than 327 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude in the biggest meta-analysis of nearly 3000 patients, the five-year survival was 50% for sleeve lobectomy compared to 30% for pneumonectomy. Operative mortality was 3% vs. 6% for pneumonectomy, and locoregional recurrence was 17% vs. 30%. These results are broadly consistent across all the 13 cohort studies presented here many of which document a 20-year single centre experience or more. There are significant issues in all cohort studies on this subject as, due to their non-randomized nature, the reason for not performing a sleeve resection may well have been more advanced disease, which would necessarily mean that the pneumonectomy patients would have a lower expected survival and higher local recurrence. In addition, there have been many large cohort studies to date and thus no more are required, as future studies are unlikely to resolve this issue. Thus, the only study that would adequately correct for this issue would be a randomized trial, but to prove a 10% increase in five-year survival a 300 patient study would be needed. This is bigger than any study ever done in this area and as some centres took 30 years to collect these numbers of potential sleeve patients an RCT is not a realistic possibility. Therefore, we conclude that no more cohort studies should be performed, as the results will be consistent with the meta-analyses and an RCT to eliminate their bias is unattainable, and thus no more research should be done on this topic and surgeons should use the figures presented above and in more detail in this best evidence topic to govern their management in the future.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Can leucocyte depletion (LD) reduce reperfusion injury following cardiopulmonary bypass?'. Altogether more than 74 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that there appears to be little or no clinical benefit gained from the use of LD treatment. The majority of studies, looking at outcomes including the duration of hospital and intensive care unit (ICU) stay, intubation time, inotropic support required and postoperative arrhythmias, found the results comparable between patients receiving LD treatment and controls. Biochemical parameters of reperfusion inflammation and cardiac damage are reduced in many studies, suggesting an attenuation of reperfusion injury at a cellular level, but this does not appear to be transferable to clinical improvement. However, one study using patients with severely low left ventricular ejection fractions (LVEF), found those receiving LD treatment required less inotropic support and experienced a significant increase in LVEF postoperatively when compared with controls, indicating that the benefit of LD may depend on preoperative status and susceptibility to reperfusion damage. In conclusion, LD should not be used routinely in cardiac surgery.

Background Nonspecific abdominal pain (NSAP) accounts for 40 % of all general surgical admissions. Data suggest that conditions such as irritable bowel syndrome and gynaecological pathologies can be misdiagnosed as NSAP. Delayed diagnosis and management can cause increased morbidity. Our aim was to follow-up a cohort of patients with an initial diagnosis of NSAP to determine their eventual diagnosis.Method Hospital episode statistic (HES) data were reviewed to identify 100 acute surgical admissions coded as NSAP at discharge between January and December 2008. Medical records were systematically reviewed over a 3-year follow-up period to identify further investigations, operations and any eventual diagnoses in patients who fulfilled NSAP criteria. General practitioners were contacted to evaluate any further GP surgery visits and hospital referrals for this cohort of patients.Results A total of 59 were incorrectly coded as NSAP; only 41 fulfilled the criteria of NSAP at discharge from the initial acute admission. The majority of patients correctly diagnosed as NSAP were female (71 %) individuals. Median age across both genders was 25.7 years (interquartile range 19.4-37.7 years). At three yearly followup, 54 % of patients appropriately labelled as NSAP were diagnosed with a specific pathology.Conclusion This study highlights that around half of patients correctly labelled with NSAP were subsequently diagnosed with a specific pathology. Our results suggest that patients diagnosed with NSAP should be followed up to avoid additional morbidity from misdiagnosis. Furthermore, the current coding system for NSAP needs to be modified.

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Bromelain-based enzymatic debridement (ED) is a topical treatment that is growing in popularity for the non-surgical management of burn wounds. Although initially used for small injuries, experience has grown in using it for burns >15% Total Burns Surface Area (TBSA). A household explosion resulted in burns to multiple patients, with four requiring burn wound debridement. This case report demonstrates their management using ED. Four adult male patients were treated with ED, mean age 38.4 years. Their injuries ranged from 5–24% TBSA (mean 14.9%), with a high proportion of intermediate-deep dermal injury to their faces and limbs. Our centre has performed enzymatic debridement since 2016 and all senior burns surgeons and burns intensive care specialists in the team are experienced in its use. We perform enzymatic debridement using Nexobrid™ (Mediwound Ltd., Israel). Three patients were managed on a single theatre list, using ED for their burns at 19, 16 and 23 hours post-injury. One patient had ED of his injuries on intensive care at 18 hours. Patients with >15% TBSA were treated in a critical care setting with goal directed fluid therapy. Through the use of enzymatic debridement we were able to achieve burn debridement for four patients in under 24 hours. While not a true mass casualty incident, our experience suggests that for an appropriately resourced service it is likely to have advantages in this scenario. We suggest that burns services regularly using this technique consider inclusion into mass casualty protocols, with training to staff to enable provision in such an incident.

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