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  1. Jonathan Wyatt

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    Dangers in the waiting room ▸

    The potential risk of cross infection via the traditional doctor's white coat has been well publicised. Just when white coats appear to have been largely phased out of use in A&E, a new potential risk has emerged in the form of soft toys. The authors of this study from New Zealand examined the bacterial contamination of toys in the waiting rooms of general practice surgeries. They found that, in contrast with “hard” toys, “soft” toys showed heavy contamination with coliforms and other bacteria. Considering their results in conjunction with the fact that soft toys are less easy to clean and disinfect, they recommend the withdrawal of soft toys from general practice waiting rooms. Perhaps it is also time for soft toys in A&E to go the same way as white coats . . .

    Risk of sudden infant death syndrome does not appear to be related to febrile convulsions in siblings ▸

    It has been previously hypothesised that there is an aetiological relation between sudden infant death syndrome and febrile convulsions. In a large and robust study of more than 30 000 children, the authors attempted to investigate this possible relation by comparing the risk of sudden infant death syndrome in siblings of children who had suffered febrile convulsions with that of siblings of children who had never had febrile convulsions. They found no increased risk of sudden infant death syndrome in siblings of children who had previously suffered febrile convulsions.

    Subdural haemorrhage in infants ▸

    Young children all too frequently present to hospital with subdural haemorrhage. Managing these children and investigating the circumstances of injury is a difficult process. This review can be recommended to anyone who is likely to be involved in the care of children with subdural haemorrhage.

    Man's best friend? ▸

    The finding of this Australian study that dogs continue to pose a risk to humans comes as no great surprise. Data collected from the state of Victoria (estimated population 4.7 million people) appeared to show that the highest rate of serious injury involved young children. One of the markers of severity used in the study was admission to hospital, but this approach may be flawed, because of a possible increased tendency to admit young children for treatment of certain injuries, as compared with older children and adults. The authors do not propose any new measures in order to reduce dog bites, but believe that the focus should continue upon legislation, particularly in relation to certain breeds.

    Risks of reversing vehicles: technology may have the answer ▸

    While it is very encouraging that child pedestrian death rates have fallen in many countries in recent years, the authors of this Austrian study focus upon the relatively neglected problem of vehicles causing death or injury by reversing or rolling backwards. From their data, they conclude that toddlers playing or left unattended in driveways or farmyards are at particular risk. They advocate physically restricting child access to driveways and greater use of infrasonic park distance technology in the rear bumpers of cars.

    Pre-existing warfarin therapy may not affect outcome after head injury ▸

    It has always rather been assumed that patients who are already taking warfarin before sustaining an injury (particularly to the head) are likely to have a worse outcome. This large retrospective study of 2942 patients who presented over a six year period to trauma centres in Pennsylvania aimed to address this issue. The authors have interpreted their results as suggesting that in both head injured and non-head injured patients, anticoagulation with warfarin for a pre-existing problem does not adversely affect mortality or length of hospital stay. The major drawback of this study is that patients are compared according to their anatomical injuries and physiological status upon presentation to hospital. It does not take into account the fact that patients who are already taking warfarin and who sustain an injury may be at much greater risk of developing a serious complication (such as intracranial haemorrhage).

    Meeting the challenge of psychiatric frequent attenders ▸

    This audit highlights the problems posed by patients with psychiatric problems who present repeatedly to A&E. Frequent psychiatric attenders in a London teaching hospital were found to account for 26% of all psychiatric attendances. The vast majority of these people had had previous contact with local mental health services. The introduction of a system of multidisciplinary care plans resulted in a significant reduction in A&E presentations by the frequent psychiatric attenders.

    The neglected very elderly trauma patient ▸

    This study adds weight to conclusions from previous papers from both sides of the Atlantic that very elderly trauma patients (aged over 80 years) have better outcomes if they are treated in centres where the full range of facilities are available and used to treat them. The authors of this retrospective six year study compared the outcomes of very elderly trauma patients treated in US trauma centres with those who were treated in other (acute care) hospitals. They used reasonably standard methodology, analysing data on 455 patients collected in the Major Trauma Outcome Study. Very elderly patients treated in the trauma centres had significantly better outcomes. This study does have some limitations, some of which are acknowledged by the authors. These include the retrospective design, some missing data and most importantly, the possibility that bias may have crept in as the different groups of patients were not randomly assigned to receive treatment in the different hospitals.

    Management of advanced heart failure ▸

    The authors reviewed all of the available robust evidence regarding the medical management of advanced heart failure. They concluded that current management is based more upon consensus rather than upon randomised trials. Inevitably and quite reasonably, the authors call for more research. They make the point that given the resurgence of established drugs such as β blockers, this research needs to be directed not only to developing new strategies, but also for selecting and optimising therapies already available.

    More unnecessary abdominal radiographs ▸

    It is well recognised that plain abdominal radiographs are of limited value in the investigation of patients with various non-specific abdominal symptoms and signs. Current guidelines from the Royal College of Radiologists in London are quite specific regarding the indications for such radiographs. Bearing this in mind, the findings of this study from a UK hospital are quite remarkable. The authors report that having reviewed 1309 medical admissions to hospital, they discovered that plain abdominal radiographs had been performed on 131 patients (10%), with 38 radiographs being requested by A&E doctors. The reasons for requesting these 131 radiographs conformed to the recommended guidelines in only 16 cases (12%). From the information provided in the paper, it would seem that no requests for radiographs were ever refused! Perhaps the hospital needs to introduce the system used with apparent success elsewhere, namely that requests for radiographs are only accepted by the radiographers if they conform to accepted guidelines.

    Projected demands for long term care for older people in England rise sharply ▸

    At a time when A&E departments appear to be suffering the effects of hospitals being overfilled with patients waiting for various forms of care, this report will come as no comfort to those working in A&E in England. The authors from the London School of Economics conclude that in order to keep pace with demographic pressures over the next 30 years, residential and nursing home places would need to expand by around 65%, and long term care expenditure would need to rise by approximately 150% in real terms.

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