921
Operating
at
night
department of surgery must have discussed the question "Which surgical operations should be done at night, and who should do them?". In the UK, there is general Every general
surgeon in every
agreement with the conclusions of the Confidential
Enquiry into Perioperative Deathsl that too many surgical procedures are being done at night and by too junior and inexperienced surgeons. McKee and his associates at the Health Services Research Unit at the London School of Hygiene and Tropical Medicine2 have now looked at what happened at night (before and after midnight) in four UK hospitals during four non-consecutive months (to avoid seasonal fluctuations). In each case a panel of experts then assessed the data to see whether night surgery had been necessary. The picture that emerged is all too familiar. Emergency admissions accumulate in the surgical wards and the accident centre during the day and early evening, and an "emergencies" list is arranged to start after the end of the elective afternoon lists when an operating theatre and attendant staff can be made available. The surgeon is usually the duty registrar or senior house officer (81 %) and seldom the consultant (6%). The cases are accorded a priority and operations such as appendicectomy and opening of abscesses tend to be left to the end because they usually "keep" and because they render the theatre "dirty". This is why appendicectomy and abscess cases accounted for no less than 53 % of all operations done after midnight. This style of working in general surgery is ingrained into generations of surgeons, first as juniors doing it, and later as consultants allowing it; most surgeons know no other way. It is said that the system allows keen registrars to gain experience. Another reason for night-time surgery is that next morning all the theatres will be booked with elective lists and no-one will want to "break" a list for an emergency because then it will run out of allocated time and an elective case will get cancelled. Thus emergency cases may be forced to wait until the end of the next day if they have not been done during the night: it is not unknown for patients to go eighteen hours or more before reaching the operating theatre. McKee’s consensus panel suggested some clinical guidelines to determine which of the more common surgical emergencies might be regarded as urgent enough to warrant night surgery and which might wait. They rightly advocate caution in this exercise because ultimately the needs of individual patients must be taken into account., Thus each hospital should draw up a surgical emergency protocol for guidance of juniors (this would make a good target for surgical audit). A consultant surgeon should be involved more often in the decision whether to operate or not-and in the operation itself in some cases, at least in a supervisory capacity. General hospitals should designate and maintain a day-time operating theatre
complete with nurses, technicians, and an anaesthetist for emergency use only and the entire surgical team "on take" must be available to attend to emergencies and be free of other commitments. At least 30% of all night surgery could be safely delayed or avoided, and the after-midnight cases reduced to a trickle. The resulting upheaval would affect managers as well as doctors. Consultant expansion in general surgery is still painfully slow despite Achieving a Balance,3 and there is a perpetual shortage of anaesthetists and theatre-trained nurses. Few general hospitals have spare theatre capacity. Working practices, surgical team schedules, and individuals’ sessional arrangements would need to be reorganised. Nevertheless, the rewards would be great in terms of improved services to patients and the welfare of surgeons in reducing out-of-hours working. Who is going to make a start? N, Devlin HB, Lunn JN. Report of a Confidential Enquiry into Perioperative Deaths. London: Nuffield Provincial Hospitals Trust/ Kings Fund, 1987. 2. McKee M, Ginzler M, Priest P, Black N. Which general surgical operations must be done at night? Ann R Coll Surg Engl 1991; 73: 1. Buck
295-302.
3.
Department of Health and Social Security. Hospital medical staffing: achieving a balance. London: HM Stationery Office, 1986.
Diarrhoea and malnutrition wards in developing countries children with diarrhoea associated with growth faltering. Inadequate intake of bulky diets with poor nutrient content and low bioavailability, either as a result of anorexia or because foods have been withheld for cultural reasons, is often suggested to explain these fmdings.! Other factors include malabsorption, altered metabolism, and losses of endogenous nutrients. Many children in the community are also underweight, short, or thin by comparison with international standards. Since diarrhoea and growth faltering are so common it seemed likely that they were causally associated, and in several of the community-based studies of undernourished children the impact of diarrhoea and other infections on growth has been noted.3,4These observations led to the proposal that reduction of prevalence of diarrhoea, more widespread use of oral rehydration, and better dietary management of diarrhoea are important strategies for improving nutritional status. Such assumptions have now been In most
paediatric
one comes across
questioned. It is
that dietary intake is considerably among children with acute watery
true
decreased diarrhoea
severe
enough
to
precipitate hospital
admission,2 and that intake is also reduced in dysentery and persistent diarrhoea, but these conditions account for less than 10% of diarrhoea episodes in many communities. The mild nature of most episodes may account for the limited impact of diarrhoea on dietary intake in community-based studies in Nigeria5 and Bangladesh.6Dickin and
922
colleagues,s who measured energy intake in Nigerian children during diarrhoea and after recovery, noted that overall energy consumption was 11% less during diarrhoea than on recovery but a third of the children ate more when they had diarrhoea than when they were healthy. Intakes of breast milk and porridge were similar in the two phases; despite the children’s anorexia the mothers were able to maintain porridge intake by more frequent feeds. The difference in energy intake was mainly attributable to differences in intake of other solid foods, presumably different types of snack. A community study in Bangladesh showed no decrease in energy intake during diarrhoea but less food was eaten during episodes of fever.6In a more recent analysis of measurements of energy intake, and prevalence of diarrhoea and fever, in Bangladeshi children7 a random effect regression model was used to assess the relative importance of these variables on weight gain. It was calculated that additional weight gains of 10, 25, and 30 g per month could be achieved if diarrhoea alone, fever alone, or both, respectively, were eliminated. These children, aged 5-30 months, received about 70 kcal (294 kJ)/kg bodyweight per day (considerably less than their requirements for optimum growth of about 100 kcal/kg per day). Another prediction was that additional weight gains of about 50 g per month could be expected if recommended energy intakes were achieved, even with customary levels of diarrhoea and fever. 80 g per month weight gain was predicted if the same dietary intake was achieved in the absence of diarrhoea or fever. In Colombia, diarrhoea had no adverse nutritional effect on children who were better nourished as a result of receiving regular supplementation from birth to 36 months.8 In this issue (p 907) Lunn and colleagues describe their studies of intestinal permeability and growth faltering in Gambian infants. They relate intestinal permeability, assessed by measurement of urinary excretion of lactulose and mannitol after an oral dose of these sugars, to linear growth and weight gain. In view of the very close correlation between intestinal permeability and growth the researchers believe that abnormalities of the small intestine are responsible for a major part of the growth faltering exhibited by these infants. However, association does not necessarily imply causality. As Lunn et al discuss, their results do not resolve the argument of whether diarrhoea or diet is the cause of infant growth faltering, but the regression equations for permeability versus growth show that permeability predicts about 40% of the observed variation in weight and height increments. The infection/malnutrition complex is well recognised. The topic was comprehensively described by Scrimshaw and colleagues in 1968 and by Tomkins and Watson in 1989.10 More recently Briend" has critically assessed the evidence for a diarrhoea/ malnutrition cycle. He finds the arguments
for an increased risk of prolonged and diarrhoea higher mortality among children who are underweight, short, or thin. The data supporting diarrhoea as an important cause of malnutrition are not so consistent. Although nutritional disorders among severely ill children with dysentery and persistent diarrhoea syndrome are often pronounced, especially when diarrhoeal illness is associated with a severe systemic disturbance, such findings cannot be extrapolated to the community. The results do not detract from the importance of improving food hygiene, appropriate weaning, food technology, water supplies, and sanitation, or of reducing deaths from dehydration. However, the contribution of diarrhoeal disease control towards improving nutrition may be smaller than we thought.
convincing
1.
Ljungqvist BG, Mellander O, Svanberg US-O. Dietary bulk as a limiting factor for nutrient intake in pre-school children. J Trop Paediatr 1981;
27: 68-73. 2. Molla A, Molla AM, Rahim A, Sarker SA, Mozaffar Z, Rahaman M. Intake and absorption of nutrients in children with cholera and rotavirus infection during acute diarrhoea and after recovery. Nutr Rev 1982; 2: 233-42. 3. Rowland MGM, Cole TJ, Whitehead RG. A quantitative study into the role of infection in determining nutritional status in Gambia village children. Br J Nutr 1977; 37: 441-50. 4. Black, RE, Brown KH, Becker S. Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pediatrics 1984; 73: 799-805. 5. Dickin KL, Brown KH, Fagbule D, et al. Effect of diarrhoea on dietary intake by infants and young children in rural villages of Kwara State, Nigeria. Eur J Clin Nutr 1990; 44: 307-17. 6. Black RE, Brown KH, Becker S, Yunus M. Longitudinal studies of infectious disease and physical growth of children in rural Bangladesh: 1. Patterns of Morbidity. Am J Epidemiol 1982; 115: 304-14. 7. Becker S, Black RE, Brown KH. Relative effects of diarrhea, fever, and dietary energy intake on weight gain in rural Bangladeshi children. Am J Clin Nutr 1991; 53: 1-5. 8. Lutter CK, Mora JO, Habicht JP, Rasmussen KM, Robson DS. Nutritional supplementation eliminates child stunting due to diarrhea. Am J Clin Nutr 1989; 50: 1-8. 9. Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. Geneva: World Health Organisation, 1968. 10. Tomkins A, Watson F. Malnutrition and infection: a review. Geneva: World Health Organisation (Administrative Committee on Coordination/Subcommittee on Nutrition), 1989. 11. Briend A. Is diarrhoea a major cause of malnutrition among the under-fives in developing countries? A review of available evidence. Eur J Clin Nutr 1990; 44: 611-28.
Triazolam
hearings
in
Europe
On Oct 16 the Committee on Proprietary Medicinal Products of the European Community meets in Brussels to discuss triazolam. It will take into the previous day’s session of the account Pharmacovigilance Working Party. We understand that Upjohn will be making a presentation to the working-party and will then answer questions from the committee. There is not much precedent for hearings with this degree of informality though clearly manufacturers have the right to be heard. The question is whether the other eleven member States represented in Brussels will have had time to digest the information that prompted the UK Licensing Authority to withdraw the drug on Oct 2. An update on the controversy appears on p 938.
Operating
at
night
department of surgery must have discussed the question "Which surgical operations should be done at night, and who should do them?". In the UK, there is general Every general
surgeon in every
agreement with the conclusions of the Confidential
Enquiry into Perioperative Deathsl that too many surgical procedures are being done at night and by too junior and inexperienced surgeons. McKee and his associates at the Health Services Research Unit at the London School of Hygiene and Tropical Medicine2 have now looked at what happened at night (before and after midnight) in four UK hospitals during four non-consecutive months (to avoid seasonal fluctuations). In each case a panel of experts then assessed the data to see whether night surgery had been necessary. The picture that emerged is all too familiar. Emergency admissions accumulate in the surgical wards and the accident centre during the day and early evening, and an "emergencies" list is arranged to start after the end of the elective afternoon lists when an operating theatre and attendant staff can be made available. The surgeon is usually the duty registrar or senior house officer (81 %) and seldom the consultant (6%). The cases are accorded a priority and operations such as appendicectomy and opening of abscesses tend to be left to the end because they usually "keep" and because they render the theatre "dirty". This is why appendicectomy and abscess cases accounted for no less than 53 % of all operations done after midnight. This style of working in general surgery is ingrained into generations of surgeons, first as juniors doing it, and later as consultants allowing it; most surgeons know no other way. It is said that the system allows keen registrars to gain experience. Another reason for night-time surgery is that next morning all the theatres will be booked with elective lists and no-one will want to "break" a list for an emergency because then it will run out of allocated time and an elective case will get cancelled. Thus emergency cases may be forced to wait until the end of the next day if they have not been done during the night: it is not unknown for patients to go eighteen hours or more before reaching the operating theatre. McKee’s consensus panel suggested some clinical guidelines to determine which of the more common surgical emergencies might be regarded as urgent enough to warrant night surgery and which might wait. They rightly advocate caution in this exercise because ultimately the needs of individual patients must be taken into account., Thus each hospital should draw up a surgical emergency protocol for guidance of juniors (this would make a good target for surgical audit). A consultant surgeon should be involved more often in the decision whether to operate or not-and in the operation itself in some cases, at least in a supervisory capacity. General hospitals should designate and maintain a day-time operating theatre
complete with nurses, technicians, and an anaesthetist for emergency use only and the entire surgical team "on take" must be available to attend to emergencies and be free of other commitments. At least 30% of all night surgery could be safely delayed or avoided, and the after-midnight cases reduced to a trickle. The resulting upheaval would affect managers as well as doctors. Consultant expansion in general surgery is still painfully slow despite Achieving a Balance,3 and there is a perpetual shortage of anaesthetists and theatre-trained nurses. Few general hospitals have spare theatre capacity. Working practices, surgical team schedules, and individuals’ sessional arrangements would need to be reorganised. Nevertheless, the rewards would be great in terms of improved services to patients and the welfare of surgeons in reducing out-of-hours working. Who is going to make a start? N, Devlin HB, Lunn JN. Report of a Confidential Enquiry into Perioperative Deaths. London: Nuffield Provincial Hospitals Trust/ Kings Fund, 1987. 2. McKee M, Ginzler M, Priest P, Black N. Which general surgical operations must be done at night? Ann R Coll Surg Engl 1991; 73: 1. Buck
295-302.
3.
Department of Health and Social Security. Hospital medical staffing: achieving a balance. London: HM Stationery Office, 1986.
Diarrhoea and malnutrition wards in developing countries children with diarrhoea associated with growth faltering. Inadequate intake of bulky diets with poor nutrient content and low bioavailability, either as a result of anorexia or because foods have been withheld for cultural reasons, is often suggested to explain these fmdings.! Other factors include malabsorption, altered metabolism, and losses of endogenous nutrients. Many children in the community are also underweight, short, or thin by comparison with international standards. Since diarrhoea and growth faltering are so common it seemed likely that they were causally associated, and in several of the community-based studies of undernourished children the impact of diarrhoea and other infections on growth has been noted.3,4These observations led to the proposal that reduction of prevalence of diarrhoea, more widespread use of oral rehydration, and better dietary management of diarrhoea are important strategies for improving nutritional status. Such assumptions have now been In most
paediatric
one comes across
questioned. It is
that dietary intake is considerably among children with acute watery
true
decreased diarrhoea
severe
enough
to
precipitate hospital
admission,2 and that intake is also reduced in dysentery and persistent diarrhoea, but these conditions account for less than 10% of diarrhoea episodes in many communities. The mild nature of most episodes may account for the limited impact of diarrhoea on dietary intake in community-based studies in Nigeria5 and Bangladesh.6Dickin and
922
colleagues,s who measured energy intake in Nigerian children during diarrhoea and after recovery, noted that overall energy consumption was 11% less during diarrhoea than on recovery but a third of the children ate more when they had diarrhoea than when they were healthy. Intakes of breast milk and porridge were similar in the two phases; despite the children’s anorexia the mothers were able to maintain porridge intake by more frequent feeds. The difference in energy intake was mainly attributable to differences in intake of other solid foods, presumably different types of snack. A community study in Bangladesh showed no decrease in energy intake during diarrhoea but less food was eaten during episodes of fever.6In a more recent analysis of measurements of energy intake, and prevalence of diarrhoea and fever, in Bangladeshi children7 a random effect regression model was used to assess the relative importance of these variables on weight gain. It was calculated that additional weight gains of 10, 25, and 30 g per month could be achieved if diarrhoea alone, fever alone, or both, respectively, were eliminated. These children, aged 5-30 months, received about 70 kcal (294 kJ)/kg bodyweight per day (considerably less than their requirements for optimum growth of about 100 kcal/kg per day). Another prediction was that additional weight gains of about 50 g per month could be expected if recommended energy intakes were achieved, even with customary levels of diarrhoea and fever. 80 g per month weight gain was predicted if the same dietary intake was achieved in the absence of diarrhoea or fever. In Colombia, diarrhoea had no adverse nutritional effect on children who were better nourished as a result of receiving regular supplementation from birth to 36 months.8 In this issue (p 907) Lunn and colleagues describe their studies of intestinal permeability and growth faltering in Gambian infants. They relate intestinal permeability, assessed by measurement of urinary excretion of lactulose and mannitol after an oral dose of these sugars, to linear growth and weight gain. In view of the very close correlation between intestinal permeability and growth the researchers believe that abnormalities of the small intestine are responsible for a major part of the growth faltering exhibited by these infants. However, association does not necessarily imply causality. As Lunn et al discuss, their results do not resolve the argument of whether diarrhoea or diet is the cause of infant growth faltering, but the regression equations for permeability versus growth show that permeability predicts about 40% of the observed variation in weight and height increments. The infection/malnutrition complex is well recognised. The topic was comprehensively described by Scrimshaw and colleagues in 1968 and by Tomkins and Watson in 1989.10 More recently Briend" has critically assessed the evidence for a diarrhoea/ malnutrition cycle. He finds the arguments
for an increased risk of prolonged and diarrhoea higher mortality among children who are underweight, short, or thin. The data supporting diarrhoea as an important cause of malnutrition are not so consistent. Although nutritional disorders among severely ill children with dysentery and persistent diarrhoea syndrome are often pronounced, especially when diarrhoeal illness is associated with a severe systemic disturbance, such findings cannot be extrapolated to the community. The results do not detract from the importance of improving food hygiene, appropriate weaning, food technology, water supplies, and sanitation, or of reducing deaths from dehydration. However, the contribution of diarrhoeal disease control towards improving nutrition may be smaller than we thought.
convincing
1.
Ljungqvist BG, Mellander O, Svanberg US-O. Dietary bulk as a limiting factor for nutrient intake in pre-school children. J Trop Paediatr 1981;
27: 68-73. 2. Molla A, Molla AM, Rahim A, Sarker SA, Mozaffar Z, Rahaman M. Intake and absorption of nutrients in children with cholera and rotavirus infection during acute diarrhoea and after recovery. Nutr Rev 1982; 2: 233-42. 3. Rowland MGM, Cole TJ, Whitehead RG. A quantitative study into the role of infection in determining nutritional status in Gambia village children. Br J Nutr 1977; 37: 441-50. 4. Black, RE, Brown KH, Becker S. Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pediatrics 1984; 73: 799-805. 5. Dickin KL, Brown KH, Fagbule D, et al. Effect of diarrhoea on dietary intake by infants and young children in rural villages of Kwara State, Nigeria. Eur J Clin Nutr 1990; 44: 307-17. 6. Black RE, Brown KH, Becker S, Yunus M. Longitudinal studies of infectious disease and physical growth of children in rural Bangladesh: 1. Patterns of Morbidity. Am J Epidemiol 1982; 115: 304-14. 7. Becker S, Black RE, Brown KH. Relative effects of diarrhea, fever, and dietary energy intake on weight gain in rural Bangladeshi children. Am J Clin Nutr 1991; 53: 1-5. 8. Lutter CK, Mora JO, Habicht JP, Rasmussen KM, Robson DS. Nutritional supplementation eliminates child stunting due to diarrhea. Am J Clin Nutr 1989; 50: 1-8. 9. Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. Geneva: World Health Organisation, 1968. 10. Tomkins A, Watson F. Malnutrition and infection: a review. Geneva: World Health Organisation (Administrative Committee on Coordination/Subcommittee on Nutrition), 1989. 11. Briend A. Is diarrhoea a major cause of malnutrition among the under-fives in developing countries? A review of available evidence. Eur J Clin Nutr 1990; 44: 611-28.
Triazolam
hearings
in
Europe
On Oct 16 the Committee on Proprietary Medicinal Products of the European Community meets in Brussels to discuss triazolam. It will take into the previous day’s session of the account Pharmacovigilance Working Party. We understand that Upjohn will be making a presentation to the working-party and will then answer questions from the committee. There is not much precedent for hearings with this degree of informality though clearly manufacturers have the right to be heard. The question is whether the other eleven member States represented in Brussels will have had time to digest the information that prompted the UK Licensing Authority to withdraw the drug on Oct 2. An update on the controversy appears on p 938.
